Every finding on record at Power County Skilled Nursing Facility

Based on observation, interview, policy review, and review of the U.S. Food and Drug Administration 2022 Food Code, the facility failed to appropriately store, distribute, label foods, and clean cookware appropriately. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The facility's General Storage and Damaged Products policy dated 11/10/23, documented dietary employees are instructed to label and date all opened food items.The facility's Dry & Cold Food Storage policy dated 11/10/23, documented temperatures of all refrigerators and freezers will be recorded daily on the temperature log sheets. All prepared foods will be kept covered, labeled, and dated. All opened food products will be placed in proper containers for storage, labeled, dated, and refrigerated. All other perishables such as cheese, mayonnaise, jelly, etc are to be kept no longer than the best used by date on the container. The facility's Sanitizer Bucket policy dated 4/15/26, documented to refresh the bucket every two hours or more often as needed. On 6/8/26 starting at 7:35 AM, the surveyor observed the following in the kitchen:a. The FDA Food Code Section 6-301.14 Handwashing signage documented, a sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees.- No handwash signage posted by the handwash sink. On 6/9/26 at 12:05 PM, the Food Service Supervisor stated the handwash signage had recently been removed and needed to be put back up but had not yet been.b. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.In the walk-in refrigerator: - Opened unsealed bag of shredded cheese with no open date. In the reach in refrigerator:- Opened gallon of milk with no opened date- Opened gallon of Lactaid milk with no opened date In the dry food pantry:- Opened two bags of chile pods with no opened date In the food prep area:- One cleaned skillet with encrusted black food on the inside of the skillet In the food prep area:- The sanitizer bucket log documented the bucket had been changed or refreshed every four hours in June 2026.c. The FDA Food Code Section 4-302.12 Food Temperature Measuring Devices documented the presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded. The Refrigerator and Freezer temperature log was missing temperature data from June 5, 6, and 7, 2026.On 6/9/26 at 12:10 PM, the Food Service Supervisor stated the opened food items should have been sealed correctly, been labeled with the opened date, temperature logs should have been completed every day, and cookware cleaned appropriately and were not.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:During review of the facility daily staffing sheets, the surveyor noted missing nurse staffing data and census data on the following dates.- The daily staffing sheets had not documented the actual hours worked by nursing staff.- 5/28/26 missing resident census- 4/6/26 missing nurse data for 0600 to 1800 shift- 3/19/26 missing nurse data for 0600 to 1800 shift- 3/14/26 missing nurse data for 1800 to 0600 shift- 3/4/26 missing nurse and CNA data for 1800 to 0600 shift- 2/26/26 missing nurse data for 1800 to 0600 shift- 2/14/26 missing resident census- 2/13/26 missing nurse data for 1800 to 0600 shift- 1/22/26 missing resident census- 1/15/26 missing resident censusOn 6/8/26 at 1:30 PM, the DON stated the daily staffing sheets should have been completed correctly and had not been.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The facility's Dining Room policy dated 1/1/24, documented staff are to encourage residents to wash hands in sink or with washcloth or sanitize prior to each meal.The following was observed for hand hygiene:On 6/8/26 at 8:10 AM, observed breakfast meal served to the residents in rooms 9, 14, 15, and 18. The residents were not offered hand hygiene before eating their meals.On 6/8/26 at 10:14 AM, CNA #1 stated they should have offered hand hygiene to the residents before they ate their meals. She also stated staff are supposed to be carrying a large bottle of hand sanitizer to clean the resident's hands.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1of 1medication carts audited. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 6/9/26 at 10:00 AM, observed during the medication cart audit, the narcotic accountability sheets had the following dates without licensed nurse signature documented:-4/26/26 On-coming signature-4/27/26 Off going signature-4/29/26 Off going signature-5/8/26 On-coming signature-5/8/26 Off going signature-5/14/26 Off going signature-5/17/26 On-coming signature-5/17/26 Off going signature-5/23/26 On-coming signature-5/23/26 Off going signature-6/5/26 On-coming signature-6/6/26 Off going signatureOn 6/9/26 at 10:15 AM, RN #1 stated two nurses should have signed the narcotic accountability sheet and had not.On 6/9/26 at 1:19 PM, the DON stated two nurses should have signed off on the narcotic count sheets.

Based on staff interview and review of employee personnel files, it was determined the facility failed to ensure each CNA's annual performance reviews were completed at least once every 12 months for 3 of 3 CNAs (#2, #3, and #4) whose personnel records were reviewed for sufficient and competent CNA staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility. Findings include:On 6/9/26 at 11:00 AM, during review of CNA employee personnel files, observed that CNA #2, #3, and #4 had not performance review documentation since 2024.On 6/9/26 at 11:10 AM, the HR Director stated the facility had not conducted any CNA performance reviews since 2024 as they are revising the process.

Based on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include:The FDA Food Code Section 5-501.113 Covering Receptacles documented receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment. On 6/8/26 at 7:40 AM, the surveyor observed a 50-gallon trash can in the food prep area not being used that was about half full and had no lid.On 6/9/26 at 12:15 PM, the Food Service Supervisor stated she was not aware the garbage can required a lid but would get one.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect resident current code status. This was true for 1 of 2 residents (Resident #4) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include:The facility's Care Plan policy dated [DATE], documented care plans will be reviewed quarterly, annually, and with change of status to ensure that they are current for the resident's care.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities) and depressive disorder.On [DATE] at 8:42 AM, Resident #4's medical record Plan for Emergency Care and Intensity of Treatment document dated [DATE], documented she was a full code meaning she wanted CPR to be initiated on her if needed. Resident #4's care plan dated [DATE], documented she was a DNR and did not want CPR initiated if needed.On [DATE] at 8:45 AM, the DON stated Resident #4's care plan was completed in error and should have been revised but had not been.

Based on observation, record review, and interview, it was determined the facility failed to ensure physician's orders were followed. This was true for 1 of 2 residents (Resident #11) whose physician's orders were reviewed. This had the potential for adverse effects and possible harm to resident's medical and physical status. Findings include:Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including dementia and chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness).On 6/8/26 at 9:15 AM, Resident #11's physician order documented, oxygen per nasal cannula continuous. two times a day for COPD Titrate oxygen levels to maintain between 88-92%. Sats not to exceed 92%.Resident #11's medical record SpO2 monitoring documented desaturations below 88% without interventions on the following dates.- 5/23/26 at 4:27 PM - 87% SpO2 on room air- 5/16/26 at 10:20 AM - 87% SpO2 on room airResident #11's medical record documented the following while on supplemental oxygen the SpO2 exceeded 92% without any nursing intervention.- 5/29/26 at 7:17 PM - 96% on supplemental oxygen- 5/29/26 at 9:26 AM - 96% on supplemental oxygen- 5/29/26 at 7:06 AM - 96% on supplemental oxygen- 5/27/26 at 9:26 AM - 95% on supplemental oxygen- 5/18/26 at 7:44 PM - 95% on supplemental oxygen- 5/7/26 at 7:19 PM - 98% on supplemental oxygen- 5/7/26 at 9:27 AM - 97% on supplemental oxygen- 5/6/26 at 7:09 PM - 97% on supplemental oxygenResident #11's nurse progress notes documented high SpO2 while on supplemental oxygen therapy without any interventions documented.- 5/7/26 at 4:17 PM - 97% SpO2, O2 saturation assessed and resident sating at 97% with 2 L NC. - 5/7/26 at 10:36 PM - 98% SpO2, O2 sats on 2 L/NC, out to dinner with peers. On 6/9/26 at 3:00 PM, the DON stated Resident #11's SpO2 should have been better monitored and the physician's oxygen order more closely followed by staff and was not.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were treated with dignity. This was true for 1 of 1 resident (Resident #3) reviewed for foley catheters. This deficient practice placed Resident #3 at risk of embarrassment and diminished sense of worth. Findings include:The facility's Promoting/Maintaining Resident Dignity policy, dated 1/15/26, documented 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.Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke) and urinary tract infection.On 6/8/26 at 8:12 AM, observed from outside Resident #3's room, his foley catheter bag hanging on the side of his bed without a cover.Resident #3's care plan dated 9/12/25, documented he had a foley catheter related to a diagnosis of neurogenic bladder.On 6/8/26 at 8:17 AM, CNA #1 stated Resident #3's foley catheter bag should have been covered since his door was open.On 6/9/26 at 2:32 PM, the DON stated she never thought that the catheter should have been covered when in the room with the door open and yes, it was a privacy issue.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a written notice of transfer and bed hold policy was provided to the resident or their representative when residents were transferred to the hospital. This was true for 1 of 1 resident (Resident #4) reviewed for transfers. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility. Findings include:The facility's Bed Hold policy dated 2/1/18, documented two written notices of this bed hold policy and procedures will be issued to the resident, family member, or legal representative. The first notice will be given upon admission. The second notice of this bed hold policy will be given to residents at their time of transfer for hospitalization.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities) and depressive disorder.On 6/8/26 at 11:32 AM, Resident #4's medical record had no documentation of a written bed hold form being completed when she was transferred to the hospital on 2/23/26.On 6/9/26 at 9:05 AM, the Social Worker stated she had not completed a bed hold document for Resident #4 when she was transferred to the hospital in February 2026 and she should have.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure person-centered comprehensive care plans were developed and implemented to address residents' needs. This was true for 6 of 12 residents (#1, #2, #9, #11, #15, and #120) whose care plans were reviewed. This failure created the potential for harm should residents receive inappropriate or inadequate care. Findings include: The facility's Care Plans policy, dated 1/1/24 documented the care plan for each resident at the facility would be individualized according to each resident's needs or wants as much as possible. 1. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. Resident #1 physician's order documented the following: - Risperidone (antipsychotic) 0.5 mg by mouth two times a day, ordered 1/24/25 - lorazepam (antianxiety) 0.5 mg by mouth at bedtime related to anxiety disorder, ordered 1/17/25. - Monitor and document her behavior: . yelling and 2. restlessness and to provide interventions such as: a. activities b. puzzles and word searches. Resident #1's care plan revised 7/31/24, documented she had behavior issues of loud rumination (repeating the same thing over and over) related to her dementia. Sometimes this disrupts group activities such as meals and games. Resident #1's care plan goal was to document her behavior daily on behavior monitor. Resident #1's April and May 2025 Behavior monitor documented she was being monitored for the following behaviors: paranoia, hallucination, delusion, verbal aggression, repetitive anxious statements, agitation, and getting up without assistance. These behaviors were not documented in Resident #1's care plan. On 5/28/25 at 3:01 PM, the LSW stated Resident #1 was being monitored for paranoia, hallucination, delusions, and verbal aggression. When asked if these behavior were in the care plan, LSW then reviewed Resident #1's care plan and stated No. The LSW stated Resident #1's behaviors that was being monitored were not in the care plan and it should be in the care plan. 2. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including dementia, urinary tract infection and chronic pain. A care plan initiated on 11/2/23, documented Resident #2 was taking an antidepressant and directed staff to encourage her to read, go outside, knit or join in group activities when she shows signs of increased sadness. The care plan also directed staff to monitor her for adverse side effects and report if suspected. The care plan did not identify what side effects the staff should monitor. Resident #2's April and May 2025 Behavior monitor documented she was being monitored for the following behaviors: increased sadness, sleeping a lot and overeating. These behaviors were not documented in her care plan. On 5/28/25 at 2:25 PM, LSW stated Resident #2's behavior of sleeping a lot and overeating were not documented in the care plan. The LSW also stated the care plan should document what side effects the staff should monitor. 3. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including aphasia ((an impairment of language due to brain injury, affecting the production or comprehension of speech and the ability to read or write) following a stroke. A care plan initiated on 5/2/24, documented Resident #15 was on psychotropic medication for her anxiety and depression. Resident #15's symptoms documented the following anger and talking slow or low and I stop talking. The care plan did not indicate Resident #15 was to be monitored for adverse side effects of her psychotropic medication. Resident #15's April and May 2025 Behavior monitor documented she was being monitored for the following behaviors: snappy, short tempered, forgot she was given her medications, and air hunger anxiety. These behaviors were not documented in her care plan. On 5/28/25 at 2:55 PM, the LSW stated Resident #15's behaviors of being snappy and short tempered and having air hunger were not documented in her care plan and it should be in her care plan. The LSW also stated Resident #15's care plan did not document she was to be monitored for adverse side effects of her psychotropic medication. 48402 4. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, anxiety, and major depressive disorder. Resident #11's care plan dated 7/18/24, did not identify she had bipolar, anxiety or depression. On 5/29/25 at 9:19 AM, the LSW stated Resident #11's care plan did not include documentation of interventions or mood and behavior triggers. The LSW also stated Resident #11 was a trauma survivor, but her care plan does not document triggers. 5. Resident #120 was admitted to the facility on [DATE], with multiple diagnoses including brain abscess, swelling of the brain, and seizures. A fall assessment dated [DATE], documented Resident #120 was identified a moderate risk for falls. Resident #120's record documented he had a history of falls at home. An incident report dated 5/11/25, documented Resident #120 had a witnessed fall while trying to get his glasses from the floor. Resident #120's care plan did not include documentation of fall preventions or interventions. On 5/29/25 at 1:39 PM, the DON stated the care plan should have reflected the risk for falls and should have been revised on 5/11/25 after his last fall. 6. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including protein-calorie malnutrition, malignant neoplasm, and history of falls. An Admission MDS assessment dated [DATE], documented Resident #9 had bed rails used daily. Resident #9's care plan did not include documentation indicating she used bed rails. On 5/29/25 at 9:46 AM: The LSW stated, Resident #9's care plan did not include the bedrails she used daily however, it should have.

Based on staff interview, it was determined the facility failed to ensure there was a qualified dietary manager with required competencies and skills. This deficient practice had the potential to affect all the 20 residents residing in the facility who received food from the kitchen. Findings include: On 5/29/25 at 12:38 PM, the DM stated she started in the facility working as a dietary manager about five weeks ago. She stated she did not have the certification yet, but she registered herself to take the classes to become a certified dietary manager. The DM stated she was being supervised by their Registered Dietitian and is in constant communication with him/her. On 5/29/25 at 2:13 PM, the DON stated the Dietary Manager was not certified, but she is being supervised by their Registered Dietitian. When asked if the facility had a full-time dietitian, the DON stated No. The Registered Dietitian visits the facility at least once a week

Based on observation and staff interview, it was determined the facility failed to ensure kitchen staff wear their hair restraints appropriately and discard outdated food items in the kitchen. These deficiencies had the potential to affect the 20 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food borne illnesses. Finding include: 1. The FDA Food Code 2022, Section ,d+[DATE].11 Effectiveness. (Hair Restraints) states except as provided in paragraph (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-serve and single-use articles. On [DATE] at 12:10 PM, the Dietary Aide #1 was observed in the kitchen with her hair not completely restrained to cover her bangs and the hair around her face. On [DATE] at 2:24 PM, the Dietary Manager stated Dietary Aide #1 should have worn her hair restraint to completely cover her hair. 2. An initial kitchen inspections was conducted on [DATE] at 10:58 AM, with Dietary Aide #2. The following were observed: - 2 Hershey Syrup with best by date ,d+[DATE] - 1 Hershey Syrup Zero Sugar with best by date ,d+[DATE] - 1 Farmer Brothers Seasoning dated [DATE] - Taco mix - expiry date of [DATE] - Soup Base - undated A second kitchen inspection was conducted on [DATE] at 12:38 PM with Dietary Aide #1. The following were observed: - 1 Hershey Syrup with best by date ,d+[DATE] - 1 Hershey Syrup with best by date ,d+[DATE] - 2 bags of flour tortilla expired on [DATE] - 4 bags of spinach tortilla with best by date [DATE] - 1 bag of corn tortilla expired on [DATE] - 1 bag of corn tortilla expired on [DATE] On [DATE] at 1:00 PM, The Dietary Manager was informed of the above items expiry date and best by date, and stated the food items should not be in the kitchen and should be discarded.

Based on facility document review, and staff interview, it was determined the facility failed to ensure the Quality Assessment and Assurance (QAA) committee took actions to identify and resolve systemic problems. This failure affected 20 of 20 residents residing in the facility. The deficient practice resulted in failure to report resident assessments and comprehensive care planning which had the potential for adverse outcomes when residents' needs were not identified. Findings include: The facility's QAPI plan revised on 1/2/24, directed the QAPI committee to do the following: - Include all departments and employees in the plan. - Maintain a comprehensive, effective system for monitoring and evaluating. - Assure patient care is provided at an optimal level. - Focus on improving systems and processes using a systemic approach. - Increase communication and transparency of corrective action to improve processes and systems facility wide. - Develop criteria for identifying causes with potential risks and correcting the problem. - Protecting financial resources The facility's Long-Term Care performance improvement plan (PIP) documents the following identified concerns: - Medication audits to reduce medication errors - see F760 - Timely completion of Minimum Data Set (MDS) - see F640 - Care plan and Resident Assessment - see F656 and F657 On 5/30/25 at 1:08 PM, the Administrator and the DON stated the QAPI committee conducts a monthly review of audits. The facility utilizes different departments for different perspectives. The DON stated she is not able to provide measurements of improved PIP's. She also stated she bases her achieved percentage on the number of incidents that occurred during the prior month but does not have a way to track the improved performance plan.

Based on record review, staff interview, and review of the RAI manual, it was determined the facility failed to ensure MDS assessments were completed and reported timely. This was true for 7 of 9 residents (Resident #1, # 6, #9, #11, #12 #13, #120) reviewed for encoding and transmitting resident assessments. This failure created the potential for harm and inaccuracy of assessments when residents were not assessed timely to identify their needs. Findings include: The RAI manual, dated October 2024, version 1.19.1, documented the ARD must be within 92 daysafter the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCQA, or Annual assessment + 92 days). 1. Resident #9 was admitted to the facility on [DATE], with multiple diagnosis including malnutrition, seizures, and history of falling. Resident #9's Admission MDS assessment dated [DATE], was transmitted to CMS database, but her Quarterly MDS assessment documented an ARD of 1/13/26, it was 31 days overdue. 2. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, anxiety, and major depressive disorder. Resident #11's Quarterly MDS assessment dated [DATE], was transmitted to CMS database, but her Annual MDS assessment with ARD of 4/17/25 was not completed, it was 28 days overdue. 3. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including constipation, muscle weakness, and diabetes mellitus. Resident #12's Annual MDS assessment dated [DATE], was transmitted to CMS database, but his Quarterly MDS assessment with ARD of 3/24/25 was not completed, it was 52 days late. 4. Resident #120 was admitted to the facility on [DATE], with multiple diagnoses including, seizures, swelling of the brain and brain abscess. Resident #120's Admission MDS assessment with ARD of 5/1/14 was not completed, it was 21 days overdue. On 5/29/25 at 11:58 AM, the DON stated, we are not reporting the assessments to CMS, we have no excuse, we are behind. 36193 5. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. Resident #1's Quarterly MDS assessment, dated 1/20/25 was transmitted to the CMS database. but her Quarterly MDS assessment with ARD of 4/22/25 was not transmitted, it was 23 days overdue. 6. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Huntington's disease (a neurological disorder that affects a person's movements, thinking ability, and mental health, with symptoms often including chorea, which are rapid, involuntary movements of the limbs and face). Resident #6's Quarterly MDS assessment, dated 1/23/25 was transmitted to CMS database, but her Quarterly MDS assessment with ARD of 4/25/25 was not completed, it was 20 days overdue. 7. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including dementia. Resident #13's Annual MDS assessment dated [DATE] was transmitted to CMS data base, but her Quarterly MDS assessment with ARD of 5/18/25 was not completed, it was 11 days overdue. On 5/29/25 at 11:58 AM, the DON stated, we are not reporting the assessments to CMS, we have no excuse, we are behind.

Based on record review and staff interview, it was determined the facility failed to ensure residents' assessments accurately reflect their status. This was true 4 of 12 residents (#2, #11, #16, and #17) whose bedrails were assesed as a restraint. This created the risk for harm when residents' were not accurately assessed. Findings include: 1. Resident #17 was admitted to the facility on [DATE], with a diagnosis of adult failure to thrive (a decline in overall health and functional abilities). Resident #17's Quarterly MDS assessment dated [DATE], documented he used his bed rails daily under section P- Restraints Resident #17's care plan dated 8/19/24, documented his bed rails were used for mobility. It also documented that he has been informed of the risk of using side rails. A bed rail assessment dated [DATE], documented the bed rails would be used for improved independence. 2. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, anxiety, and major depressive disorder. Resident #11's care plan dated 7/18/24, documented she may have her bed rails up or down as desired. Her care plan also stated she would be evaluated quarterly and if she obtained an injury related to the bed rails they may have to be removed. A Quarterly MDS assessment dated [DATE], documented she used her bed rail daily under section P- Restraints A Side Rail assessment dated [DATE], documented the bed rail was not used for mobility or independence. It also documented Resident #11 was not able to use the bed control. On 5/29/25 at 11:58 AM, The DON and LSW stated, the MDS was coded incorrectly as Resident #9, #11, and #17 do not use bed rails as a restraint. 3. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including dementia,urinary tract infection and chronic pain. Resident #2's Quarterly MDS assessment dated [DATE], documented she use a bed rail daily under section P - Restraints. Resident #2's Initial Side Rail assessment dated [DATE], documented she used the side rail to improve her mobility and independence, and she is able to use the bed controls. Resident #2's care plan, initiated 9/4/24 documented she was using two side rails in bed for mobility. The care plan also documented Resident #2 and her POA were aware of the dangers of using a side rail and they have signed a consent. On 5/29/25 at 9:44 AM, the DON stated Resident #2 uses the side rail as a mobility aid and it was not restraining her movement in bed. The DON stated Resident #2 was coded as using a restraint in her MDS because she used the side rail daily and she did not want to falsify her record by documenting she was not using a side rail. 4. Resident #16 was admitted to they facility on 10/1/24, with multiple diagnoses including Alzheimer's disease and apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked) following stroke. Resident #16's Initial Side Rail assessment dated [DATE], documented he used the side rail to improve his mobility and independence, and he is able to use the bed controls. Resident #16's care plan, initiated 2/2/24, documented he used one side rail for his repositioning. On 5/29/25 at 9:44 AM, the DON stated Resident #16 uses the side rail as a mobility aid and it was not restraining Resident #16 movement in bed. The DON stated Resident #16's was coded as using a restraint in his MDS because he used the side rail daily and she did not want to falsify his record by documenting he was not using the side rail. 36193

Based on observation and staff interview, it was determined the facility failed to ensure resident's right to privacy was maintained during cares. This was true for 1 of 1 resident (Resident #6) observed during cares. This deficient practice placed Resident #6 to experience embarrassment and psychosocial distress if her body was exposed to others unnecessarily. Findings include: The SOM Appendix PP, dated 4/25/25, documented each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy or not only his or her own physical body, but of his or her personal space, including accommodations and personal care. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Huntington's disease (a neurological disorder that affects a person's movements, thinking ability, and mental health, with symptoms often including chorea, which are rapid, involuntary movements of the limbs and face). On 5/28/25 at 2:08 PM, LPN #2 provided wound care to Resident #6's bottom. Resident #6 was in bed with her shorts down to her knees exposing her periarea as she moved from lying on her back to her side. The window blind was open as LPN #2 continued to complete Resident #6's wound care. On 5/28/25 at 2:16 PM, LPN #2 stated I should have closed the blinds before performing her wound care.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 1 of 12 residents (Resident #16) whose care plan was reviewed. This created the potential for Resident #16 to experience harm if cares and services were not provided appropriately due to inaccurate information in his care plan. Findings include: Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked) following stroke. The facility's Care Plans policy, dated 1/1/24 documented residents' care plans will be reviewed quarterly, annually, and with change of status to ensure that they are current for the residents' care. An I&A report documented the following: - On 3/15/25 at 4:10 PM, Resident #16 had an unwitnessed fall with no injury. The I&A documented he continued to get out of his bed, and it was recommended for Resident #16 that he may need an alarm placed on for safety. - On 3/20/25 at 4:30 PM, Resident #16 had an unwitnessed fall with no injury. The I&A documented his tab alarm was on. Review of Resident #16's care plan did not document he had a tab alarm. On 5/29/25 at 9:13 AM, the DON reviewed Resident #16's care plan and stated she did not find the tab alarm on his care plan, only just leave the call button within reach was in his care plan. The DON stated Resident #16's care plan should have been updated to include the tab alarm in his care plan when it was placed after his fall.

Based on record review, and staff and resident interview, it was determined the facility failed to ensure professional standards of care were followed for 1 of 12 residents (Resident #69) reviewed for quality of care. Resident #69's physician's order was to restrict his fluid intake to 1,500 ml was not followed. This deficient practice had the potential to adversely affect or harm Resident #69 when his fluid intake was not restricted or monitored. Findings include: Resident #69 was admitted to the facility on [DATE], with multiple diagnoses including Syndrome of Inappropriate Secretion of Antidiuretic Hormone (a condition in which the body retain too much water and commonly leads to hyponatremia which is low levels of sodium in the blood). A physician's order, dated 12/9/23, documented Resident #69 was on 1,500 ml of fluid restriction. A care plan initiated on 11/26/24, documented Resident #69 was on fluid restriction of 1,500 ml, on which the kitchen would supply 1,200 ml and leaves him with 300 ml of other fluids. On 5/28/25 at 11:43 AM, Resident #69 stated he was on fluid restriction. When asked how much water was he allowed to have, Resident #69 did not answer. Review of Resident #69's 5/17/25 - 5/29/25 total fluid intake documented he has taken more than 1,500 ml of fluid on the following dates: - 5/17/25 = 1,780 ml - 5/18/25 = 1,560 ml - 5/19/25 = 1,840 ml - 5/20/25 = 1,800 ml - 5/21/25 = 1,530 ml - 5/22/25 = 2,220 ml - 5/24/25 = 1,620 ml - 5/25/25 = 1,740 ml - 5/26/25 = 1.740 ml - 5/27/25 = 1,770 ml - 5/28/25 = 1,510 ml - 5/29/25 = 1,320 ml On 5/30/25 at 11:31 AM, the DON stated Resident #69 was on 1,500 ml of fluid restriction. The DON reviewed Resident #69's fluid intake record and stated Resident #69 was difficult to control on his fluid intake. She stated we should have monitored him more closely to ensure he is only taking his required fluid requirement.

Based on record review and staff interview it was determined the facility failed to ensure residents were properly assessed for bed rails. This was true for 3 of 9 resident (Resident #1, #9, and #11) whose records were reviewed for bed rails. This failure created the potential for harm when residents were not assessed for entrapment. Findings include: The facility's Side Rail Used/ Restraint Policy, dated 2/15/17, documented all residents requiring side rails, will be given a risks vs. benefits of side rail use form to review and a consent form. Residents will have a side rail use assessment completed quarterly with their MDS reporting and with any changes in their status. 1. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including malnutrition, breast cancer, and history of falls. On 5/27/26 at 1:56 PM, Resident #9 was observed resting in bed comfortably with the left side of her bed against the wall and a bed rail on the right side. A request for bedrail assessment and risk vs. benefits was requested and not provided. 2. Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, major depressive disorder, and muscle weakness. Resident #11's care plan dated 7/18/24, documented she may have her bed rails up or down as desired. Her care plan also stated she would be evaluated quarterly and if she obtained an injury related to the bed rails they may have to be removed. A Side Rail assessment dated [DATE], documented the following: 1. Will side rails be used for mobility? No 2. Will side rails be used for improved independence? No 3. Will resident be able to use the bed controls? No 4. Are side rails in good working order? NA 5. Are side rails installed correctly and safely? 6. Does the resident request the side rails are up when in bed? No 7. Is there any potential or risk for resident to have extremities caught on side rails? NO 8. They have been assessed and are safe to be used with this resident? No 9. If side rails will be used has the resident and family been informed of use such as upper injuries from falls and lim[bs] being caught in rails.- No On 5/29/25 at 5:35 PM, the DON and LSW stated the prior DON had assessed residents for bed rails but did not document the assessments correctly. However, none of the bed rails are currently used as a physical restraint. 36193 3. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. On 5/28/25 at 10:40 AM, Resident #1 was observed in bed with one side rail in raised position. Resident #1's Side Rails Assessment form, dated 10/10/22, documented the following assessment/questions and next to it was Yes and No column: 1. Will side rails be used to improve mobility? 2. Will side rails be used to improve independence? 3. Will resident be able to use the bed controls? 4. Will the side rails in good working order? 5. Are the side rails installed correctly and safely? 6. Does the resident request the side rails are up when they are in bed? 7. Is there any potential or risk of the resident their extremities caught in the side rails? 8. They have been assessed and are safe to be used with this resident? 9. If side rails will be used, has resident and family been informed of risks of use such as upper injuries from falls and lim[bs] being caught in rails? Assessment/question #1, #2, #3, #4, #5, #6, and #8 had a check mark on the No column and assessment #9 has NA on the Yes column. The facility was unable to provide documentation that Resident #1 was assessed quarterly for her side rail use. On 5/29/25 at 2:15 PM, the DON with the LSW present reviewed Resident #1's Side Rails Assessment. The DON stated she did not know why the assessment was filled out incorrectly. The LSW stated it was not filled out appropriately.

Based on observation, policy review, record review, and staff interviews, it was determined the facility failed to ensure residents did not develop recurrent avoidable Stage II pressure ulcers, treatment of [REDACTED]. This was true for 1 of 2 residents (Resident #6) reviewed for pressure ulcers. Resident #6 was harmed when she developed a recurrent Stage II pressure ulcer to her right buttock and her physician was not notified. Findings include: The facility's Policy and Procedure for Skin Assessments and Treatment, dated 4/21/14, documented: *Residents were to receive weekly skin assessments, institute preventive measures as necessary, and monitor the healing of pressure sores, skin tears, abrasions, and bruises. * A resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. * A resident having pressure sores received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. *An avoidable pressure ulcer meant the resident developed a pressure ulcer and the facility did not evaluate the resident's clinical condition, implement interventions or revise the interventions as appropriate. *A pressure sore was defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue and they were staged to classify the degree of tissue damage observed. * Stage I pressure sores are not open wounds. They may be painful, appear reddened, do not blanch (lose color briefly when you press your finger on it then remove your finger), and can feel either firmer or softer than the area around the sore. *Stage II sores are broken open, worn away, or form an ulcer, which is usually tender and painful. The sore expands into deep layers of skin, can look like a scrape, blister, or shallow crater in the skin. At this stage, some skin may be damaged beyond repair and die. *If skin breakdown was noted the resident's physician was notified. Any treatment was to change to what the doctor ordered immediately after the order was given. *Pressure sores will be documented on every shift, and whenever any changes or problems occur; when a pressure sore or strong potential for a pressure sore has been identified the treatment plan shall be implemented, the goals of treatment include keeping the physician informed of progress of healing and the physician's orders [REDACTED]. *Interventions for pressure sores included the licensed nurse was to monitor all wounds every shift. *The skin licensed nurse team was to evaluate wounds weekly and as needed, and document location, stage, length, width, color, treatment, progress, and any wound condition changes. The Lippincott Manual of Nursing Practice, tenth edition, directs nurses to stage pressure ulcers so appropriate treatment can be started by following the staging system of the National Pressure Ulcer Advisory Panel which includes Stages I-IV, Unstageable and Suspected Deep Tissue Injury. The National Pressure Ulcer Advisory Panel website (www.npuap.org), accessed on 9/11/19, defines Stage I and Stage II pressure injuries as follows *Stage I - Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness), which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. *Stage II - Partial-thickness loss of skin with exposed dermis (thick layer of living tissue below the top of the skin that contains blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Resident #6 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #6's care plan, dated 4/2/19, directed staff to turn/reposition and change Resident #6 at night every 2-3 hours and as needed. The care plan did not document specific nursing care for Resident #6's pressure ulcer. Resident #6's annual MDS assessment, dated 6/23/19, documented she was severely cognitively impaired and required extensive physical assistance of two or more persons with bed mobility, transfers, walking, toilet use, and personal hygiene. The MDS documented Resident #6 was at risk of developing pressure ulcers and did not have an unhealed pressure ulcer. A Skin Observation Assessment Tool, dated 6/21/19 at 8:24 AM, documented to See nurse's notes. The tool included areas to document the site, type, length, width, depth, and stage of the wound. These areas were not completed. A Nursing Progress Note, dated 6/21/19 at 8:25 AM, documented Resident #6 had a thin skinned area to her upper right inner buttock, and the area was not open. Further description including stage, length, width, color, and treatment of [REDACTED]. A Nursing Progress Note, dated 6/28/19 at 9:11 AM, documented Resident #6 had a small thin skinned area to her left inner buttock and a large thin skinned area to her right inner buttock, and they were cleaned well, and barrier cream was applied. Further description including an identifying number for each area, and the stage, length, width, and color of the 2 areas and the surrounding tissue were not documented. Further documentation regarding the thin-skinned area on Resident #6's left inner buttock was not found in subsequent skin assessments or Nursing Progress Notes. A Nursing Progress Note, dated 6/30/19 at 5:26 PM, documented Resident #6 had a small open sore to her right buttock which was cleaned, barrier cream was applied, and the nurse left Resident #6's buttock open to air with a pillow under her. The progress note documented the dressing of the wound was deferred to the night shift nurse to apply. Further description including stage, length, width, color, and progress of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 7/1/19 at 4:29 PM, documented Resident #6 was laid down, turned and repositioned since scab to right buttocks was still visible, not bleeding, not open, and barrier cream application was continued. Further descriptions of the open sore and surrounding area were not documented. A Skin Observation Assessment Tool, dated 7/5/19 at 8:29 AM, documented to See nurse's notes. The site, type, and dimensions for length, width, depth and the stage of the observed wound were not documented. A Nursing Progress Note, dated 7/5/19 at 8:33 AM, documented Resident #6's right inner buttock had a 1 cm diameter open area, the wound bed was pink with flat edges, and there was minimal serosanguinous drainage (contains both blood and a clear yellow liquid). The wound was cleaned well with normal saline, covered with [MEDICATION NAME] border lite (self- adherent dressing that absorbs drainage and maintains a moist wound environment), and barrier cream was applied to the buttocks. Further description of stage, length, width, depth, and color of the open sore and surrounding area were not documented. A Nursing Progress Note, dated 7/6/19 at 4:36 AM, documented Resident #6's right buttock had a 1 cm open area and it was cleaned, antibiotic ointment was applied, and barrier cream was applied and secured with [MEDICATION NAME] dressing. The dressing was dated. Resident #6 was repositioned after meals and at bedtime from side to side off her buttocks. Further description of the open sore and of the surrounding area were not documented. A Nursing Progress Note, dated 7/6/19 at 4:54 PM, documented Resident #6's right buttock still had a [MEDICATION NAME] dressing and she was repositioned after meals and at bedtime from side to side off her buttocks, and staff would continue to monitor. Further description of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 7/8/19 at 5:03 PM, documented barrier cream was applied to Resident #6's small open area on her right inner buttock and staff would continue to monitor. Further description of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 7/9/19 at 1:07 PM, documented Resident #6 had a small red area on her right inner buttock. The area was not open and was healing. The area was cleansed, and zinc was applied. Further description of the sore and the surrounding area were not documented. A Skin Observation Tool, dated 7/12/19 at 8:44 AM, documented to See nurse's notes. The site, type, and dimensions for length, width, depth, and the stage of the observed skin conditions were not documented. A Nursing Progress Note, dated 7/12/19 at 8:46 AM, documented Resident #6 had a ½ cm x ¾ cm open area to her right upper inner buttock, with flat edges, the wound bed was pink, and no foul odor was noted. The note documented the wound was cleaned well and [MEDICATION NAME] lite border dressing was applied. Further description including the stage of the open sore, depth of the sore, and specific description of surrounding area were not documented. A Nursing Progress Note, dated 7/13/19 at 9:13 AM, documented continued treatment of [REDACTED].#6's right upper inner buttock, with no foul odor, and the [MEDICATION NAME] border dressing was still intact. Further description of the open sore and the surrounding area were not documented. Notification of Resident #6's physician regarding the wound was not documented. A Nursing Progress Note, dated 7/14/19 at 4:00 AM, documented Resident #6 had an open area on her right inner buttock which was cleaned, zinc cream applied, a [MEDICATION NAME] dressing was not in place, and Resident #6 continued to be repositioned from side to side. Further description of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 7/14/19 at 10:25 AM, documented Resident #6's open area on her right inner buttock had no foul odor, was cleaned well, and a [MEDICATION NAME] lite border dressing was applied. Further description of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 7/15/19 at 3:23 PM, documented a soiled [MEDICATION NAME] dressing was removed from Resident #6's right inner buttock, the open area was cleansed, and zinc ointment was applied, with no signs and symptoms of infection. Resident #6 was frequently turned at least every 2 hours. Further description of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 7/16/19 at 5:37 PM, documented Resident #6's right inner buttock was cleansed, zinc ointment was applied, and the wound was left to open air. Further description of the open sore and the surrounding area was not documented. A Nursing Progress Note, dated 7/17/19 at 12:09 AM, documented zinc paste was applied to Resident #6's coccyx area (tailbone). Further description including stage, length, width, depth, color, and progress of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 7/18/18 at 1:17 AM, documented Resident #6 was kept dry and zinc was applied to the open area of her right buttock. Further description of the open sore and the surrounding area were not documented. A Skin Observation Tool, dated 7/18/19 at 6:58 AM, documented to see nurse's notes. The site, type, and dimensions for length, width, depth and the stage of the observed wound(s) were not documented. A Nursing Progress Note, dated 7/18/19 at 7:00 AM, documented Resident #6's small area to right inner buttock where skin had been open was now closed but still thin skinned, and the area was cleaned well, and barrier cream was applied. Further description of the wound and surrounding area was not documented. A Nursing Progress Note, dated 7/18/19 at 10:23 AM, documented the skin nurse assessed Resident #6 this morning and findings were: Resident #6's right inner buttock upper area was resolved with only thin skin. The area was cleaned, barrier cream applied, and Resident #6 was being turned side to side. Further description of the area and surrounding tissue were not documented. Nursing Progress Notes, dated 7/19/19 to 7/24/19, 5 notes total, documented Resident #6 had zinc cream applied to her resolved right buttock open site, the area appears closed, continues to resolve, and is resolved were used to describe the wound. Further description of the wound and surrounding area was not documented. A Skin Observation Tool and Nursing Progress Note, each dated 7/26/19, did not include documentation of Resident #6's buttock wound. A Nursing Progress Notes, dated 7/27/19 at 1:05 AM, documented Resident #6's open area on her right buttock had resolved. Further description of the area was not documented. A Skin Observation Tool, dated 8/2/19 at 7:48 AM, did not document the condition of her right buttock area. A Nursing Progress Note, dated 8/2/19 at 12:13 PM, did not document the condition of her right buttock area. A Nursing Progress Note, dated 8/9/19 at 10:58 AM, documented Resident #6's pannus area had redness and splits on both sides. The note did not document the condition of the skin on her right buttock. A Skin Observation Tool, dated 8/9/19 at 4:09 PM, documented Resident #6 had no skin issues and her skin was clean, warm, pink, and dry. The documentation on the Skin Observation Tool conflicted with the documentation in the Nursing Progress Note completed on the same day. A Skin Observation Tool, dated 8/16/19 at 7:53 AM, documented Resident #6 had clean, dry, and intact pink skin. The note did not document the condition of the skin on her right buttock. A Nursing Progress Note, dated 8/16/19 at 7:54 AM, documented treatment of [REDACTED]. Resident #6's record did not include documentation of the condition of the skin on her right buttock from 7/28/19 through 8/22/19, 26 days. A Skin Observation Tool, dated 8/23/19 at 7:57 AM, documented a .5 x 1.25 cm purplish red thin skinned area to Resident #6's right inner buttock. The area was cleansed, and barrier cream was applied. Further description was not documented. The site, type, and dimensions for length, width, and stage of the observed area were not documented. A Nursing Progress Note, dated 8/23/19 at 2:10 PM, documented Resident #6 had purplish thin skin area on the right buttock, barrier cream was applied, and the plan was for Resident #6 to lay down between meals. Further description including stage, length, width, and color of the wound and surrounding area were not documented. Treatment applied to the area was not documented. A Nursing Progress Note, dated 8/26/19 at 2:18 AM, documented to continue to monitor Resident #6's Coccyx area, she was turned every two hours, and ointment to her buttocks was applied at every change of her incontinence brief. Further description of the wound and surrounding area was not documented. A Nursing Progress Note, dated 8/28/19 at 3:51 PM, documented Resident #6 had an open area on the right side of her coccyx, barrier cream was applied, she was laid down between meals, and repositioned from side to side. Further description including stage, length, width, depth, and color of the wound and surrounding area were not documented. A Nursing Progress Note, dated 8/29/19 at 12:58 AM, documented Resident #6 was sleeping on her side off the thinning scar of her coccyx and staff repositioned her side to side between incontinent brief changes. Further description including stage, length, width, and color of the wound and surrounding area were not documented. A Nursing Progress Note, dated 8/29/19 at 1:30 PM, documented continued monitoring of Resident #6's coccyx area, she was laid down after breakfast, and barrier cream was applied to her buttocks at every incontinence brief change. Further description including stage, length, width, and color of the wound and surrounding area were not documented. A Nursing Progress Note, dated 8/29/19 at 11:50 PM, documented Resident #6 was sleeping on her side off her buttocks, she was kept clean and dry between bedtime rounds, good peri care was provided, and zinc was applied to her buttocks and resolving open site of old scar. Further description including stage, length, width, depth, location, and color of the wound and surrounding area were not documented. A Nursing Progress Note, dated 8/30/19 at 1:20 AM, documented an open site. Her incontinence briefs were changed every 2 hours and peri care was provided, she was repositioned side to side, and zinc ointment was applied. Further description including stage, length, width, depth, color, and progress of the open sore and the surrounding area were not documented. A Skin Observation Tool, dated 8/30/19 at 8:31 AM, documented Resident #6 had a .5 x 1.5 cm purplish red area to her right inner buttock, with no drainage from the area, it was cleansed, and barrier cream applied. The type, depth, and the stage of the observed wound were not documented. A description of the surrounding area was not documented. A Nursing Progress Note, dated 8/31/19 at 12:29 AM, documented Resident #6 was turned side to side every 2 hours with continence brief changes, peri care was provided, and zinc was applied to her closing right buttock old open scar site. Further description including stage, length, width, depth, color, progress and location of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 9/1/19 at 4:40 PM, documented purplish open skin at Resident #6's right inner buttock, with barrier cream applied. Further description of the wound and surrounding area was not documented. A Nursing Progress Note, dated 9/3/19 at 2:08 PM, documented Resident #6 had an open skin area in her coccyx area which was cleansed, and cream applied. Further description of the open sore and the surrounding area were not documented. A Nursing Progress Note, dated 9/4/19 at 5:38 PM, documented an open skin area on Resident #6's coccyx area, the area was cleansed, cream was applied, and she was repositioned every 2 hours. Further description including stage, length, width, depth, color, and progress of the open sore and of the surrounding area were not documented. Resident #6's record, including the above Nursing Progress Notes and Skin Observation Tools, did not include documentation her physician was notified of the pressure wound on her right buttock area. Resident #6's wounds were not described and staged per the facility's policy to ensure objective data upon which to assess progress toward healing and the effectiveness of treatment. On 9/5/19 at 10:00 AM, CNA #1 and CNA #2 were observed providing incontinent care to Resident #6. CNA #1 and CNA #2 washed their hands and applied gloves and assisted Resident #6 into her bed to lay down. Resident #6 had an open wound in the upper part of the right gluteal cleft area (right buttock near the central crease) which measured 2 cm x 3.5 cm. The wound was red in the center with peeling skin around the right side. CNA #1 cleaned stool from Resident #6's peri-area with wipes, tucked the dirty brief under Resident #6 and placed clean briefs under her without changing her gloves after cleaning the per-area. CNA #1 then picked up the tube of barrier cream, squeezed cream onto her dirty gloves and applied the barrier cream to Resident #6's buttocks. CNA #1 did not change her gloves or perform hand hygiene after providing incontinent care to Resident #6 and before handling the clean briefs and applying the barrier cream. On 9/5/19 at 10:10 AM, CNA #1 and CNA #2 stated the wound was checked by the nurse once a week. When asked if there were any other treatments for the wound they stated no, just the barrier cream. On 9/5/19 at 10:30 AM, CNA #1 stated she should have removed her gloves, performed hand hygiene, and replaced with clean gloves before applying the barrier cream to Resident #6's buttocks and before handling new, clean briefs. On 9/6/19 at 10:53 AM, RN #1, the facility's designated wound care nurse, said she documented measurements in the progress notes or on the Skin Observation Tool. She stated she measured wounds weekly and said she did not document the measurements and she should be. RN #1 said she did not know how to describe the wounds using the correct terminology, or what to document. She stated she did not number the wounds when they were identified. She stated she did not notify Resident #6's physician about the right buttock wound. Nursing Progress Notes and Skin Observation Tools documented the skin on Resident #6's right buttock area opened and closed, as follows: 6/21/19 - 6/29/19, closed or thin-skinned 6/30/19 7/8/19, open sore or scab 7/9/19 - 7/11/19, closed or thin-skinned 7/12/19 - 7/18/19 at 1:17 AM, open sore 7/18/19 at 7:00 AM through 7/27/19, closed or thin-skinned 7/28/19 - 8/22/19, no documentation of the right buttock area 8/23/19 - 827/19, closed or thin-skinned 8/28/19 - 9/5/19, open sore Resident #6 was harmed when: *She developed an avoidable recurrent pressure ulcer to her right buttock. *Her physician was not notified of the pressure ulcer on her right buttock and wound care was provided to the pressure ulcer without a physician's orders [REDACTED].

Based on observation, staff interview and record review it was determined the facility failed to ensure 3 of 3 (#1, 6, 7) residents reviewed for pressure ulcers, did not have reoccurrence of pressure ulcers and preventive measures were implemented. Resident #6 was harmed when preventive measures were not implemented and the resident had a reoccurrence of 6 Stage 2 pressure ulcers to her coccyx. Resident #1 was harmed when preventive measures were not in place and she suffered the reoccurrence of a Stage 2 pressure ulcer. Resident #7 was harmed when a reoccurring Stage 2 pressure ulcer developed under his catheter tubing and a stage 2 pressure ulcer developed due to his incontinence brief. Additionally the resident's pressure relieving devices were not implemented. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual MDS dated [DATE], and Quarterly MDS dated [DATE], recorded: *Cognitive Skills for daily decision making- 3, Severely impaired- never/ rarely made decisions. *Rejection of cares: 0, behavior did not occur. *Bed mobility- 3-3, extensive assistance, 2 person physical assist. *Transfer- 3-3, extensive assistance, 2 person physical assist. *Functional Limitation ROM (Range of motion)- Upper extremity: 2, impairment on both sides. Lower extremity: 2, impairment on both sides. *Urinary incontinence- 2, frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding.) *Risk of pressure ulcers- Yes. *Unhealed pressure ulcers at Stage 1 or higher- No. *Moisture associated skin damage- Marked as present. The resident's Quarterly MDS dated [DATE], was the same with the following exceptions: *Transfer- 4-3, total dependence, 2 person physical assist. *Urinary incontinence- 3, always incontinent (no episodes of continent voiding). *Unhealed pressure ulcers at Stage 1 or higher- Yes. *Number of Stage 1 pressure ulcers: 1 *Were pressure ulcers present on the prior assessment: Yes. *Moisture associated skin damage- Not marked this assessment. NOTE: The resident had a decline in transfers, urinary continence, had a stage 1 pressure ulcer, with none in the 2 previous assessments. Moisture associated skin damage was not identified on the 3/18/14 assessment and was on the prior 2 assessments. The resident's Braden scale for predicting pressure sore risk dated, 9/21/13, 12/13/13, and 3/13/14, recorded the resident at "High Risk" for development of pressure sores. The resident's Narrative Care plan dated September 2013, recorded: *Page 6: "I am incontinent of both bowel and bladder. I require your assistance with every aspect of my toileting. I do wear disposable briefs to help maintain my dignity. Assist me to sit on the commode first thing in the morning, just before bed, before and after meals and PRN. Even if I am already incontinent when you check me assist me with sitting on the commode to see if I can void more." *Page 9, 10, 11: "Since I am incontinent and also non-ambulatory I am at greater risk for skin breakdown I am not able to reposition myself and also have no way of actually letting you know that I need to have my position changed. For over a year I have had a chronic area on my coccyx that gets macerated. Numerous treatments and interventions have been done and it will improve for a brief time but then develops again. The LN is following my physician orders [REDACTED]. During the day you need to change my position every 2-3 hours and at night I am able to go 3 hours without needing to be repositioned. Float my heels or use heel protectors on me when I am in bed or the recliner. Make sure that I have a pressure relieving pad in my wheelchair and that the air mattress on my bed is working." The resident's Physician Assistant (PA) progress note, PA orders, the wound or pressure sore identification and progress note (Skin Nurse PU progress note - SNPN) and the nurse's notes (NN) recorded: *PA orders: 12/3/13-"D/C (discontinue) [MEDICATION NAME] please." *PA orders: 12/10/13- "D/C [MEDICATION NAME]. Start CA Alginate to buttocks QD (with) dressing. [MEDICATION NAME] to skin PRN but QD at minimum." *PA note: 12/10/13 "Skin Fragile (with) Stage 1 coccyx." "Assessment & Plan 1) Skin Care-Fragile dishydrotic skin (with) overlay of immobility due to subtle breakdown of coccyx will start Calcium Alginate QD- due to long term [MEDICATION NAME]/Clortrimozole use may be weeks to resolution due to friability, [MEDICATION NAME] to skin (at) least QD." *SNPN: 12/14/13 "Coccyx" Size: "L(length) 1.5 cm (centimeter), W(width) (less than) 0.25 cm, D(depth) 0. Started out as a split." Stage: "Stage 1 per PA- DX (diagnosis)." Wound Bed: "Granulation 95%." Periwound: "Intact." *PA note: 12/17/13 Assessment and Plan: "1) Decubitus- Doing well (with) Silver Algonite however dressing not on when patient seen this morning. Will continue until resolution." *SNPN: 12/21/13 "Coccyx" Size: L. 1.5 cm, W. together." Stage: "Stage 1 per PA. Looks like split to me." Wound Bed: "Granulation 95%." Periwound: "Macerated. This area is frequently macerated in appearance. R/T (related to) increase moisture." Change in Plan & comments: "Continue as per PA order." *SNPN: 12/28/13 Size: "L 1.5 cm, W. 1.5 cm" Stage: "Stage 1." Wound Bed: "Granulation 25%." Periwound: "Macerated." response to treatment: "Continue as per MD order" NOTE: The orders were written by the PA. The resident had not been seen by the MD. Refer to F 387. *PA orders: 12/28/13 "[MEDICATION NAME] to affected areas (Buttocks legs - Arms." *PA note: 12/31/13 CC (Chief complaint): "Decubitus evolving to Stage 2-3 (with) Calcium Alginate unavailable (at) this time. Pt. (patient) has significant immobility and very sensitive skin (with) breakdown of coccyx area and long term topical steroid use (illegible). What was thought as dermatophysis- this was d/c'd and [MEDICATION NAME] started as no fungus seen and I support the steroid use precipitated skin breakdown. Initial Stage 1 now 2-3 while waiting Ca Alginate and continued incontinence. Has been side lying only." *SNPN: 1/4/13(sic -1/4/14): Size: L 1.5, W 2, D NA (not applicable)." Stage: "Stage 1" Wound Bed: "Granulation 50%" Periwound: "Intact. Macerated." Response to treatment: "Continue TX (treatment) per PA order." Change in plan (and) Comments: "filling in some." The Skin nurse documented a picture of the resident's coccyx, with an open wound. NOTE: The PA, on 12/31/13, 3 days earlier, staged the pressure ulcer as a Stage 2-3. The Skin nurse documented the wound as a Stage 1, with granulation tissue, and included a picture of the coccyx which documented an open wound. The wound had increased in size from 12/21/13 to 1/4/14; on 12/21/13 the width was "together," and on 1/4/14 was 2 cm. The PA documented on 12/17/13 the wound was doing better with Ca Alginate but the treatment was not in place when he saw the resident. *PA progress note: 1/14/14 Assessment /Plan/ Labs: "Decubitus 1) Healing nicely- Ag Alginate in use- Depth (decreased) No secondary infection seen." Plan -"Continue to resolution." *SNPN: 1/18/14 Size: "L 2 cm, W 6 cm, D 0." Stage: "Stage 1," Wound Bed: "Granulation 10%." Periwound: "macerated." Response to treatment: "Increasing in size." Change in plan (and) comments: "MD will be notified regarding need for new T. (treatment)." The Skin nurse documented 2 pictures of the resident's coccyx, with an open wound. *NN: 1/18/14 "(PA name) called (phone number). Stated buttocks looks more macerated and peeling. (PA name) said keep same Ca+ tx and he will re-eval(uate) on Tuesday Jan. 21, 2014." NOTE: The wound had increased in size from 1/4/13(14) to 1/18/14 from L 1.5 cm to L. 2 cm and width 2 cm to 6 cm. There was no documentation that the Skin nurse saw the resident between those dates, which was 2 weeks. The Skin nurse documented the MD would be notified; however, there was documentation that the PA, not the MD, was contacted. *NN: 1/19/14 10:52 am, "Coccyx area is improving--drying overnight OTA (open to air). *NN: 1/20/14 03:00 am, Repositioned Side to Side q 3 H (every 3 hours). coccyx clean / dry/ OTA (open to air)." NOTE: The resident's coccyx was OTA and turned every 3 hours. PA ordered treatment was not in place. *PA progress note: 1/21/14 CC: "review wound care. decubitus Stage II - III coccyx. Still (with) slow healing. Much of this due to body habitus (and) maceration of incontinence.- only side lying now Ag Alginate in use." Assessment/ Plan/ labs: "Decubitus A) will try [MEDICATION NAME] AG as Ag Alginate (with) no success. B) Side lying only." NOTE: On 1/18/14 the Skin nurse documented the MD would be notified regarding need for new treatment to the wound. There was no documentation that the MD was notified or responded. The PA addressed the wound 3 days later. *PA order: 1/21/14 "1) Stop Ag Alginate. Start [MEDICATION NAME] Ag to coccyx decubitus daily (and) PRN. 2) Vit C 1000 mg (milligram) p.o. (by mouth) BID (twice daily). 3) Side lying only please or prone if tolerated." *NN: 1/22/14 3:00 am, "Rt. (resident) repositioned side to side q 3 h. Coccyx kept clean and dry." *NN: 1/22/14 5:00 am, "Coccyx OTA." *NN: 1/22/14 11:00 pm, "Resident is resting, peri care complete, [MEDICATION NAME] applied to skin sore to inner crease of buttock, is looking smaller (and) less red." *NN: 1/24/14 11:00 pm, "Resident is resting, peri care complete, [MEDICATION NAME] applied to skin wound to buttock, is looking less less red (and) resolving." *SNPN: 1/25/14 Size: "L 2 cm, W 6 cm, D (with) 1 cm split (with) edges together." Stage: "Stage I looking better than last week." Wound bed: "Granulation 100%" Periwound: "Macerated slight." The Skin nurse documented a picture of the wound, and recorded: "PA 'cleaned' it up and changed the TX on 1/21/14." NOTE: NN documented the resident was being turned every 3 hours, the wound was being left OTA, and was improving. The Skin nurse documented no change in size of the wound from 1/18/14 to 1/25/14. *SNPN: 2/1/14 Size: "L 3/4 cm, W -, D -, split only" Stage: "Stage II" Change in plan & comments: "[MEDICATION NAME] to wound, keep dry." *PA progress note: 2/4/14 Assessment/ Plan/ Labs: Decubitus A) Healing (with) [MEDICATION NAME] AG, B) Maceration gone. C) Sidelying." *SNPN: 2/8/14 Size: 2.5 (and) 0.5 cm, W "0.75 (and) 0.25 cm, D 0 now is separated into 2 sores." Stage: "Stage II, Partial thickness" Response to treatment: "[MEDICATION NAME] Ag is working" Change in plan & comments: "No." *PA progress note: 2/18/14 CC "Decubitus has increased in size (and) depth. Stage III." Assessment/ Plan/ Labs: Decubitus of coccyx A) Stop [MEDICATION NAME] Ag. B) Start Flexigel QD. C) Limit [MEDICATION NAME] to buttocks fold. D) Debridement next week." *PA orders: 2/18/14 "D/C [MEDICATION NAME] AG. D/C [MEDICATION NAME] to buttocks creases. Start Flexigel (Hydrogel) to decubitus change QD (and)PRN" *SNPN: 2/22/14 Size: "Area L 7 cm, W 8 cm, D -, 3 sores (with) varying sizes." Stage: over total area, 1 sore separated = 3 sores." Wound bed: "Granulation 100%" Periwound: "Intact" Change in plan & comments.: "Continue as per PA orders." *PA order: 2/25/14 "May use [MEDICATION NAME] to areas around Flexigel PRN." *SNPN: 3/1/14 Size: "L 3 cm, W 3 cm, D 0, (no) split noted" Stage: "Stage I." Change in plan & comments: "Flexigel Drsg. continues." *SNPN: 3/8/14 Size: "L NA, W NA, D NA, no open areas or redness noted." Stage: "Stage I" Response to treatment: "Resolved right now." Change in plan & comments. "No (change in) Preventative measures." *NN: 3/13/14 1:26 am, "Buttock and coccyx area look clean, skin intact, pink. Flexigel to buttock area." *NN: 3/13/14 2:30 pm, "Peri care given no open areas. White callus like skin in buttock crease new order given to use [MEDICATION NAME] to coccyx prn and [MEDICATION NAME] oint(ment) to buttocks prn-flexigel no longer available." *NN: 3/14/14 10:15 am, "Bottom looks great cleaned (and) applied Flexigel." *NN: 3/15/14 10:00 am, "Area on coccyx cleand (and) left open to air flexigel not available." *NN documented by Skin nurse: 3/15/14 6:30 am, "Late entry: No open area noted near coccyx. Will not resolve at this time because the area is so fragile it (is) prone to breakdown." *SNPN: 3/15/14 Stage: "Stage I" Response to treatment: "No no open areas noted." 6:30 am, "Late entry: No open area noted near coccyx. Will not resolve at this time because the area is so fragile it prone to breakdown." *SNPN: 3/22/14 Response to treatment: "No open areas but remains fragile (and) dark pink." *NN: 3/22/14 2:09 pm, "[MEDICATION NAME] (and) drsg. to bottom looks ok." *NN: 3/22/14 11:00 pm, "Resident is resting, peri care complete, [MEDICATION NAME] applied to skin area of buttock, there does appear to be a split at the most inner crease of buttock just upward from rectum." *NN: 3/23/14 1:44 pm, "Buttock area cleaned, circular areas caution to open up." TX done per order. *NN: 3/23/14 7:00 pm, "Buttock is macerated (and) peeling. Pericare / Buttocks clean (and) OTA." *NN: 3/23/14 11:00 pm, "Buttocks OTA." *NN: 3/24/14 2:00 am, Repositioned to (left) side. Buttock OTA. Some improvement from Maceration noted." *NN: 3/24/14 10:53 am, Rt. skin looks macerated some of the white damp has sloughed off. redress (with) [MEDICATION NAME](sic)." *NN: 3/25/14 1:27 pm, New order for Hydrophyllic dressing most like Flexigel DC [MEDICATION NAME]. Use on coccyx." *PA progress note: 3/25/14 "Decubitus that comes (and) goes- augmented by incontinence - will start Hydrophyllic similar to Flexigel as it is no longer (illegible)." *PA order 3/25/14 "Please D/C [MEDICATION NAME] to coccyx - use Hydrophyllic dressing most similar to Flexigel daily and PRN." On 3/24/14 at 4:10 pm, CNA #1 and CNA #2 were observed to change the resident's brief. The resident had an open reddened area to the right buttocks into the crease of the rectum. The area of skin around the wound was wet and appeared macerated. CNA #2 stated, "Usually it has a dressing on it. It comes and goes. It is strange, it's like scarred tissue." On 3/25/14 from 9:33 am until 11:45 am, the resident was lying on her right side with a flattened pillow behind her left back. Bilateral feet were on the bed with socks on her feet. On 3/25/14 from 2:25 pm until 4:10 pm, the resident was on her left side with a flattened pillow behind her back and bilateral feet were on the bed, with socks on. On 3/25/14 at 4:10 pm, the DON and LN #3 were observed to check the resident's coccyx. The resident's incontinence brief was in place, but not hooked. The DON stated, "We get her completely healed then it opens up and she keeps breaking down. It looked good the other day." LN #3 stated, "I just think you need to be aware of it. The flexigel is good." The DON stated, "We can't get the flexigel but we can get the other one. He ordered one that is very similar to the flexigel." The DON stated, "She is soaked. There is no dressing on it right now; we have [MEDICATION NAME] we have been putting on it." The resident had soaked through the extra pad that was placed inside the brief, the brief and the cloth pad on the bed. The open wound was on the right buttock into the crease of the rectum. The DON asked the LN, "When did we run out of the flexigel." The LN stated "When I told him and he ordered the other one." The DON asked, "When did this one open up." The LN answered, "It wasn't there last Sunday." The surveyor told the DON the surveyor had observed the open area the night before and the DON stated, "I am sure it was." The area was cleaned with wipes and a new brief applied. The LN was asked, by the surveyor, about dressing the open wound and she stated, "Just leaving it to the air." The LN stated, "I am going to look at her feet too." The heels were observed to be in direct contact with the bed. The DON stated to the LN, "Have them come and get her heels off the bed." When the surveyor asked about the air bed the resident was on, the DON stated, "It's an Air Pro mattress overlay. It's continuous. It deflates one line and the next line has air in it." The mattress was observed by the surveyor to have air flow pockets that rotated with air. The resident was positioned on the left side when the DON and LN#3 had completed the observation. On 3/25/14 at 4:30 pm, 2 CNA's were observed to enter the resident's room. When they exited the room the resident was positioned on the right side. The resident's feet had a pillow between the lower legs. The right foot laid laterally to the side, on the bed. The left foot was on top of the pillow with the heel on the bed. Socks were in place. On 3/25/14 at 5:55 pm, the resident was wheeled to the dining room in her wheelchair. On 3/26/14 at 9:25 am, 9:52 am, 10:05 am, 11:45 am and 11:59 am, the resident was in bed on her left side, with a pillow between the lower legs. The resident's bilateral feet had socks on and the heels were directly on the bed. On 3/26/14 at 11:59 am, CNA #2 and CNA #4 got the resident up for lunch. When the surveyor asked if the resident was wet and if there was a dressing on the resident's coccyx wound, CNA #4 stated, "Yes, she is wet." CNA #2 stated, "The new dressing will be in tomorrow, there is nothing on there now." On 3/26/14 at 1:15 pm, the resident was awake in bed, lying on her left side, with a pillow between the lower legs. The right foot was on top of the pillow and the left foot was under the pillow. Both heels were resting directly on the bed, with socks on. On 3/26/14 2:00 pm, the surveyor asked the DON for the documentation of the open area that was observed on 3/25/14. The DON stated, "(LN name) would have done it yesterday, maybe in the nurse notes." Documentation was not found. When asked if she would have expected documentation of the new open area, the DON stated, "Yes I would have." When asked what she would call the wound, the DON stated, "Probably a Stage II or III." On 3/26/14 at 2:10 pm, when asked what the current pressure sore treatment, LN #5 stated, "We are using [MEDICATION NAME] ointment; suppose to put it on every 1 to 1 1/2 hour. I am supposed to check it for being wet." When asked when the Hydrophyllic dressing that was ordered on [DATE], would be in, the LN stated, "I am not sure when the new ordered treatment will be in, will have to ask Central Supply." The LN called Central Supply staff and stated, "It will be in tomorrow morning." On 3/26/14 at 2:19 pm, LN #5 and CNA #2 were observed to check the resident. The LN stated, "I just need to check her." The resident was on the left side, with a pillow between her legs. The right foot was off the pillow and directly on the bed, the left was directly under the pillow on the bed. LN #5 was asked if the heels were floated. She stated, "No, that is not floated." LN #5 and CNA #2 were asked if the resident had heel boots and both stated, "No, she doesn't have any." The surveyor asked LN #5 to describe the resident's wound. LN #5 stated, "I don't know." When asked how many open areas were on the resident's coccyx, LN #5 counted and said, "I would say 6. It did not look like this last week when I was here." When was asked about the flexigel and when it was last used, she stated, "Yes, (it did work) but I was told we could no longer get the flexigel. What I remember, it was last week when we last used it. It looks really bad. It is peeling." LN #5 applied the [MEDICATION NAME]. The LN#5 and CNA#2 were asked if there was any special training that had been provided for turning residents and floating their heels. CNA #2 stated, "I think we had an inservice about turning them and floating heels, like when they are on their back you put the pillow under their legs. But like with her on her side, it's hard to do that." On 3/27/14 at 9:55 am, the DON was informed of the concerns with the resident being soaked through to the pad on the bed, the resident's turning schedule, the inconsistency of the application of ordered treatments and heels not being floated. The DON stated, "I know I have them change her every 1 1/2 to 2 hours, because she is so wet. I can see that is not being done." The DON was asked if the facility had heel protectors for the resident, and she stated, "Yes we do and it is not just at night. They all know how to float heels, it's not just putting a pillow under them." 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS's dated, 10/22/13 and 1/21/14, documented: *BIMS score on 10/22/13- 8, cognition moderately impaired. On 1/21/14- 4, cognition severely impaired. *Both assessments- Rejection of cares: No. *Both assessments- Transfer: 3-3, extensive assistance, 2 person assist. *Both assessments- Bed mobility: 3-3, extensive assistance, 2 person assist. *Both assessments- Functional limitation in ROM: Upper extremity- 2, impairment on both sides. Lower extremity- 2, impairment on both sides. *Both assessments- Risk of pressure ulcers: Yes. *Unhealed pressure sores on 10/22/13- No. On 1/21/14- Yes. *Current number of unhealed pressure ulcers at each stage: Number of stage 2 pressure ulcers: 1. Date of oldest Stage 2 pressure ulcer: 12/21/13. The resident's Braden scale for predicting pressure sore risk dated 10/18/13 and 1/17/14 documented a score of 16, at mild risk. The resident's Narrative care plan dated July 2013, documented: *Page 17, 18, 19: "I am at risk for developing pressure sores as well as other skin problems. I require your assist with making significant position changes. I am wheelchair bound and also have incontinence of bowel. I have a hx (history) of skin breakdown on my coccyx, and feet. Make sure that the air mattress on my bed is working every day. Use heel protectors or float my heels when I am in bed if I agree. My physician has ordered ointments/creams that can be used for skin issues. Reposition me every 2-3 hours around the clock. (NOTE: Changed August 2013 to "during the day.") (10/16/13) I am able to go 8(hours) at noc.(night) (without) being disturbed for position (changes). If any pressure areas develop cut back on the time (between) checks. At night when you empty my foley check me for bowel incont.(ence)." "1/8/14 Critic Acid (and) xeroform to coccyx," "1/28/14 I do have a sore on my buttock but goal is unchanged." The resident's temporary care plan dated 1/28/14, documented: *"I have an open area on my right buttock. Physician gave order on 1/25/14 for critic acid (and) xeroform BID (twice daily) Have me lay on my sides in bed. The night shift has been keeping my buttock open to air at noc.(night). I am also not drinking fluids like I should so you need to offer me fluids (and) encourage me to drink them. While I have this open area you will need to reposition me more often. The skin nurses check the area (every) week (and) record the size (and) other info on my open area." NOTE: The care plan did not give a specific time frame for turning and repositioning the resident at night. The narrative care plan documented, "8 hours". PA progress notes, SNPNs, NN and PA orders, documented: *NN: 9/13/13, "Rt(right) buttocks has two open(which open is crossed out) scaley areas (one) on each side - Stage II. Laid (down) btwn (between) meals." *NN: 9/22/13, "Buttock open (with) no (change.)Crm (cream to open areas (after) cleaning. Repositioning per DON. Keeping off buttock area. OTA." *NN: 10/17/13, "skin issues to buttocks are resolved, no scaley area, or redness noted. Moisture barrier applied to buttock for protection," *NN: 11/18/13, "No new skin issues." *SNPN: 12/21/13 Wound site: "Ischium" Size: "L 0.75 cm, W 2 cm" Stage: "Stage II" Wound bed: "Granulation 5%." Periwound: "Intact. Scaly at edges but intact around that." Change in plan & comments: "Monitor (and) use moisture barrier cream or (illegible)." *SNPN: 12/28/14 Size: "L 2 cm, W 2 cm, D NA" Stage: "Stage I" Wound bed: "Granulation 100%" Periwound: "Intact" *SNPN: 1/18/14 Size: "L 1.5 cm W 1.5 cm D 0" Stager: "Stage II" Response to treatment: "Appears to be slowly healing." Change in Plan & comments: "Bag balm TX continues." *SNPN: 1/25/14 Size "L 2 cm W 2 cm D shallow" Stage: "Stage II" Wound Bed: "Slough 100%" Response to treatment: "TX (changed) 1/25/14" Change in plan & comments: "Xeroform drsg (and) critic acid oint(ment)." *PA order: 1/25/14 "Criticaide (and) Xeroform on sore on (right) buttock until healed (BID) per telephone order from (PA's name)." *PA note: 1/28/14 CC: "Evaluation of (right) buttock decubitus. She has an intermittent breakdown on (right) buttock (no) specific antecedent event. By hx this may have been an old area of breakdown (and) is fragile VS (versus) an old sebaceous cyst that periodically (illegible). Regardless my evaluation is timed only after notification of breakdown and seeing today."Assessment/Plan /Labs: "Decubitus A) Healing (with) good granulation tissue seen. B) Continue (with) decubitus care (decrease of friction) (and) protection. C) Side lying only. D) May add Vit. C (and) medicated pad other than xeroform in future depending on resolution." NOTE: This was the first documented evidence that the PA had seen the wound, that was first documented by the skin nurse on 12/21/13. The PA documented the area of breakdown as intermittent, and the old area of breakdown as fragile. *SNPN: 2/1/14 Size: "L 2 cm W 1 cm" Stage: "Stage II" Wound Bed: "Slough 100 %." *PA note: 2/4/14 CC: "(Follow up) (left) buttock decubitus. Had granulation tissue on last exam of (left) buttock decubitus.- Initial re(check)." Assessment/Plan/Lab: "Decubitus A) Healing well. B) Continue [MEDICATION NAME] (with) Ag VS xeroform (illegible). C) Side lying." NOTE: The PA refers to the left buttock rather than the right buttock which is reflected in all other documentation. *SNPN: 3/22/14 size: "L 0.75 W 0.50" Stage "Stage II" Wound Bed: "Granulation 90%" Periwound: "Intact" Response to treatment: "Closing up." On 3/24/14 at 4:00 pm, the resident was lying in bed on her left side. She had socks on and both feet were resting directly on the bed. A pillow was between the resident's lower legs. On 3/25/14 at 9:25 am, 9:32 am, 9:45 am, and 9:55 am, the resident was up in her wheelchair in the dining room, participating in a seated exercise activity. At 10:12 am, 10:39 am, 10:55 am, 11:25 am, and 11:39 am, the resident was sitting in a lounge chair in the TV room. On 3/25/14 at 11:52 am, the resident was transferred to her wheelchair and positioned at the dining room table. The resident was observed at the dining room table until 12:21 pm. NOTE: The resident was in a seated position on her buttocks for approximately 3 hours. On 3/25/14 at 1:28 pm, 2:25 pm, 2:35 pm, 3:05 pm, 3:40 pm, 4:00 pm, and 4:35 pm, the resident was in bed. The resident was lying on her back with the head of her bed slightly elevated. A pillow was positioned under her lower legs with both of her heels directly on the pillow. She had socks on her feet. On 3/25/14 at 4:35 pm, the resident's position remained unchanged and the resident's family was in to visit. On 3/25/14 5:30 pm, and 5:55 pm, the resident's visitors were gone. The resident remained in the same position in the bed. NOTE: The resident was observed by the surveyor to be in the same position from 1:28 pm until 5:55 pm, which was approximately 4 hours and 25 minutes. Her heels were not floated and she was lying on her back. On 3/25/14 at 6:05 pm, the resident was assisted up from bed and wheeled to the dining room in her wheelchair. On 3/26/14 from 8:04 am until 10:00 am, the resident was observed in her wheelchair in the dining room. On 3/26/14 at 10:00 AM the resident was wheeled to her room and assisted to bed by CNA#4 and CNA #6. CNA #4 told the resident, "Let's get you off your bottom, roll that way," pointing to the right. CNA #4 placed a pillow behind the resident's back and between the resident's lower legs. The right foot was directly on the bed and the left foot was on top of the pillow with the foot on the pillow. On 3/26/14 at 11:46 am, the resident was observed being wheeled from the shower room by CNA #2. The surveyor asked CNA #2 if the resident had a shower, and she stated, "No, we also potty them in the shower room." When asked how the resident's bottom looked, the CNA stated, "It has a bandage on it, so I didn't see it." On 3/26/14 at 1:08 pm, the resident was in bed in her room, positioned on her back. She had a pillow between her lower legs with her heels rested directly on the bed. LN #5 was in the room and when the surveyor asked if the resident's heels were floated, she stated, "Nope they are not." The LN left the room to get help to reposition the resident. On 3/26/14 at 2:17 pm, the resident was lying on her back with a pillow behind her lower legs with both heels resting directly on the bed. On 3/26/14 at 2:50 pm, LN #5 and the surveyor went in to observe the resident's position. The resident was in the same position. When asked about floating the heels with a pillow, the LN stated, "It doesn't work very good with her." The LN agreed the resident's feet were directly on the bed, and stated, "Yeh, these won't work, they just smash down." The resident's buttocks were observed with the assistance of CNA #7 and LN #5. The right buttock had a small dark scabbed area approximately 2 cm x 1 cm. The right and left buttocks were red and the xeroform dressing was falling off. The LN #5 stated, "It doesn't stay on very good. Her bottom is very red. I wonder why it does that?" The resident was oozing stool. The LN cleaned the resident of the stool, and put the dressing back in place, and stated, "It doesn't stay, see it doesn't stay in place." The LN pulled up the brief and asked CNA #7, "Is her bottom always that red?" The CNA replied, "Yup, when she is in her wheelchair and we toilet her it is red." The surveyor asked if it was that red when she was positioned off of her buttocks, the CNA replied, "Nope." The resident was positioned on her right side with heels floated on 2 pillows. On 3/26/14 at 3:59 pm, the resident was on her right side and heels were floated on pillows. On 3/27/14 at 9:55 am the DON was told about the concerns of the resident not being repositioned. When asked if there were heels boots for the resident, she stated, "I don't know. I will have to check." On 3/27/14 at 5:00 pm the administrator and DON were informed of the findings. No further information was provided. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's current care plan (CP), dated 2/14, included in the "ADL's will be met daily" section the resident was incontinent of stool, had a catheter, was in a wheelchair and at risk for pressure sores and other skin issues. The CP documented the resident would scratch until he bled and the sit to stand mechanical lift was to be padded as it rubbed his leg. The CP interventions were: *Check under the catheter strap when getting dressed in the morning and undressed at night. *When resting in the recliner or in bed use heel protectors or float heels. *Skin assessment head to toe every 12 hours. The resident's Nursing Notes (NN) and Alteration in Skin Report (ASR) documented the following: *1/1/14 NN at 3:00 p.m. -"Blisters found right thigh poss (possibly) from resident scratching." ASR - The Problem was identified as blisters on the right thigh. The Cause was documented as, "Scratching or the F/C (foley catheter) tubing against his skin." *1/2/14 NN at 3:30 p.m. - "Poss blisters now look like scratches sm (small) open areas." NN at 11:00 p.m. - "Does have sm(all) red possible scratch markings to his right lateral upper thigh, no open skin sore noted..." *1/3/14 NN at 9:00 a.m. - "Fax reply re (regarding) blisters found yesterday. No new orders." NN at 11:00 p.m. - "...no changes in broken blister to his right upper thigh, no signs of infection." *1/4/14 NN (time not documented) - "Blisters noted right hip/up thigh area - dry and clean - have popped." NN at 11:00 p.m. - "...no change in skin wounds to right upper thigh..." ASR - The Problem was identified as blisters on the "right thigh area." The Cause was documented as, "Scratching or the F/C (foley catheter) tubing against his skin." *1/5/14 NN at 1:36 p.m. - "Right thigh blisters closed, no weeping or s/s (signs/symptoms) of infection." *1/6/14 NN at 4:06 a.m. - "Right thigh scabbed over and closed." NN at 10:50 a.m. - "Right scabs int

Based on observation, record review, and staff interview, it was determined the facility failed to ensure 1 of 2 sample residents (#2) reviewed for pressure ulcer prevention did not develop an avoidable pressure ulcer. Resident #2 was harmed when 3 Stage II pressure ulcers developed while at the facility. Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent quarterly MDS assessment, dated 11/20/12 documented she required extensive assistance of 2 staff for bed mobility, transfers, dressing and personal hygiene. The assessment stated the resident was at risk for pressure ulcers but did not have any at the time of the assessment. Resident #2's medical record included history of a pressure sore to her right great toe on 3/31/11. An Alteration In Skin Report (AISR) dated 10/2/11 documented the resident had a pressure sore caused from her sock rolling up in her shoe and the podiatrist had debrided "it again on 9/1/11." The Braden Scale for Predicting Pressure Sore Risk documented on 3/9/12, 8/4/12 and 11/9/12, that Resident #2 was at moderate risk for developing pressure ulcers. a. Resident #2's 4/11/12 NN, documented the left, "Ankle with 2 open/scabbed areas." The note documented the one was 1 cm x 0.5 cm and the other was 1 cm x 0.25 cm. The 4/12/12 NN documented, "Rt (resident) has 2 scabbed sores on outer L (left) ankle where foot is very contracted down and ankle has rubbed..." An Investigation dated 4/11/12, documented the resident had 2 sores on her left ankle as stated above. The What Does Staff Say Occurred section stated "looks like pressure sores." The Comments section under Administrative Review stated "Use pillows to elevate. Has boots to wear to relieve pressure." The investigation did not indicate what caused the pressure to the resident's ankles, therefore it was not clear how the pillows or boots would prevent future pressure ulcers. The care plan did not include the resident was to wear boots to prevent pressure ulcers. The resident was observed wearing slippers or socks, but not pressure relieving boots during observations on 2/12/13 through 2/14/13. The 4/12/12 AISR documented the 2 ulcers and stated in the Recommendations or Comments section, "L (left) foot is very contracted needs more padding." During observations on 2/12/13 through 2/14/13 staff was observed to put pillows behind her legs. Wound or Pressure Care Identification and Progress Records documented the following: 4/12/12 - Two ulcers that were unstageable, without pain, no drainage and 100% Eschar (dead skin) on the left foot near the ankle bone. The sizes were documented as 1.5 cm x 1 cm and the other was 1 cm by 1 cm. 4/21/12 - The size of the pressure ulcers was the only change in the documentation which documented both ulcers were now 1 cm by 1 cm. 4/27/12 - One of the pressure ulcers was documented as resolved. The other was documented as a stage I that was 1/2 cm by 1/2 cm with no drainage, 100% [MEDICATION NAME] (regeneration of the top layer of skin). 5/5/12 - The remaining ulcer was documented as a Stage I with no drainage and 100% [MEDICATION NAME]. 5/17/12 - The ulcer was documented as resolved. b. Resident #2's medical record included a 1/10/13 order from a podiatrist to "Please apply [MEDICATION NAME] oint(ment) and Band-Aid to ulcer on tip of right 2nd toe...." Nursing notes (NN) reviewed from 12/28/12 through 1/10/13 documented nothing about the resident's right 2nd toe. A nursing note dated 1/10/13 at 10:00 a.m. documented the above order. On 2/12/13 at 9:26 a.m. Resident #2 was observed in the activity/dining room with her foot off of the foot pedal of her wheelchair. Her foot was pointing down with her toes touching the floor and the back of her foot against the foot pedal. On 2/13/13 at 10:30 a.m. the surveyor observed the wound on the resident's right 2nd toe. The wound was an unopened area 0.5 cm x 0.25 cm. The outer area of the wound was red. LN #1 confirmed the area was red around the outer edges. The Director of Therapy was interviewed on 2/12/14 at 11:10 a.m. regarding the resident's foot not being on the foot pedal and the possibility of pressure on the heel and the toe. The therapist stated his concern regarding the resident's comfort as well as pressure and immediately adjusted the resident's wheelchair pedal. AISRs for 12/1/12 through 12/28/12 documented, "none" (no skin issues) in the Problem section of the Skin Assessment. The surveyor requested all weekly AISRs from 12/1/12 through 2/13/13; however, none were provided for 12/29/12 through 1/10/13. On 2/14/13 at 10:45 a.m., the DON was asked for any additional information regarding the above ulcer. The DON stated there should have been a Quality Measure (QM) report (incident/accident report) for the ulcer. The DON did not respond when asked how injuries could be prevented if a QM or investigation had not been completed to identify the source of the injury. The surveyor requested any information regarding the above ulcers. Later that day the DON provided additional AISRs; however, no QM, Wound Pressure Sore Identification form documenting wound size, drainage etc. or any other documentation for the cause of the ulcer was provided. Resident #2's "Narrative Care Plan" (CP), dated 2/12 included a goal to not have any skin breakdown during the next quarter. The only revision to the CP was to use a moisture barrier when needed, dated 3/5/12. The Area/Problem/Strength included: daily skin checks, repositioning, pressure relieving mattress, pressure relieving pad in wheel chair, float heels in recliner and bed ensuring there was nothing in the toe of her shoe as she previously had a pressure sore on her toe, placing a pillow between her knees when she was in bed to prevent knees and feet from rubbing and extra protein at each meal. The CP did not include any intervention changes after the pressure ulcers were identified on 4/12/12. On 2/14/13 at 10:45 a.m. the DON was asked for any additional information regarding the above ulcers. The DON did not respond when asked how injuries could be prevented if a QM or investigation did not identify the source of the injury. Later that day the DON provided the investigation for the 4/11/12 ulcers; however the investigation did not identify what caused the pressure ulcers. Resident #3 was harmed when the facility failed to prevent avoidable pressure ulcers by identifying the cause of the pressure and implementing preventative measures to specifically address the reason for the pressure ulcers. On 2/14/13 at 5:00 p.m. the Administrator and the DON were informed of the above concerns. The facility provided no further information.

Based on record review, staff interview, and review of the facility's ASRs, QMMs, and SUMMS, it was determined the facility did not ensure a resident's treatment plan for pressure-related wounds was re-assessed after the resident developed recurring skin breakdown. This involved 1 of 3 residents (#5) reviewed for pressure-related injuries. Findings include: On 10/24/11 a recertification survey was conducted at the facility. F314 was cited after the facility failed to ensure a resident received the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. The facility's POC, with alleged correction date of 11/28/11, documented, in part, "...The charge nurses were approached on a 1-1 basis by the DON concerning pressure ulcers and their responsibility to monitor all residents for skin issues. There is a skin nurse downstairs and one upstairs and a RN to assist them with skin issues, they are all responsible to address skin issues and monitor that the cares are being done for each resident..." Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. NOTE: Resident #5 was reviewed for skin breakdown during the most recent annual recertification survey of 10/24/11. The wound treatment plan at that time was barrier cream and bag balm to the sites. There was no deficient practice identified by the survey team. During the follow up survey the facility's QMM investigation reports were reviewed from the allegation date of 11/28/11 through current. The following was documented regarding Resident #5: *"12/3/11: New areas of splitting on coccyx x (times) 3 noted. Not quite open but red & macerated. 1 is 2 cm long, one 1.5 cm & one is 1/2 cm long all (with) edges well appx (approximated) & all above rectum...Fragile skin cont(inue) to monitor...from turning, shearing??..Recurring problem..." NOTE: The report was signed/dated by the DON on 12/12/11. The Administrator's signature/date was left blank. Please refer to F225. After the survey team reviewed the above QMM, Resident #5's record and the facility's ASRs and SUMMs were reviewed after 10/24/11 to determine if the resident continued to develop "recurring" skin breakdown and if so, did the facility reassess the resident's wound treatment plan prior to its allegation date of 11/28/11. The facility's ASRs, Nursing Notes (NNs), and SUMMs documented the following in part regarding Resident #5: *10/27/11, NN: "...Res ('s) bum looks great! All areas which were split are closed..." *10/28: "Cont to provide incont(inence) care q 2 (every 2 hours with) moisture barrier to buttocks and coccyx. Turned q 2 (hours.)..." *10/29: "Stage 1 breakdown L(eft) side of coccyx is now open (with) slight bleeding noted. Diameter is now 0.5 cm...Splits in buttock crease are resolved at this time..." *10/30: "Still pink but blanches area from rectum to apx (approximately) 5-6 cm above rectum then goes to the L sacrum round pink area there darker red macerated area Stage II (2) there - nonblanchable..." *11/5: "...still pink above rectum & off to the L has 6 cm long split & just above rectum & 2 small open areas on coccyx center apx 1/2 cm round each and area to the left of the sacrum is red round 2 cm & has 1/2 cm scab on there." *11/12: "Assessed coccyx looking much better 1 cm split above coccyx pressure ulcer to L sacrum is resolved. Areas are still pink but it appears to be scar tissue." *11/14, SUMM: "Right buttock has a red area noted this am. Not open." *11/15: "Left buttock just off the coccyx is open 0.5 cm. Entire area is red." *11/23: "Coccyx is open to air and is moist looking..." *11/23, NN: "Split in coccyx worse edges white too moist. Open to air..." *11/24: "New Gel/liq(uid) cushion for bed to assist (with) eleviating (sic) pressure on res('s) coccyx..." NOTE: There was no documentation in the resident's record that a determination was made that the gel cushion was appropriate for use over an air mattress. *11/25, SUMM: "Using new cushion and coccyx is looking better." *11/26, NN: "Splits above rectum are resolved at this time. No open or red areas noted. Gel pad appears to be helping. Caregivers taught to use draw sheet for turning so as not to pull on her skin." *11/26/11, ASR: "2 small splits above rectum. DATE (of onset) 11/5/11. CAUSE: Very fragile skin - ongoing issue. INTERVENTION OR TX: Good peri cares after each incontinent episode. Bag Balm or moisture barrier prn & up for meals only. RECOMMENDATIONS OR COMMENTS: Reposition frequently using the draw sheet to turn her. DATE RESOLVED: 11/26/11." *11/28, NN: "...small slit continues et (and) barrier placed..." *11/29, SUMM: "1/2 cm split area on coccyx..." *12/1: "Has two splits on buttocks. Using the gel pad in bed and geri chair." *12/3, NN: "Rt (Resident) has splits which are macerated but not quite open & red applied protective balm...Sent fax to MD as well." *12/3, ASR: "3 splits in buttocks crease...Found 12/3/11. CAUSE: Turning procedure. INTERVENTION OR TX: Proper turning. RECOMMENDATIONS OR COMMENTS: When she turns she torques her hips backwards causing the caregiver to use her hips for pulling her over>>they need to use the draw sheet only. SIZE: (of wounds) 2.0 cm, 1.5 cm, 0.5 cm." *12/5, SUMM: "Open areas on buttocks..." *12/6: "...3 splits on buttocks." *12/7: "Bottom is raw, (staff's name) thinks gel pad isn't working on her." *12/10, ASR: "Now only 1 split in buttocks crease...SIZE: 3 cm long. Raw looking area more red than open. Looks like a pencil line right in the buttock's crease." *12/14, SUMM: "Bottom looks bad" *12/15: "Bottom looks good." *12/17, ARS: "Now only 1 split in buttocks crease...SIZE: 2.0 cm. Closed Looks like a red line." *12/23: "Now only 1 split in buttocks crease...SIZE: 1.0 cm split, no red areas, looks great." *12/26, NN: "Coccyx 2.5 cm split area et oint (and ointment) applied..." *12/27: "Coccyx split continues to be cleansed and barrier crm (cream) applied..." *12/29, SUMM: "Bum looked white, wet and macerated this am." *12/30: "Bottom looks bad." *12/30, ARS: "Now only 1 split in buttocks crease...SIZE: 4.0 split (filling in) with some excoriation posterior oeri (sic) area due to 3 recent BMs." *1/2/12, NN: "...Coccyx split open et edges white, too moist...Rt on side using gel pad (with) blue chuck (sic) under skin..." NOTE: It was unclear why the blue chux was placed next to the resident's skin. NOTE: The facility provided copies of 26 SUMMs from 11/14 through 12/30/11. The reports documented that at least 5 but mostly 9 staff members attended the meetings. There was no documented evidence the Administrator attended any of the meetings and no evidence the Administrator reviewed or signed the notes. NOTE: The NNs from 10/29/11 through 1/2/12 documented the sites re-opened multiple times. The treatment plan for the open areas continued to be moisture barrier cream and/or bag balm. The resident continued to be turned every 2 hours. The Federal guidance under F314, The Healing Pressure Ulcer, directs in part: "...If a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and the resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions is also indicated. Results may vary depending on the resident's condition and interventions/treatments used. The complexity of the resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rationale for continuing the present treatment (for example, why some, or all, of the plan's interventions remain relevant despite little or no apparent healing)...Dressings and Treatments: Determination of the need for a dressing to a Stage I or II ulcer is based upon the individual practitioner's clinical judgement and facility protocol based upon current clinical standards of practice..." On 1/4/12 at 2:40 pm, one of the two wound care LNs was interviewed. She stated she was not certified as a wound care LN, and worked under the direction of an RN, also not a certified wound nurse. The LN stated she performed the wound treatments. She was asked what wound care products had been used in the past in attempts to heal the wounds and to prevent recurring breakdown. She named one [MEDICATION NAME] dressing and one [MEDICATION NAME] which was used "over a year ago." She stated staff currently use a barrier cream and bag balm and indicated these two products "seem to work best." She was asked when the treating physician last assessed the sites. She stated, "Not in a long time." She also stated, "It's just a recurring problem." On 1/4/12 at 3:00 pm, the DON was interviewed. She acknowledged that none of the licensed staff were certified in wound care. The DON was asked how the decision was made to use the gel cushion on top of the air mattress. She indicated that staff attended a recent pressure ulcer conference and a representative of the gel cushion made a recommendation for it's use. The DON also stated, "We talked to the doctor." She stated the name of the treating physician. The DON acknowledged at this time that no physician had evaluated the resident's recurring skin breakdown. "It's been a struggle to have the MDs evaluate the wounds." NOTE: Resident #5's record revealed the treating physician had not evaluated the resident since 9/14/11, at which time there was no reference made to the resident's recurring skin breakdown to the buttock region. There was one Physician's Telephone Order, dated 12/19/11 and written by the wound care LN, which directed: "Do not try Nu-Skin Spray. DX: open skin areas. Via fax. (Name of the treating physician.)" The treating physician signed/dated the order on 12/20/11. The "fax" which was referenced in the telephone order from staff to the physician was not found in the resident's record making the response by the physician not to use the Nu-Skin Spray unclear. The facility failed to ensure: *the treating physician was involved in the management of Resident #5's recurring skin breakdown *that during the Stand UP meetings discussions occurred to consider other community resources, such as consultation by a certified wound care specialist to evaluate the resident's recurring skin breakdown and to make recommendations *that after the wounds healed the staff attempted to use other protectant wound care products in the attempt to prevent recurring breakdown. There was no documented rationale for continuing the present treatment, as identified in the Federal guidance under F314, "for example, why some, or all, of the plan's interventions remain relevant despite little or no apparent healing." The facility's non-compliance continued.

Based on observation, record review, staff interview, and review of the facility's Wound or Pressure Sore Identification and Progress Records and Alteration in Skin Reports, it was determined the facility failed to ensure 1 of 2 residents (#2) reviewed for pressure ulcers (PU) received the necessary treatment and services to promote healing, prevent infection, and prevent new PUs from developing. Specifically, Resident #2 was admitted to the facility with dark purplish discoloration to both heels. Resident #2 was harmed when the heel PUs were not monitored for 4 days and progressed to non-stageable (per facility documentation). In addition, the left heel PU became infected and oral and intramuscular antibiotics were necessary, the left heel PU reoccurred, and a stage II PU developed on the right outer ankle. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Braden Scale for Predicting Pressure Sore Risk in Home Care, dated 11/23/10, 11/30/10, 12/3/10, and 12/17/10 scored Resident #2 at 18, or mild risk, for developing PU. No other pressure sore predicting documents/assessment were found in the resident's chart. The resident's Admission Nursing Assessment, dated 11/23/10, contained a Skin Condition section with a back side body diagram on which was documented "dark discolored" with a line drawn to both heels, both of which were circled. The resident's 11/3/10 admission MDS assessment, coded in part: * Cognitive impairment, but understood others and understood by others; * Extensive 1 person assistance for locomotion on and off unit/dressing; * Extensive 2 person assistance for bed mobility/transfers/locomotion in room/toilet use; * Wheelchair/walker use; * At risk for pressure ulcers (PU); * One unhealed PU; * One stage 1 PU and 1 PU non-stageable due to slough or eschar; and * Pressure reducing device for bed and application of dressings to feet. Note: This MDS coded the resident as having only 1 unhealed PU and coded the presence of 2 PUs, 1 stage 1 and 1 non-stageable. Resident #2's 3/1/11 quarterly MDS assessment, coded PUs the same as above, except: * Two stage 2 PUs, 1 present on admission; * Date of oldest PU 12/10/10; * Granulation tissue was the most severe tissue type for any PU; * No worsening in PU since prior assessment; * Pressure reducing device for bed, ulcer care, and application of dressings to feet. Note: This MDS coded the oldest PU as 12/10/10. However, 1 PU was coded as present when the resident was admitted to the facility on [DATE]. The resident's 5/31/11 quarterly MDS assessment, coded PUs the same as the one above, except: * No stage III, stage IV, or non-stageable PUs; * Slough was most severe tissue type for any PU. Note: This MDS assessment coded 2 stage 2 PUs but that slough was the most severe tissue type. The MDS defines stage 2 PUs as, "Partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." Resident #2's 8/30/11 quarterly MDS assessment, coded PUs the same as the one above, except: * Two healed stage 2 PUs were present on the prior MDS assessment; and * Pressure reducing device for bed. Note: Refer to F278, MDS Accuracy, regarding coding errors in Resident #2's MDS assessments. Review of Resident #2's admission orders [REDACTED] * 11/23/10 - "Wear knee high ted (sic) hose 10 more days then DC (discontinue)..." * 11/24/10 - "Heel protectors/float heels in bed." * 11/29/10 - "(T)egaderm heel to heels bilat - Dx- Blisters bilat. (change) Biweekly & PRN if soiled ([MEDICATION NAME] heel to bilateral (both) heels, diagnosis - Blisters bilaterally. Change bi-weekly and as needed if soiled.)" * 12/10/10 - "OK to DC [MEDICATION NAME] heel (and) use Allevyn to (right) heel only. DX-blisters heels bilat. " * 12/21/10 - "Culture open sores. Begin dressings (Allevyn or similar (dressing) to ulcers). [MEDICATION NAME] 25 mg PO q (every) AM Dx: open sores to heels (B) (bilaterally)." * 12/24/10 - "[MEDICATION NAME] 1 gm IM Q 24 (hours) x 3 days also start Bactrim DS 1 PO BID x 10 days...Dx: (increased) temp Red Hot Draing (L) foot ([MEDICATION NAME] 1 gram intramuscular injection every 24 hours for 3 days. Also, start Bactrim DS 1 by mouth 2 times a day for 10 days. Diagnosis: [REDACTED]." An Analysis of Findings in Resident #2's PU CAA, dated 11/30/10, documented, "I have an unstageable pressure area on my (L) heel (and) a Stage I on my (R) heel. I spend most of my time in a w/c (wheelchair) or recliner...I need you to make sure my heels are floated." The resident's PU Plan of Care, dated 12/2/10, included the following problems: * Non-stageable left heel PU and stage 1 right heel PU; * "Both heels are now stage II," added 12/20/10; * [MEDICAL CONDITION] in lower extremities, added 12/21/10; * "(I)nfection (left) heel antbxs (antibiotics) ordered," added 12/24/10; and * "Scabs," added 3/2/11 in handwriting next to the "Both heels are now stage II" entry. The 12/2/10 PU Plan of Care Interventions for Resident #2 included: * Float heels at all times, in recliner or bed; * Dressings per physician's orders [REDACTED]. * LN to check heels on a daily basis and record progress once a week; * Reposition every 2 to 3 hours; * Do not put shoes on until the heel sores are healed. Use non-skid socks; * [MEDICATION NAME] (diuretic medication) every morning, added 12/21/10; * Antibiotics as ordered and notify physician if symptomatic after 2 weeks or elevated temperature, added 12/24/10; and * Air mattress on bed, added 7/30/11. Resident #2's 12/2/10 PU Plan of Care documented resolution of problems as follows: * "8-18-11 Heels (without) scabs."; * "[MEDICAL CONDITION] will not be greater than 1 (plus) during next quarter" - 3/2/11; * "1-31-11 Resolved infection." Note: An initial Plan of Care was not found in the resident's chart. Review of Resident #2's Nursing Notes (NN), dated 11/23/10 at 1:45 p.m. through 10/17/11 at 11:00 p.m., revealed the following documentation, in part: * 11/23 at 1:45 p.m., "admitted ...Heels are discolored purplish, blanch slightly...knee hi (sic) ted (sic) hose removed (and) sent to laundry as they were bloody..." Note: TED hose are commonly order after surgery to prevent blood clots. TED hose also help to reduce swelling, or [MEDICAL CONDITION], in the low extremities. * 11/23 at 4:30 p.m., "...Need to have order for ted socks...Heal (sic) protectors (and) floating heals..." * 11/24 at 11:16 a.m., "...does better in w/c (wheelchair) where she can 'cruise'..." * 11/26 at 11:30 a.m., "...very content to wheel around in w/c..." * 11/27 at 10:00 p.m., "...Note 3 (plus) [MEDICAL CONDITION] in (R)LE (right lower extremity) (and right) foot, ted (sic) hose on...needs to be put in recliner (and) elevate LEs..." * 11/28 at 1:00 a.m., "...note (L) (left) heel black, (R) heel small area black(,) pillow under (L) leg (and) towel roll under (R) ankle to keep heels off bed..." * 11/28 at 7:00 a.m., "(Checked)...feet found heel protectors for this resident- has dark areas apx (approximately) 2 cm (centimeters) round (R) heel (and) apx 4 cm round (L) one - (R) feels tight (L) feels boggy - heels floated...(and) did have air mattress on..." * 11/29 at 6:40 a.m., "(Resident) states blisters on heels are pretty sore..." Note: From 11/23/10 at 4:30 p.m. to 11/27/10 at 10:00 p.m., there was no indication the resident's heels were reassessed or her heels were floated for almost 4 and 1/2 days. In addition, there was no indication any type of foot wear/protection was in place during this time, particularly when the resident self propelled in the w/c. The NN documentation included: * 12/6 at 11:00 p.m., "...needs frequent redirecting why LEs need elevated..." * 12/12 at 3:17 a.m., "...(L) heel dressing was not intact at 0130 (1:30 a.m.)...patches replaced...(L) heel has clear drainage saturating old dressing. Foul odor detected..." * 12/16 at 10:46 a.m., "...(L) drsg...saturated (and) falling off...Small amt (amount)...odor..." * 12/18 at 10:30 a.m., "...both heels drsgs saturated (with) yellow exudate bilat no foul odor...(L) heel open area is 6 cm (by) 4 cm wound bed (with) granulation tissue 90% (with) edges containg (sic) slough all the way around...(R) heel 2 cm (by) 2.5 blister has popped 50% granulation (and) 50% slough..." * 12/20 at 10 p.m., "Note 3 (plus) [MEDICAL CONDITION] bilat LEs...(L) foot (with) foul odor, like rotted flesh (and) drsg...fluid filled (and) leaking from edges, drng (drainage) serosanguinous...(L) heel...looks open 3 layers center red soft (and) borders white no blanching noted...Res(ident) requires constant redirecting on why legs must be elevated (and) no pressure on heels...possible need for culture..." * 12/21 at 10:03 a.m., the physician ordered culture of the open sores, Allevyn or similar dressings and [MEDICATION NAME], (a diuretic medication). * 12/21 at 10:40 a.m., "...Rt (right) heel 1 cm circle in the center-area 1 cm (by) 1 cm (by) 2 cm no odor-pink...left heel-drainage on center of drsg no odor noted culture done...sm(all) white areas noted-odd shaped 6 cm (by) 4 cm..." * 12/24 at 10:50 a.m., "...temp(erature) elevated slightly 99.7 orally..." * 12/24 at 12:30 p.m., "(T)emp 100.2...(R) foot healing really well...(L) heel now (with) white film on there (and) a few opaque areas (white) noted - foul odor noted...Called MD (physician)...informed...infection like sx (symptoms) of (L) foot (and) (up) temp..." Note: The physician ordered 2 antibiotics, [MEDICATION NAME] injections daily for 3 days and Bactrim by mouth 2 times a day for 10 days. And, a laboratory report, dated 12/24/10 at 2:20 p.m., and noted as "Final," documented, "Isolation of Staphylococcus aureus." Note: There was no evidence the foul odor at the left heel was reported to the physician after it was noted on 12/12/10 or after the odor was again noted on 12/16/10. And again, there was no indication of what type of foot wear/heel protection, if any, was in place when the resident was up for meals and to use the bathroom. The NN documentation also included: * 2/18 at 2:08 p.m., "(L) heel is 100% resolved scab off. (R) heel still very small scab still intact..." Note: On 2/18 the left heel was noted as resolved. However, NN entries for 2/26 at 11:16 a.m. through 4/4 at 9:30 p.m. noted "scabbing" and "small scab" on the resident's left heel. Either the 2/18 documentation was in error, or the left heel PU reoccurred. NN dated 7/14 through 7/28/11 also documented a pressure sore at the resident's right outer ankle. However, there was indication regarding the stage of this PU. This PU was noted as resolved on 7/28/11. During the survey, Resident #2 was observed wearing black shoes with her feet on the floor on the following dates/times: * Seated in a regular chair at a downstairs dining table: 10/18/11 from 8 to 8:35 a.m., 10/19/11 at 12 noon, and 10/20/11 at 8:10 a.m.; * Ambulating with a walker with staff assistance: 10/18/11 at 2 p.m. and 2:45 p.m.; * Seated on, or ambulating independently with a Merry walker: 10/18/11 at 5 p.m., 10/19/11 at 11 a.m. and 4:20 p.m., and 10/20/11 at 7:30 to 7:40 a.m. * Seated in a w/c: 10/19/11 from 2 to 3:00 p.m. On 10/19/11 at 11:05 a.m., LN #11 was asked about the Resident #2's heel PUs. LN #11 acknowledged the resident was admitted with discolored heels that turned into blisters and PUs. The LN provided a binder with Alteration in Skin Reports (ASR). She stated that she and LN #12 both completed weekly ASRs to track skin issues for multiple residents. The ASRs included an area for the name/initials of the person who completed the form and the date, as well as sections to document the following: resident's name, problem, date, cause, interventions or treatment, recommendations or comments, size, and date resolved. LN #11 was interrupted and had to excuse herself. Review of the ASRs, dated 11/26/10 through 7/29/11, revealed the following regarding Resident #2's bilateral heel PUs: * 11/26: There was no documentation regarding the resident's heels. Note: This was day 4 after the resident's admission to the facility and indicated the resident's heels were not assessed. * 12/3: "friction" and "shear" to the (R) and (L) heels "on admit," [MEDICATION NAME] heel to both heels, "keep heels off floor (and) bed if possible," and measurements: (R) 10 cm x (by) 8 cm and (L) 2 cm x 2 cm; * 12/10: "blister" to both heels "on admit," Allevyn to the (R) heel and [MEDICATION NAME] heel to the (L), and measurements: (R) 4 cm x 2 cm, (L) 10 cm x 8 cm. Note: The 12/3 heel measurements may have been in error, as all of the ASRs through 1/29/11 noted the (L) heel measurements were larger than the (R). * 12/24: "open blister" at both heels with "infected" by the (L), Allevyn dressing to both heels, antibiotics, float heels, measurements: (R) 2 cm x 1 cm, (L) 6 cm x 4 cm. * 2/18: "(One) scab (R) heel (L) heel resolved 2/18/11." Note: The left heel PU was noted as healed on 2/18/11. However, the ASR for 2/26 through 4/1/11, noted a scab to the resident's (L) heel that varied in size from 1/2 cm x 1/2 cm, to 1/4 x 1/4, to "tiny," then back to 1/2 cm x 1/2 cm on 4/1. * 4/8 and 4/15: "No skin issues." * 4/22 and 4/29: Scabs to both heels. * 5/13: "R heel L Heel. With admittance. Pressure. OTA (open to air)-float heels as she will allow. Heel protectors when in bed. Continue to monitor. Both are 0.5 cm..." * 5/20: "Both heels crusty callus like areas...0.5-1.0 cm." Note: The resident's heels were not noted in the ASRs again until 6/18, when the left heel was once again noted as resolved. Other ASRs, dated 7/15, 7/22, and 7/29/11 documented an "Outer R ankle" problem that started on 7/14/11, was caused by "Possible pressure or friction," and measured 1 x 1 cm. The 7/22 ASR noted decreased size, and the 7/29 ASR noted resolution of the problem on 7/28/11. On 10/20/11 at 1:30 p.m., the interview with LN #11 resumed. The LN provided another binder of ASRs, which she indicated contained some duplicates. She also provided a 3rd binder which contained Wound or Pressure Sore Identification and Progress Records (WPSIPR). LN #11 stated the WPSIPR were used to track PUs for individual residents on a weekly basis. Review of WPSIPRs, dated 11/30/10 to 4/29/11 and 6/3/11 to 6/24/11, revealed the following documentation, in part, regarding Resident #2's heel PUs: * 11/30: (L) 6 cm x 4 cm, unstageable; (R) "2 cm dark x 4 cm red," not staged; * 12/4: (L) 10 cm x 8 cm, not staged; (R) 2 cm x 2 cm; unstageable; and 100 % slough was also documented but did not indicate to which PU it applied; * 12/10: (L) 10 cm x 8 cm, stage 2, partial thickness, 100% granulation; (R) 4 cm x 2 cm, not staged, 100 % slough; * 12/18: (L) 6 cm x 4 cm, stage 2, full thickness, yellow drainage, 100% granulation and 10% slough; (R) 2.5 x 2 cm, stage 2, full thickness, copious yellow drainage, 50% granulation/slough; * 12/24: (L) 6 cm x 4 cm, stage 2, partial thickness, copious yellow purulent and foul smelling drainage, "100% slough (with) deeper crease of slough present;" No documentation for the (R); * 1/1: (L) 4 cm x 3 cm, stage 2, partial thickness, moderate serous drainage, 70% granulation, 30% slough; (R) 2 cm x 2 cm, stage 2, partial thickness, 100% eschar; Note: The remaining WPSIPR documentation through 2/18//11 was similar to the above, save the diminishing size of both PUs and resolution on the (L) on 2/18/11. However, between 2/18 and 3/4/11, an undated WPSIPR documented, "(L) heel sm(all) scab present again same spot," and identified it as stage 2, partial thickness, with 100% eschar. Note: No other WPSIPRs were found for Resident #2 after 4/29/11, until 6/3/11. The 6/3 WPSIPR identified 0.5 x 0.5, stage 2, 100 % eschar for both of the heel PUs. The next WPSIPR regarding the (L) heel were dated 6/17 and 6/24, with resolution noted 6/24/11. And, the next WPSIPR regarding the (R) heel was dated 6/18/11 which noted resolution. Another WPSIPR, dated 7/14, documented a non-stageable, 1 cm x 1 cm (R) outer ankle wound with 100% eschar. A handwritten question mark symbol and the notation, "Could possible be a scrape" was next to the space to indicate if the area was pressure related. However, by the next entry, dated 7/28/11, the wound was documented as resolved. After review of the ASR and WPSIPR, LN #11 stated, "Now I'm getting confused." The LN indicated that LN #12 would be able to better explain the documentation. At 2:15 p.m. that afternoon, LN #11 assisted the surveyor to observe Resident #2's bilateral LE. Both of the resident's heels and ankles were intact and there were no indications of stage 1 or greater PUs noted. On 10/21/11 at 8:50 a.m., LN #12 was interviewed briefly and resumed at 11:15 a.m. with the DON present. LN #12 stated the facility used 4 binders, 2 with ASRs and 2 with WPSIPR, to track skin problems residents upstairs and downstairs. The LN stated WPSIPRs were used to track PUs and ASRs were used to track all skin issues, which included PU. LN #12 provided 3 of the binders but stated she was unable to locate the second WPSIPR binder. When asked if Resident #2's bilateral heels were reassessed during the 4 days after admission, LN #12 reviewed the resident's chart, ASR and WPSIPR documentation, and stated, "I don't see any. We focused on the hip it looks like." When asked if the facility identified the cause of the (L) heel PU infection, LN #12 stated, "The answer is no." LN #12 stated several times that the ASR and WPSIPR binders were incomplete, out of order, and "totally messed up." Resident #2 was admitted to the facility with stage 1 PU to both heels. However, the resident was harmed when the facility failed to reassess the PU for at least 4 days even though the resident was ambulatory with the use a w/c, walker, or human assistance, and the heel PU progressed to blisters. Blisters, by definition are stage 2. Also, at various times, the heel PUs were documented to contain slough and/or eschar but were documented as stage 2 and sometimes non-stageable. By definition, slough would indicate stage 3, stage 4, or non-stageable; and, eschar would indicate stage 4 or non-stageable. At one point, the (L) heel PU became infected and required the use of oral and IM antibiotics. At one point, the (L) heel PU was documented as healed but only a few days later was again noted in the ASR and WPSIPR. And, the resident later sustained a stage 2 PU to the (R) lateral ankle. On 10/21/11 at 1:45 p.m., the Administrator and DON were informed of the issue. No further information was received from the facility.