Every finding on record at Prestige Gardens Rehabilitation and Nursing Center

Based on observation, staff interviews, and record review, the facility failed to ensure a multi-use glucometer was cleaned with the appropriate cleansing wipes during use for multiple residents. This affected two (Residents #21 and #16) of two residents observed for medication administration. The facility census was 66.Findings include: Observation of medication administration on 06/23/26 between 7:19 A.M. and 8:13 A.M. revealed Licensed Practical Nurse (LPN) #110 cleaned the multi-use glucometer with an alcohol wipe prior to obtaining a blood sugar measurement for Resident #21. After LPN #110 obtained a blood sugar measurement for Resident #21, LPN #110 cleaned the multi-use glucometer with an alcohol wipe. LPN #110 then obtained the a blood sugar measurement for Resident #16 with the same multi-use glucometer. Interview with LPN #110 at the time of the observation confirmed the glucometer was a multi-use glucometer and was used for all residents that required blood sugar measurements on the 200 hall. LPN #110 confirmed he used alcohol wipes to clean the multi-use glucometer. LPN #110 confirmed the multi-use glucometer was not supposed to be cleaned with alcohol wipes, but it was supposed to be cleaned with special bleach wipes that were present in the bottom drawer their medication cart. Interview on 06/23/26 at 8:20 A.M. with Regional Nurse #106 confirmed the multi-use glucometer should be cleaned with bleach wipes and not with alcohol wipes. Regional Nurse #106 confirmed all nursing staff received education on multi-use glucometer usage and cleaning. Review of the document titled, Assure Prism Multi Blood Glucose Monitoring System Cleaning and Disinfecting the Assure Prism multi Blood Glucose Monitoring System, revealed the following disinfectant wipes have been shown for safe use with this meter: Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani-Cloth Germicidal Disposable Wipes, and CaviWipes1.

Based on record review, interview, observation, review of facility policy and review of manufacture guidelines, the facility failed to ensure an assessment or evaluation for a reasonable accommodation of need regarding a bed handrail was completed. This affected one resident (#43) out of three residents reviewed for accommodation of needs. The facility census was 63.Findings Include:Review of the medical record for Resident #43 revealed an admission date of 02/24/25. Diagnoses included total retinal detachment of left eye, asthma, chronic ischemic heart disease, and acute on chronic systolic heart failure.Review of the plan of care dated 02/25/25 revealed Resident #43 required a two person assist for transfers. The plan of care also identified the resident had behaviors related to refusals of treatment and preferred the bed in the highest position despite education on risks of injury due to falling. Interventions included educating the resident on risks of keeping the bed in the highest position and encouraging safe mobility.Review of physician orders revealed an order for an air mattress to the bed with monitoring of placement every shift for skin prevention dated 10/20/25.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition with a Brief Interview for Mental Status score of 13. The resident required assistance for bed mobility, transfers, toileting, dressing, and hygiene and utilized a wheelchair for mobility.Review of the medical record revealed no documented assessment, care plan intervention, or evaluation of the resident's request for handrails to address fear of falling.Observation and interview on 04/27/26 at 2:10 P.M., Resident #43 stated he would like handrails on his bed due to a fear of falling out of bed. He stated staff informed him that state would not allow handrails and reported he had been asking for approximately one year. He stated the facility had not completed an assessment to determine if handrails would be appropriate. An observation during the interview revealed the resident had an air mattress in place and there were no handrails.Interview on 04/27/26 at 2:36 P.M., the Administrator and Director of Nursing (DON) stated that residents with pressure reducing air mattresses automatically did not have handrails due to risk of entrapment. She stated the facility did not complete individual risk assessments for handrails when an air mattress was in use and that the resident's fear of transfers had been known since admission.Interview on 04/27/26 at 3:24 P.M., Administrator stated he was not aware of the resident's fear of falling, despite staff reports indicating prior knowledge. He stated there were no assessments in place to evaluate the appropriateness of handrails and would review the chart for additional information.Interview on 04/28/26 at 9:55 A.M., Administrator stated he spoke with Resident #43 who confirmed the ongoing fear of falling since admission. He stated staff confirmed awareness of the concern and that review of the medical record revealed no documentation of assessment or interventions related to the request for handrails. He further stated that manufacturer guidelines for the air mattress did not prohibit the use of handrails and indicated that use of bedrails should be based on an individualized assessment of the resident's physical and mental status. He stated the guidelines indicated bedrails may be used if needed to prevent fall related injury and if the resident was deemed safer with them. He confirmed that handrails were placed on the resident's bed following surveyor intervention and that a restraint assessment would be completed. He confirmed the resident was independently capable of maneuvering in bed and that handrails would be appropriate.Review of facility policy and manufacturer guidance related to bed safety and the Easy Air mattress revealed that decisions regarding the use of bedrails should be based on an individualized assessment of the resident's physical and mental status.Review of the facility policy titled, Bed Safety revealed that if bedrails are needed to prevent fall related injury, they may be used based on facility assessment and the resident's safety needs. The guidance further indicated that the use of bedrails is not prohibited with the mattress and should be determined by the facility.This deficiency represents non-compliance investigated under Complaint Number 2624876.

Based on observation, record review, staff interview, and facility policy review, the facility failed to timely assess a resident after a fall and timely document the fall in the residents medical record. This affected one (Resident #14) out of three residents reviewed for falls. The facility census was 63.Findings Include: Review of the medical record for Resident #14 revealed an admission date of 08/23/24. Diagnoses included Huntington's disease, hypothyroidism, constipation, and dementia.Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls.Review of the plan of care dated 08/26/24 revealed the resident was at risk for falls due to increased need for assistance with bed mobility and transfers, Huntington's disease, overactive bladder, and history of falls. Interventions included ensuring the call light was within reach, use of bolsters to the left side and bottom of the bed, dycem to the wheelchair, ensuring the resident was sitting fully back in the wheelchair prior to transfers, use of a floor mat to the left side of the bed, maintaining a low bed, use of nonskid footwear, supervision while in the bathroom, and staff to remain with the resident while in the bathroom.Observation on 04/28/26 at 2:18 P.M. revealed Resident #14 began to shake and fell out of bed onto a floor mat, onto her back. The bed was in the low position. Staff did not immediately respond until this surveyor alerted staff. Two staff members then assisted the resident back into bed with a two person assist. The resident was not immediately assessed when found on the floor or when she was back in bed, and vital signs were not obtained. Interview on 04/28/26 at 2:58 P.M., Licensed Practical Nurse (LPN) #58 stated that the resident had Huntington's disease and had increased shaking over the past week. He stated he obtained assistance and completed a two person assist to return the resident to bed. He stated that no vital signs were taken immediately after the fall and at the time of the interview, had still not been completed. He stated an as needed (PRN) pain medication was administered after the fall but had been requested prior to the fall. He stated the resident had a care plan related to behaviors and a floor mat and reported that staff typically did not complete a fall assessment if the resident was found on the floor mat next to the bed.Review of Resident #14's nurse's notes on 04/29/26 at 7:38 A.M. revealed no documentation regarding the fall that occurred on 04/28/26.Review of the nurse's notes dated 04/29/26 at 8:40 P.M. revealed the resident was found lying next to the bed and was assessed for injury with no injury noted, range of motion was within normal limits, and the resident denied pain.Interview on 04/28/26 at 3:21 P.M., the Administrator and Regional Nurse #500 stated that the resident frequently got out of bed and this was considered a behavior. They stated that if staff observed the resident getting out of bed, they would not complete a fall assessment or obtain vital signs. They stated that if the fall was unwitnessed, staff should complete a fall assessment, vital signs, and a head to toe assessment. They further stated that if the resident was found on the fall mat, staff would typically not complete a fall assessment even if the fall was not witnessed.Review of facility policy titled Falls - Clinical Protocol, revised September 2012, revealed the facility required staff to assess and document all falls, including obtaining vital signs, assessing for injury, neurological status, pain, and changes in condition. The policy required staff to identify possible causes of the fall within 24 hours, document contributing factors, and implement interventions to prevent recurrence. The policy further required monitoring and follow up after a fall, including ongoing assessment of the resident's condition and response to interventions.This deficiency represents non-compliance investigated under Master Complaint Number 2990783 and Complaint Number 2734881.

Based on observation, medical record review, resident and staff interviews, and review of a facility policy, the facility failed to ensure pain was adequately addressed and managed for a resident with complaints of pain. This resulted in actual harm when Resident #159 experienced severe breakthrough pain from a fractured tibia and fibula and was not assessed for pain or offered pain relieving interventions, including medications, to treat the resident's pain. The resident was observed multiple times displaying outward expressions of pain including moaning, tearfulness, and fist-clinching, during general observations and during direct care. This affected one (#159) of two residents reviewed for pain. The census was 56. Findings include: Medical record review for Resident #159 revealed an admission date of 01/15/25. Diagnoses included heart failure, renal insufficiency, diabetes, depression, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #159 was cognitively intact and required setup or clean-up assistance for eating, was dependent for toileting and transfers, required substantial/maximal assistance for bed mobility and was frequently incontinent bowel and bladder. Review of the physician orders dated 03/11/25 revealed Resident #159 was to receive the narcotic pain medication Norco 7.5-325 milligrams (mg) with instructions to give one tablet every six hours as needed for pain. Further review revealed the resident was ordered the pain medication Tylenol 650 mg with instructions to give one tablet every six hours as needed for pain. Review of the care plan for Resident #159 dated 03/11/25 revealed the resident was on pain medication therapy related to generalized complaints of pain, surgical wounds, with an updated notation on 04/24/25, indicating the resident experienced pain from fracture. Interventions were to administer analgesic medications as order by the physician, monitor and document side effects and effectiveness every shift, attempt non-pharmacological interventions prior to as needed medication, monitor for increase of falls, anticipate the resident's need for pain, and respond immediately to any complaint of pain. Review of a pain assessment dated [DATE] revealed Resident #159 had frequent pain in the last five (5) days that made it hard to sleep at night and limited her day-to-day activities because of the pain. The resident's pain was rated at a seven on a 10-point scale with a goal of a pain score of one (1) and there were not any verbal descriptors documented. Review of Resident #159's May 2025 medication administration record (MAR) revealed there was not any Tylenol or Norco administered to the resident between 05/02/25 at 2:16 P.M. to 05/04/25 at 7:39 P.M. There were no pain medications administered on 05/03/25 and no documented evidence of the resident refusing Norco or Tylenol in May 2025. Further review revealed there was no documentation of non-pharmacological interventions for pain attempted between 05/02/25 at 2:16 P.M. to 05/04/25 at 7:39 A.M. Review of the progress notes dated 05/03/25 revealed there was no documentation regarding Resident #159's pain or interventions to manage pain. Observation and interview with Resident #159 on 05/05/25 at 10:47 A.M. revealed she was lying in bed tearful and moaning, and stated her pain was in her left tibia and fibula due to a fracture. The resident reported she had to wait another two hours until her pain medication was due, and she rated her pain as an eight (8) on a 10-point scale. She stated she was used to waiting until her pain medication came due. A follow-up interview with Resident #159 at 11:22 A.M. revealed on 05/03/25 she did not receive any medications for pain and usually when she was in pain the nurse would call the physician and get her more medication to help with her pain. She reported this was not done on the 05/03/25. Observation and interview with Certified Nurse Aide (CNA) #53 on 05/05/25 at 11:18 A.M. revealed, while repositioning Resident #159 the resident moaned, and CNA #53 stated the resident was in more pain than normal and could not have her pain medication until 12:00 P.M. CNA #53 stated the resident was also in pain on 05/03/25 and CNA #53 reported it to Licensed Practical Nurse (LPN) #98. Interview with LPN #98 on 05/05/25 at 1:38 P.M. revealed CNA #53 told him Resident #159 was in pain on 05/03/25. He confirmed he would usually go to the resident's room and assess the resident for pain and medicate them. LPN #98 confirmed he did not give Resident #159 anything for pain on 05/03/25 and could not remember why he did not. Interview with Registered Nurse (RN) #118 on 05/05/25 at 11:53 A.M. revealed Resident #159 reported to her at about 10:02 A.M., she was in pain that was aching since she fractured her tibia and fibula, and the resident refused the Tylenol the nurse offered. RN #118 also stated she told Resident #159 her Norco was not due yet. She stated she reported Resident #159's pain to Nurse Practitioner (NP) #502 and the NP was not going to change the order at that time. Interview with NP #502 on 05/05/25 at 11:58 A.M. denied she was called or informed when she made rounds on that day by RN #118 concerning Resident #159's pain. A subsequent interview on 05/07/25 at 10:44 A.M. with NP #502 revealed she did not work on weekends and the service was not notified of any pain issues for Resident #159 on 05/03/25. Observation and interview on 05/06/25 at 7:42 A.M. of Resident #159 revealed she was lying in bed tearful and moaning and said she was in pain with a pain level of 8. She reported she received her pain medication at 7:00 A.M. Observation and interview on 05/06/25 at 7:50 A.M. during incontinence care, placing Resident #159 in the mechanical (Hoyer) lift, and transferring her to the dialysis chair revealed, during incontinence care, Resident #159 stated every time the nurse aides turned her, she yelled out in pain, but they continue with the care. Observation revealed when the staff members placed Resident #159 in the Hoyer lift, she was tearful, moaning, and clenching her fists. CNA #45 asked the resident how her leg was doing and the resident said she was in pain and had her pain medication at 7:00 A.M. Continued observation revealed the resident moaned in pain again when the nurse aides placed her in the dialysis chair. Review of policy titled, Pain Protocol, dated 06/01/13 revealed the physician and staff will identify individuals who have pain or who are at risk for having pain. This includes a review of each person's known diagnoses and conditions that commonly cause or predispose to pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post stroke syndromes. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary (non-pharmacological) treatments. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly re view, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, including complications such as gait disturbances, social isolation, and falls.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to provide palatable meals to the residents. This had the potential to affect all 56 residents living in the facility whom all ate meals from the kitchen. The facility census was 56. Findings include: Observation of a lunch test tray meal on 05/07/25 at 11:52 A.M. revealed the meatloaf served was dark, crunchy, and dry. Interview with Regional Director of Dining Services #150 on 05/07/25 at 11:58 A.M. confirmed the meatloaf was dry. He stated it stayed in the oven too long. Interview with three (#46, 51, and 53) residents on 05/07/25 from 12:00 P.M. to 12:06 P.M. confirmed the meatloaf served to them was dry, crunchy, and cut too thin. Review of an undated facility policy titled, Food Presentation, revealed meals will be served in a manner that enhances the appetite through eye appeal. Foods are prepared to prevent overcooking of foods. Each item is checked for proper temperature, taste and consistency prior to serving time.

Based on observation, staff interview, and policy review, the facility failed to maintain proper infection control practices in handling soiled linens, sanitizing glucometers, and providing care of a gastrostomy tube. This deficient practice had the potential to affect all 56 residents residing in the facility. The census was 56. Findings included: 1. Observation on 05/08/25 at 5:10 A.M. revealed Certified Nurse Aide (CNA) #26 was walking in the 400 hall while carrying unbagged linens. Interview on 05/08/25 at 5:11 A.M. with CNA #26 confirmed he was carrying unbagged linens and recently walked out of a resident's room. CNA #26 confirmed dirty linens were to be placed in a bag prior to leaving a resident's room. Review of facility policy for soiled laundry and bedding, dated July 2009, revealed contaminated or potentially contaminated laundry is to be placed in a bag or container a the location were it is used and transport contaminated laundry in bags or containers. 2. During an observation of medication administration for Resident #32 on 05/08/25 at 6:15 A.M. revealed Licensed Practical Nurse (LPN) #90 took gentamicin cream into the room, washed her hands, and placed gloves on her hands. LPN #90 then proceeded to remove the bandage with yellow drainage on it from around the resident's gastrostomy tube (g-tube). The LPN continued the procedure wearing the same gloves, took a cotton swab, and ran it around the g-tube site, then took a new cotton swab, placed the gentamicin ointment on it, and placed ointment around the resident's g-tube site. LPN #90 proceeded to place a new dressing around the g-tube site at that time. Interview with LPN #90 on 05/08/25 at 6:29 A.M. revealed she did not wash around Resident #90's g-tube site because the medication was oil-based and she confirmed she did not change her gloves in between removing the old bandage and applying a clean treatment. Review of the policy titled, Dressing Dry/Clean, dated 09/01/13, revealed the procedure instructed staff to clean the bedside stand and establish a clean field. Next, place the clean equipment on the clean field and arrange the supplies so they can be easily reached. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. Position resident and adjust clothing to provide access to affected area. Wash and dry your hands thoroughly then put on clean gloves and loosen tape and remove soiled dressing. Next, pull gloves over dressing and discard into plastic or biohazard bag, and wash and dry your hands thoroughly. Then, open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. Label tape or dressing with date, time and initials and place on clean field. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze), wash and dry your hands thoroughly, and put on clean gloves. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). Use dry gauze to pat the wound dry. Apply the ordered dressing and secure with tape or bordered dressing per order, and label with date and initials to top of dressing. Staff then should discard disposable items into the designated container, remove disposable gloves and discard into designated container, wash and dry your hands thoroughly, then reposition the bed covers to make the resident comfortable. 3. During an observation of a blood glucose test on 05/08/25 at 6:35 A.M., LPN #90 took a glucometer out of the medication cart and cleaned it with an alcohol swab. Interview with the LPN #90 on 05/08/25 at 6:39 A.M. revealed she cleaned the glucometer with an alcohol swab because that was what she was supposed to cleanse it with. Review of policy titled, Cleansing and Disinfecting Blood Glucose Monitoring System, dated 06/01/15, revealed to use Clorox Germicidal Wipes or Super Sani-Cloth Germicidal Disposable Wipes for cleaning the glucometer.

Based on medical record review, review of infection control logs, and staff interview, the facility failed to ensure an adequate and complete antibiotic stewardship program was implemented to monitor for possible infections within the facility and determine appropriateness of antibiotic use. This had the potential to affect all 56 residents residing in the facility. The facility census was 56. Findings include: 1. Review of the facility infection logs dated between November 2024 and April 2025 revealed the facility did not include any other possible infectious findings or residents with possible symptoms of an infection that were not started on antibiotics. The facility only included those residents who were started on an antibiotic medication on their infection control tracking logs. Further review revealed the facility also did not include the start date of any symptoms of possible infections what the symptoms were, and the logs did not include whether a chest x-ray or laboratory values were ordered and/or completed. Interview on 05/08/25 at 5:50 P.M. with Regional Clinical (RC) #152 confirmed she would expect the facility to maintain a thorough infection control log of infections including information of symptom onset and what the symptoms were, if scans or laboratory values were taken and what the results were, and if the totality of the information met criteria for antibiotic usage using McGeer's criteria (a set of standardized definitions used in long-term care facilities (LTCFs) to identify and track healthcare-associated infections (HAIs). RC #152 confirmed the infection control logs from November 2024 through April 2025 were missing this information. 2. Review of the medical record for Resident #22 revealed an admission date of 06/09/21. The resident had a diagnosis of a stage four pressure wound (full-thickness skin and tissue loss). Review of a McGeer's assessment dated [DATE] revealed Resident #22 had a wound infection with symptoms including heat, redness, swelling, tenderness, and drainage at the site. Resident #22 met criteria for antibiotics. Review of Resident #22's physician orders dated 04/09/25 revealed an order for the antibiotic medication metronidazole oral tab 500 milligrams (mg) with instructions to apply cream to the sacral wound every shift and as needed. Review of the wound assessment dated [DATE] revealed Resident #22 had a stage four sacral pressure wound with drainage that was foul smelling, suggesting possible bacterial burden. The orders included instructions to fill the wound cavity with gauze puffs. Interview on 05/08/25 from 4:00 P.M. to 5:34 P.M. with RC #152 reported Resident #22's wound did not have anything to be cultured and hospice ordered the antibiotic. RC #152 stated the facility had no evidence to provide as to why a culture was not completed on the wound drainage or that the wound bed was not swabbed for possibly infectious matter. RC #152 also stated there was no evidence to provide for any additional evidence of an infection in March 2025 as the McGeer's assessment would suggest and confirmed it was on the infection log for April 2025. 3. Review of the medical record for Resident #162 revealed an admission date of 06/08/21. The resident had a diagnosis of a urinary tract infection (UTI). Review of Resident #162's urine sensitivity laboratory values revealed the resident's urine was cultured on 04/03/25 and results mentioned the culture was 75,000 colony forming units per milliliter (CFU/mL) to 100,000 CFU/mL (not over). The facility was unable to produce evidence the culture that was completed to determine organism. Review of Resident #162's McGeer's assessment dated [DATE] revealed the resident met criteria including acute dysuria or pain or swelling and over 100,000 CFU/mL of no more than two species of organisms. Review of Resident #162's physician orders from 04/07/25 to 04/09/25, and again from 04/09/25 to 04/12/25, revealed the resident was ordered the antibiotic Macrobid oral capsule 100 mg. Interview on 05/08/25 between 4:00 P.M. and 5:34 P.M. with RC #152 confirmed the facility did not have any records onsite and had to gather them from outside agencies. RC #152 stated the facility did not have a copy of Resident #162's urine culture for use of Macrobid. 4. Review of the medical record for Resident #309 revealed an admission date of 04/16/25. The resident had a diagnosis of a UTI. Review of Resident #309's urinary culture dated 04/14/25 revealed multiple organisms greater than 100,000 CFU/mL with a notation that results suggest improper specimen collection or delay in delivery. Review of Resident #309's physician orders for 04/16/25 to 04/17/25 revealed an order for the antibiotic cephalexin 500 mg oral tab with the order rewritten from 04/17/25 to 04/20/25. Review of infection control documentation provided revealed facility had no evidence of a McGeer's assessment being completed for Resident #309's UTI to determine if use of the antibiotic was appropriate. Interview on 05/08/25 between 4:00 P.M. to 5:34 P.M. with RC #152 confirmed the facility did not complete McGeer's assessments for hospital admissions and revealed Resident #309 was started on the antibiotic in the hospital and the facility does not review those to ensure they meet criteria for antibiotic use when a resident is admitted to the facility. Review of the facility policy titled, Antibiotic Stewardship, dated 12/2016, revealed antibiotics shall be prescribed under the guidance of the antibiotic stewardship program. The policy did not describe how facility shall ensure appropriateness before starting an antibiotic and did not discuss logging information related to infections.

Based on review of employee files, resident interviews and staff interviews, the facility failed to ensure a certified nurse aide (CNA) completed no less than twelve (12) hours of required in-servicing education each year. This had the potential to affect all 56 residents in the facility. The census was 56. Findings include: Review Resident #15's medical record revealed an admission date of 06/25/21. The resident was admitted with a diagnosis of major depressive disorder. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13, indicative of intact cognition. Interview with Resident #15 on 05/06/25 at 10:25 A.M. revealed she had experienced CNA #22 treating her in a disrespectful manner in the recent past. Resident #15 indicated she did not feel threatened. Review of the medical record for Resident #12 revealed an admission date of 05/01/23 with diagnoses including major depressive disorder and generalized anxiety disorder. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 14, indicative of intact cognition. Interview with Resident #12 on 05/08/25 at 3:05 P.M. revealed she had witnessed CNA #22 treating Resident #15 in an undignified and disrespectful manner. Resident #12 communicated she did not classify CNA #22's behavior as abusive, but she felt that it was disrespectful. Review of CNA #22's employee file revealed he was hired on 08/02/23. Review of CNA #22's attended in-service educations revealed he attended three (3) out of twelve in-service educations in the previous 12 months for a total of 3 hours. Review of the twelve offered in-service educations from the previous twelve months revealed he missed the in-service educations for resident rights, infection control, code of conduct compliance and ethics, emergency preparedness, elopement, customer service with a person-centered approach, first aid basics, behavior management, communication and conflict resolution, and abuse and neglect. Interview with Business Office Manager #20 on 05/08/25 at 4:14 P.M. confirmed CNA #22 only completed 3 out of 12 required in-services, for a total of 3 hours of education in the previous 12 months, and also confirmed CNA #22 did not complete the in-service educations on customer service, communication and conflict resolution, and abuse and neglect.

Based on observations, staff interviews and review of facility policy, the facility failed to provide a homelike dining environment in the main dining room, this affected eight residents that were identified as eating lunch in the dining room (Resident #5, #6, #7, #21, #28, #35, #36, and #41). The facility also failed to ensure clean linens were provided to one (Resident #309) of nine (Resident #4, #10, #14, #18, #19, #36, #50, and #51) residents reviewed for environment. The facility census was 56 residents. Findings include: 1. Observation on 05/05/25 at 11:41 A.M. of the dining room during lunch time revealed an unclean un-homelike environment when the following was observed: a full-size refrigerator with a padlock locking mechanism on the outside of it. On the refrigerator there was dry food and dust . A counter housing a sink revealed four dishes dirty with dry food , silverware, and cups from the breakfast service were present. In the far-right corner of the dining room closest to the entry to the kitchen revealed a mop bucket with a dirty mop and dirty water in it. Beside the bucket a sheet pan rack with two bins at the bottom with dirty dishes, on the top of the rack three rows down were two trays with breakfast remains on the trays. Interview with Regional Dietary Services Director #150 on 05/05/25 at 11:45 A.M. confirmed the presence of the above description of the dining room during lunch service. 2. Review of the medical record for Resident #309 revealed an admission date of 04/16/25. Diagnoses included urinary tract infection, metabolic encephalopathy, and neurocognitive disorder. Observation 05/05/25 at 10:32 A.M. revealed Resident #309 had a cut on her elbow. Resident had a pillow without a pillow case that had several dried blood stains on it. On the sheet were observed with several spots of dried blood on both the top and side of the sheet. Observation on 05/05/25 at 5:10 P.M. with Licensed Practical Nurse #97 confirmed resident had linens with dried blood. Review of facility policy titled, Quality of Life - Homelike Environment dated 05/2017 revealed residents shall be provided with a clean and homelike environment including clean bed and bath linens in good condition.

Based on record review, observations and resident interviews, the facility failed to ensure resident concerns were addressed timely and appropriately during resident council meetings. This affected six Residents (#5, #15, #17, #27, #35 and #44) that regularly attend resident council meetings. The facility census was 56. Findings include: Interview on 05/06/25 at 10:01 A.M. with Resident #30 revealed the facility staff do not respond to call lights timely. Interview on 05/06/25 at 11:10 A.M. with Resident #13 reported the facility had issues with smoke breaks including missing them, being late, and not allowing them to be long enough. He revealed the facility did not address concerns in a timely manner. Interview on 05/08/25 at 11:03 A.M. with Activity Director #16 confirmed resident have the same concerns brought up each resident council meeting including call light response times and issues with the smoke break. She revealed after the council meeting she completes the top part portion of a resident concern form and provides the form to the Administrator who passes them out to various department heads. She acknowledged issues with activities was brought up a few times and revealed they are trying to add new activities to the calendar, however a lot of resident want to keep the activities the same and not change the activities. She acknowledged a concern with having the same topic brought up every month or consistently brought up showing the facility had not addressed the issue to the residents satisfaction. Review of resident council meeting dated 06/05/24 revealed concern related to having trouble finding an aide in the dining room, showered not being timely, residents not being changed timely (incontinence care), wanting more activities, and aides on all shifts not answering call lights. Review of concern form dated 06/05/24 revealed the Assistant Director of Nursing completed an audit and check and changes were completed every two hours. Facility was unable to provide any evidence of an audit being completed. Review of concern form dated 06/05/24 revealed Activities needed to change it up and resident wanted to go on outings. The response included scheduled more outings and changed things slowly as residents do not like change. Review of concern form dated 06/06/24 revealed two resident had identified concerns regarding not receiving showers and the response was both residents had history of frequent refusals. It was not mentioned if they were offered a shower or asked about changing schedules or to trouble shoot why they had a history of refusals. It also stated staff to continue to encourage residents. Review of concern form dated 06/09/24 revealed aides on all shifts were not answering call light timely. Facility completed an audit from 7:00 P.M. to 7:00 A.M. and 7:00 P.M. to 11:00 P.M. and all were answered within 20 minutes with most answered in less than 5 minutes. It also mentioned education was provided but did not state to whom or what the education included. Review of resident council meeting dated 07/03/24 revealed concern related to an specific aide not doing her job, being rude and neglecting her duties. Review of the concern form dated 07/08/24 revealed the staff member was educated. Facility had no statements from staff, audits or observations of staff behavior documented after allegation. Review of resident council meeting dated 09/13/24 revealed concern related to activities and resident wanting more outdoor trips traveling with facility van. Facility had no evidence of any concern form from this resident council meeting. Review of resident council meeting dated 10/02/24 and 10/03/24 revealed staff on third shift shut off call lights without completing request, more outdoor activities, and issues with the 9:00 P.M. smoke break Facility had no evidence of any concern form from this resident council meeting. Review of resident council meeting dated 11/20/24 revealed concern related to call lights being shut off and not answered in a timely manner Review of the concern form dated 11/27/24 revealed interviews were completed and no concerns identified. It did not state who was interviewed. Call light audits were not completed and call light responses were not monitored. Review of the resident council meeting dated 12/2024 revealed no meeting was held this months due to holidays and illness. Review of resident council meeting dated 01/09/25 revealed concern related to nurses not passing pain medication timely. Review of the concern form dated 01/13/25 revealed more information, will discuss with a (named individual). It was unknown if this was a resident or staff. The form did not provide any added resolution of what was done or how concern was monitored for compliance. Review of resident council meeting dated 02/05/25 revealed concern related to call lights not being answered timely and being shut off without completing requests and more choices for food. Review of the concern form dated 02/10/25 revealed a call response delay was identified with plan to monitor call light. It included no call light audits or plan for how call light responses would be monitored. Facility had no evidence of any concern form from this resident council meeting related to food choices. Review of resident council meeting dated 03/07/25 revealed concern related to the 9:00 P.M. smoke break and no staff available to take residents out. Review of the concern form dated 03/10/25 the smoke break process was discussed at morning meeting and plan for camera support for write ups if staff are not taking residents out for the 9:00 P.M. smoke break. Review of resident council meeting dated 04/02/25 revealed concern related to call lights not being answered timely, wanting more activity outings, and laundry not being delivered timely. Review of the concern form dated 04/02/25 for the laundry concern stated, needs more detail. Review of the concern form dated 04/12/25 for the call lights revealed DON said he could do an audit and stated, needs more information. Review of the concern form dated 04/12/25 for the 9:00 P.M. smoke break stated the cameras were reviewed and smoke break was late and staff should be more cognizant of the smoke time but provided no plan or follow up for how facility would ensure smoke times were honored. Interview on 05/08/25 at 12:00 P.M. with Administrator confirmed the same topics had been brought up several times in the past 10 months at resident council meetings. He acknowledged the facility should address concerns that residents bring up during the resident council meetings and had no explanation for missing concern forms, and forms completed which provided little details on a plan to be in compliance. He also acknowledged putting needs more information on a concern form did not show the facility made any corrections.

Based on observation and interviews, the facility failed to ensure residents had access to their personal care needs account on an ongoing basis. This had the potential to affect all 24 (#01, #04, #05, #06, #07, #08, #10, #13, #14, #16, #19, #21, #22, #23, #25, #26, #28, #35, #36, #38 , #39, #42, #44, and #162) residents who have authorized the facility to [NAME] their personal financial accounts. The census was 56. Findings Include: An interview on 05/08/25 at 9:15 A.M. with the Business Office Manager #20 (BOM) confirmed the banking hours for residents to receive funds from their personal care needs account are 10:00 A.M. to 3:00 P.M. Monday through Friday. She denied knowing if residents could get money out of their accounts on weekends or after 3:00 P.M. during the weekdays. An interview on 05/08/25 at 10:00 A.M. with the Administrator confirmed banking hours for residents to withdraw money from their personal care accounts is Monday through Sunday 10:00 A.M. to 3:00 P.M. He denied anyone being able to get their money after these hours. A supervisor is on staff during all shifts, however, they do not have access to petty cash; to accommodate residents should they need money after 3:00 P.M. He revealed he could not trust a nurse to handle a petty cash box. Observation upon entry into the building at the receptionist area on a side table revealed a sign stating, Banking Hours Monday-Friday 10 AM to 3PM Sat. -Sun please report to the Manager on duty/Receptionist to get funds. Review of facility policy titled, Deposit of Resident Funds, dated 04/2017, revealed provide the resident's access to funds of fifty (50) dollars within a reasonable period, and access to funds more than fifty (50) dollars within three banking days.

2. Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with activities of daily living and had no history of behaviors. Review of facility self reported incidents (SRI)s revealed no submission related to verbal abuse allegation involving Resident #14. Telephone interview on 05/06/25 at 9:43 A.M. with Certified Nursing Assistant (CNA) #51 revealed she witnessed very concerning behavior from CNA #22 a little less than one month ago. CNA #51 stated that she overheard CNA #22 get into a verbal disagreement with Resident #14 and Resident #27 in the TV room/hallway and it escalated when that aide got into Resident #14's face yelling shut up and pointing finger at him. CNA #51 described it as a full-on fight and advised CNA #22 to walk away and ignore Resident #14. Furthermore, CNA #22 was saying offensive things to other residents and making side comments. CNA #51 attested this was full on verbal abuse because CNA #22 was threatening, getting too aggressive, and she believed it was going to turn into something more. CNA #51 reported to Unit Manager Nurse (UMN) #127 by phone 30 minutes after the incident occurred. CNA #51 confirmed she filled out a paper report and slid it under a staff's door. Interview with UMN #127 on 05/06/25 at 9:52 A.M. confirmed CNA #51 notified her by telephone of the incident and reported residents were getting loud with staff and that residents were yelling at CNA #22. She stated she was unsure what they were yelling about. UMN #127 confirmed CNA #22 was working the evening of the alleged incident and CNA #51 intervened. UMN #127 stated followed up was completed with Resident #14 and Resident #127 and reported there were no issues, however UMN #127 could not recall when the follow up occurred. UMN #127 stated they spoke with CNA #22 who reported residents did get loud on the evening of the incident and there was an argument. UMN #27 confirmed the interviews reveled no indications there was a problem during that night shift. UMN #127 confirmed she did not report the alleged incident of verbal abuse to the Director of Nursing and/or Administrator. Interview with Resident #14 on 05/06/25 at 9:59 A.M. confirmed CNA #22 initially yelled at Resident #27, so Resident #14 stood up for him and that is when CNA #22 got in his face and was screaming and hollering at him. He could not recall exact words. Staff intervened and the incident was over. Resident #14 confirmed he felt threatened and reported it was verbal abuse. Interview with Resident #27 on 05/06/25 at 10:04 A.M. revealed that he didn't remember the incident and did not elaborate. Interview with UMN #127 on 05/06/25 at 4:43 P.M. confirmed no paper report from CNA #51 could be located as she claimed she checked multiple places and mailboxes including the Director of Nursing (DON)'s office and her office. Interview with DON on 05/07/25 at 8.56 A.M. confirmed he had not received a report of abuse involving Resident #14 and this was the first time he heard about it. Interview with Administrator on 05/07/25 at 9:00 A.M. confirmed he was not aware of a report of abuse between CNA #22 and Resident #14. He denied having a report from CNA #51. With surveyor intervention a State Reported Incident (SRI) has been filled with the State Agency. Review of facility staff assignments, including all shifts, from beginning of April 2025 until current day were provided. CNA #22 was on schedule for various night shifts. DON confirmed that CNA #22 worked shifts through April 2025 and May of 2025 even after UMN #127 received a report of resident abuse by CNA #51 to UMN #127. Review of facility policy titled 'Abuse, Neglect, Exploitation, & Misappropriation of Resident Property,' states If a staff member is accused or suspected of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. Based on observation, medical record review, staff and resident interview and policy review the facility failed to ensure the abuse policy was followed for an injury of unknown origin for Resident #159 and an allegation of verbal abuse for Resident #14. This affected two (#159 and #14) of three residents reviewed for following the abuse policy. The census was 56. Findings included: 1. Medical record review for Resident #159 revealed an admission date of 01/15/25. Medical diagnoses included heart failure, renal insufficiency, diabetes, depression and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #159 was cognitively intact. Functional status was setup or clean up for eating, she was dependent for toileting and transfers. She was substantial/maximal assistance for bed mobility. She was frequently incontinent for bowel and bladder. Review of a progress note dated 04/16/25 at 6:00 P.M. for Resident #159 revealed the hospital had called the facility and reported the resident was being admitted due to a fall. She was out of the facility for a follow-up doctor's appointment and during transport, with a company that was an outside service, the resident fell out of her wheelchair and broke her left lower extremity and will be needing surgery. Review of the hospital paperwork dated 04/16/25 revealed Resident #159 presented to the emergency room after a motor vehicle accident with complaints of left leg pain. An X-ray revealed a displaced left tibia and fibula fractures with associated proximal fibula fracture. Review of the investigation for Resident #159 dated 04/17/25 revealed there was a timeline of events, resident interview, and hospital paperwork. Interview with Resident #159 on 05/05/25 at 10:52 A.M. revealed she went out to an appointment on 04/16/25 to see her vascular surgeon. On the way back to the facility, she reported the driver was going the wrong way and she told him he took the wrong exit and he slammed on the brakes and she became unbuckled from her wheelchair and dropped onto the floor and slid on the floor and her left leg jammed underneath the drivers seat in front of her. She revealed she was sent to the hospital and had surgery to repair her leg. Interview with the Director of Nursing (DON) on 05/05/25 at 1:04 P.M. revealed the hospital called and said the resident had been in a motor vehicle accident. He reported the facility received the hospital records and they said Resident #159 had been in a motor vehicle accident. He reported he didn't called the police department to get the details of the accident or get a police report. He confirmed he didn't investigate thoroughly, didn't report the alleged abuse, or follow the policy. Review of the policy entitled Abuse, Neglect, Exploitation, and Misappropriation of Resident's Property dated 11/01/19 revealed all incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the State Agency. Once the Administrator and the state agency were notified, an investigation of the allegation violation will be conducted. an investigation of the allegation violation will be conducted. 1. Time frame for investigation The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days 2. Investigation protocol The person investigating the incident should generally take the following actions: Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. 3. If there are no direct witnesses, then the interviews may be expanded. For example, to cover all employees on the unit, or, as appropriate, the shift. For Injuries of Unknown Source, the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well.

Based on observation, staff interviews and review of facility policy, the facility failed to provide dignity during dining when staff was standing over a resident while assisting with feeding. This affected one resident (Resident #16) out of six residents (#7, #12, #14, #15, #16, #36) reviewed for dignity. The census was 56 residents. Findings include: Review of Resident #16's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included hypertension, osteoarthritis, major depressive disorder, and generalized anxiety disorder. Review of Resident #16's quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 11, indicative of mildly impaired cognition. MDS assessment further revealed Resident #16 was independent for eating. Review of Resident #16's self care deficit care plan dated 06/22/22 revealed she was at risk for self care deficit related to an increased need for assistance with her activities of daily living depending on her mood, energy level and pain. The care plan indicated one of her interventions was to provide supervision with one person assistance. Observation on 05/05/25 from 4:32 P.M. to 4:37 P.M. revealed Certified Nursing Aide (CNA) #32 was standing over Resident #16 while assisting with feeding her. Interview with Licensed Practical Nurse (LPN) #94 on 05/05/25 at 4:37 P.M. confirmed CNA #32 was standing over Resident #16 while feeding her. Interview with CNA #53 on 05/05/25 at 4:57 P.M. confirmed the CNAs frequently stand while assisting with feeding residents. Review of a facility policy titled Assistance with Meals dated July 2017 revealed that the facility staff will serve resident trays and will help residents who require assistance with eating. Residents will be fed with attention to dignity, for example, not standing over residents while assisting them with meals.

Based on medical record review, resident interviews, staff interviews, and review of facility policy, the facility failed to protect a resident (Resident #14) after an allegation of verbal abuse by a staff member and continued to let the staff member work at the facility. This affected one resident, Resident #14, out of three residents (#15, and #16) reviewed for abuse. The facility census was 56. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with activities of daily living and had no history of behaviors. Review of facility self reported incidents (SRI)s revealed no submission related to verbal abuse allegation involving Resident #14. Interview with Regional Operations Director #154 on 05/06/25 at 9:29 A.M. revealed no reports of abuse in the last month. Telephone interview on 05/06/25 at 9:43 A.M. with Certified Nursing Assistant (CNA) #51 revealed she witnessed very concerning behavior from CNA #22 a little less than one month ago. CNA #51 stated that she overheard CNA #22 get into a verbal disagreement with Resident #14 and Resident #27 in the TV room/hallway and it escalated when that aide got into Resident #14's face yelling shut up and pointing finger at him. CNA #51 described it as a full-on fight and advised CNA #22 to walk away and ignore Resident #14. Furthermore, CNA #22 was saying offensive things to other residents and making side comments. CNA #51 attested this was full on verbal abuse because CNA #22 was threatening, getting too aggressive, and she believed it was going to turn into something more. CNA #51 reported to Unit Manager Nurse (UMN) #127 by phone 30 minutes after the incident occurred. CNA #51 confirmed she filled out a paper report and slid it under a staff's door. Interview with UMN #127 on 05/06/25 at 9:52 A.M. confirmed CNA #51 notified her by telephone of the incident and reported residents were getting loud with staff and that residents were yelling at CNA #22. She stated she was unsure what they were yelling about. UMN #127 confirmed CNA #22 was working the evening of the alleged incident and CNA #51 intervened. UMN #127 stated followed up was completed with Resident #14 and Resident #127 and reported there were no issues, however UMN #127 could not recall when the follow up occurred. UMN #127 stated they spoke with CNA #22 who reported residents did get loud on the evening of the incident and there was an argument. UMN #27 confirmed the interviews reveled no indications there was a problem during that night shift. UMN #127 confirmed she did not report the alleged incident of verbal abuse to the Director of Nursing and/or Administrator. Interview with Resident #14 on 05/06/25 at 9:59 A.M. confirmed CNA #22 initially yelled at Resident #27, so Resident #14 stood up for him and that is when CNA #22 got in his face and was screaming and hollering at him. He could not recall exact words. Staff intervened and the incident was over. Resident #14 confirmed he felt threatened and reported it was verbal abuse. Interview with Resident #27 on 05/06/25 at 10:04 A.M. revealed that he didn't remember the incident and did not elaborate. Interview with UMN #127 on 05/06/25 at 4:43 P.M. confirmed no paper report from CNA #51 could be located as she claimed she checked multiple places and mailboxes including the Director of Nursing (DON)'s office and her office. Interview with DON on 05/07/25 at 8.56 A.M. confirmed he had not received a report of abuse involving Resident #14 and this was the first time he heard about it. Interview with Administrator on 05/07/25 at 9:00 A.M. confirmed he was not aware of a report of abuse between CNA #22 and Resident #14. He denied having a report from CNA #51. With surveyor intervention a State Reported Incident (SRI) has been filled with the State Agency. Review of facility staff assignments, including all shifts, from beginning of April 2025 until current day were provided. CNA #22 was on schedule for various night shifts. DON confirmed that CNA #22 worked shifts through April 2025 and May of 2025 even after UMN #127 received a report of resident abuse by CNA #51 to UMN#127. Review of facility policy titled 'Abuse, Neglect, Exploitation, & Misappropriation of Resident Property,' states If a staff member is accused or suspected of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation.

Based on record review, interviews and facility policy and procedures review, the facility failed to ensure the physician and or prescribing practitioner documented a rationale in the resident's medical record for the use of a psychotropic drug for 180 days. This had the potential to affect one (Resident #4) out of five residents reviewed for unnecessary medications. The census was 56. Findings include: Review of the medical record for Resident #4 revealed an admission date of 11/04/22 with mild cognitive deficits. Diagnoses included traumatic hemorrhage of the cerebrum, hemiplegia and hemiplegia, acute chronic respiratory and obstructive pulmonary disease. A care plan relative to her physical and psychological needs revealed individualized interventions with measurable goals. Review of the Consultant Pharmacist Recommendation to Physician dated 7/16/24 and 2/11/25. The pharmacist requested a recommended reorder for specific number of days for the as needed (PRN) order of Lorazepam (antianxiety) 1 milligram (mg) for Resident #4 or to discontinue the medication per federal guideline. Response continue PRN use of Lorazepam for 180 days, as the benefit outweighs the risk. The physician agreed; however, did not indicate the rationale in the medical record or on the recommendation form. Review of Resident #4's Physician Order Summary Report revealed an order for Ativan (Lorazepam) Oral Tablet 1 mg give 1 mg by mouth every 12 hours as needed for 180 days. Review of Resident #4's Physician Progress Notes from 07/16/24 to 02/11/25 revealed no rationale for the use of Lorazepam as needed every 12 hours for 180 days. Review of Resident #4's Psychiatric visit notes dated 07/23/24, 03/12/25 and 04/10/25 revealed Resident #04 was not taking Lorazepam. The interview with the Director of Nursing on 05/07/25 at 1:30 P. M. revealed because the physician agreed with the pharmacist and checked the box to continue the PRN use of the Lorazepam for 180 days, as the benefit outweighs the risk, was the reason to continue the medication. An Interview by telephone on 05/07/25 at 3:24 P. M. with the Pharmacist confirmed the physician did agree to continue the medication for 180 days, but by checking the box to continue PRN use of Lorazepam for 180 days, as the benefit outweighs the risk is not enough. The physician must give a rationale to continue the psychotropic medication for 180 days in the resident's medical record. An Interview on 05/07/25, at 4:00 P. M. with the Regional Clinical Registered Nurse #152 confirmed Resident #4 sees psychiatric nurse practitioner and she should provide the rationale for the Lorazepam to be extended for 180 days. An interview on 05/07/25, at 4:50 P. M. with Regional Clinical Registered Nurse #152 confirmed Resident #4's physician did not put a rational on the pharmacy recommendations dated 7/16/24 and 2/11/25 or have a rationale in his visit notes and progress notes. The psychiatric nurse dated practitioner visits notes dated 07/23/24, 03/12/25 and 04/10/25 did not include Lorazepam as a medication Resident #4 was prescribed. Review of the Facility's Medication Regimen Reviews Policy, dated 04/2007 The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication review report and provide a written report for each resident with an identified irregularity to the ordering physician. If the Physician does not provide a pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he or she will contact the Medical Director, or -if the Medical Director is the Physician of Record-the Administrator.

Based on medical record review and staff interview, facility failed to ensure Pre-admission Screening and Resident Review (PASARR) documents were accurately completed for two (#23 and #27) of five residents reviewed for PASARR. The facility census was 56. Findings include 1. Review of the medical record for Resident #23 revealed an admission date of 03/21/23. Diagnoses included schizoaffective disorder (added 03/21/23), insomnia, diabetes, cognitive communication deficit, and encephalopathy. Review of Resident #23's PASARR dated 03/17/23 revealed the only diagnosis marked was mood disorder. Interview on 05/05/25 at 5:15 P.M. with Admissions #18 and Social Service Designee (SSD) #126 confirmed PASARR should be reviewed for accuracy at admission and updated for any changes in diagnosis during the admission. Both staff members confirmed Resident #23 PASARR document was not accurate. 2. Review of the medical record for Resident #27 revealed an admission date of 09/21/18. Diagnoses included cerebral palsy, depression, cognitive communication deficit, schizophrenia (added 11/22/23), and unspecified psychosis (added 03/05/19). Review of Resident #27's PASARR dated 09/25/18 revealed the only diagnoses marked were mood disorder, anxiety, and conversion disorder. Interview on 05/05/25 at 5:15 P.M. with Admissions #18 and SSD #126 confirmed PASARRs should be reviewed for accuracy at admission and updated for any changes in diagnosis during the admission. SSD #126 confirmed facility staff had not informed him of a change in Resident #27's diagnoses. Both staff members confirmed Resident #27's PASARR was not accurate. Review of facility policy titled, Resident Assessment Coordination with PASARR Program, dated 2024, revealed all residents shall be screened for serious mental disorders. A record of prescreening shall be maintained in the resident medical records and social service director was responsible for keeping track of each resident PASARR status.

Based on medical record review, staff interview, and policy review, the facility failed to complete and provide a bed hold notice and reason for transfer to residents and resident representative and failed to notify the long-term care ombudsman of a resident transfer as required. This affected three (#57, #56, and #12) of five residents reviewed for transfer and discharge. The facility census was 56. Finding include: 1. Review of the medical record for Resident #57 revealed an admission date of 01/30/24. Diagnoses included arthritis due to other bacteria of the right knee, chronic pain, acute kidney failure, unspecified low back pain, hypo-osmolality and hyponatremia, multiple myeloma, hypertension, pneumonia, ileus, and unspecified muscle weakness. Review progress notes dated 02/04/25 revealed Resident #57's hemoglobin (an iron-containing protein found in red blood cells that is responsible for transporting oxygen throughout the body) was 7.6 grams per deciliter (g/dL) on 01/30/25 and laboratory values were ordered to assess the resident's hemoglobin. Review of progress notes dated 02/07/25 show the provider was notified by the facility of the laboratory value results from 02/04/25 and Resident #57's hemoglobin was 6.5 g/dL. Review of physician orders dated 02/04/25 revealed routine laboratory values were ordered to assess Resident #57's hemoglobin level. Review of additional orders on 02/07/25 revealed Resident #57 was to be transferred to the hospital due to low hemoglobin. There was no evidence in the medical record of the ombudsman being notified of Resident #57's transfer to the hospital nor a bed hold notice or notice of transfer being given to the resident or representative. Interview with the facility Administrator on 05/07/25 at 9:51 A.M. confirmed facility failed to provide the ombudsman with a notification of transfer for Resident #57. Interview with the Director of Nursing (DON) on 05/07/25 at 3:25 P.M. confirmed the facility failed to complete and provide a reason for transfer notice to Residents #57 or the resident's representative. Interview with Regional Director of Operations #157 on 05/07/25 at 4:25 P.M. confirmed the facility failed to offer a bed hold to Resident #57 or the resident's representative. 3. Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease, multiple sclerosis, major depressive disorder, generalized anxiety disorder, and schizoaffective disorder. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 14, indicative of an intact cognitive status. Review of Resident #12's nursing progress notes revealed on 01/18/25 Resident #12 was discharged to the hospital related to uncontrolled pain. Review of Resident #12's electronic medical record revealed there was no evidence of a notification to the ombudsman when Resident #12 was discharged to the hospital on [DATE]. Interview with the Administrator on 05/07/25 at 9:51 A.M. revealed he could not produce any evidence the Long Term Care Ombudsman was notified of Resident #12's discharge to the hospital. Review of a facility policy titled, Transfer or Discharge Notice, dated December 2016, revealed when a resident is discharged from the facility, the resident or resident representative will be notified in writing about the reason for the transfer or discharge, the effective date of the transfer or discharge, the bed hold policy, the location to which the resident is being transferred or discharged , the name, address and telephone number of the Office of the State Long term care Ombudsman. A copy of this notice will be sent to the Office of the State Long Term Care Ombudsman. 2. Review of the medical record for Resident #56 revealed an admission date of 02/12/25 and discharge on [DATE]. Diagnoses included chronic obstructive pulmonary disease, pulmonary hypertension, heart disease and muscle weakness. Review of the progress notes dated 02/24/24 to 03/01/24 revealed Resident #56 left the facility and failed to return. Resident #56 was educated on the recommendation to return for care and declined the need for any services such as home health care. Review of Resident #56's medical record found no evidence the notice for reason of transfer was sent to the ombudsman. Interview on 05/07/25 at 2:30 P.M. with the Administrator revealed facility had no evidence the ombudsman notification was completed for Resident #56.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the appropriate and pertinent information was communicated to the receiving health care institution during a resident transfer. This had the potential to affect one (#57) of five residents reviewed for transfer and discharge. The facility census was 56. Finding Include: Review of the medical record for Resident #57 revealed an admission date of 01/30/24. Diagnoses included arthritis due to other bacteria of the right knee, chronic pain, acute kidney failure, unspecified low back pain, hypo-osmolality and hyponatremia, multiple myeloma, hypertension, pneumonia, ileus, unspecified muscle weakness. Review of physician orders dated 02/04/25 revealed routine laboratory values were ordered to assess Resident #57's hemoglobin (an iron-containing protein found in red blood cells that is responsible for transporting oxygen throughout the body) levels. Review of additional orders on 02/07/25 revealed Resident #57 was to be transferred to the hospital due to low hemoglobin. Review of progress notes dated 02/04/25 revealed Resident #57's hemoglobin was 7.6 grams per deciliter (g/dL) on 01/30/25, and laboratory values were ordered to assess Resident #57 hemoglobin. Review of progress notes dated 02/07/25 showed the provider was notified by the facility of the laboratory results results from 02/04/25 and Resident #57 hemoglobin was 6.5 g/dL. Interview with the Director of Nursing (DON) on 05/06/25 at 3:27 P.M. confirmed that laboratory values were obtained on 02/05/25 and Resident #57 was transferred to the hospital on [DATE]. The DON confirmed the facility failed to document Resident #57 was transported to the hospital with the appropriate information provided to the receiving facility. Review of facility policy titled, Transfer, Reducing Acute Care or Discharge Notice Policy, dated 04/2016, revealed the facility will use a standard tool for early recognition and management of acute changes of condition which include situation, background, and assessment or appearance.

2. Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with activities of daily living and had no history of behaviors. Telephone interview on 05/06/25 at 09:43 A.M. with Certified Nursing Assistant (CNA) #51 revealed she witnessed very concerning behavior from CNA #22 a little less than one month ago. CNA #51 stated that she overheard CNA #22 get into a verbal disagreement with Resident #14 and Resident #27 in the TV room/hallway and it escalated when that aide got into Resident #14's face yelling shut up and pointing finger at him. CNA #51 described it as a full-on fight and advised CNA #22 to walk away and ignore Resident #14. Furthermore, CNA #22 was saying offensive things to other residents and making side comments. CNA #51 attested this was full on verbal abuse because CNA #22 was threatening, getting too aggressive, and she believed it was going to turn into something more. CNA #51 reported the incident to Unit Manager Nurse (UMN) #127 by telephone 30 minutes after the incident occurred. CNA #51 confirmed she filled out a paper report and slid it under a staff's door. Interview with UMN #127 on 05/06/25 at 9:52 A.M. confirmed CNA #51 notified her by telephone of the incident and reported residents were getting loud with staff and that residents were yelling at CNA #22. She stated she was unsure what they were yelling about. UMN #127 confirmed CNA #22 was working the evening of the alleged incident and CNA #51 intervened. UMN #127 stated followed up was completed with Resident #14 and Resident #127 and reported there were no issues, however UMN #127 could not recall when the follow up occurred. UMN #127 stated they spoke with CNA #22 who reported residents did get loud on the evening of the incident and there was an argument. UMN #27 confirmed the interviews reveled no indications there was a problem during that night shift. UMN #127 confirmed she did not report the alleged incident of verbal abuse to the Director of Nursing and/or Administrator. Interview with Resident #14 on 05/06/25 at 9:59 A.M. confirmed CNA #22 initially yelled at Resident #27, so Resident #14 stood up for him and that is when CNA #22 got in his face and was screaming and hollering at him. He could not recall exact words. Staff intervened and the incident was over. Resident #14 confirmed he felt threatened and reported it was verbal abuse. Interview with UMN #127 on 05/06/25 at 4:43 P.M. confirmed no paper report from CNA #51 could be located as she claimed she checked multiple places and mailboxes including the Director of Nursing (DON)'s office and her office. Interview with DON on 05/07/25 at 8.56 A.M. confirmed he had not received a report of abuse involving Resident #14 and this was the first time he heard about the alleged abuse. Interview with Administrator on 05/07/25 at 9:00 A.M. confirmed he was not aware of a report of abuse between CNA #22 and Resident #14. He denied having a report from CNA #51. Based on observation, medical record review, staff and resident interview and policy review the facility failed to ensure an injury of unknown origin for Resident #159 and an allegation of verbal abuse for Resident #14 were investigated thoroughly. This affected two (#159 and #14) of three residents reviewed for reporting abuse. The census was 56. Findings included: 1. Medical record review for Resident #159 revealed an admission date of 01/15/25. Medical diagnoses included heart failure, renal insufficiency, diabetes, depression and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #159 was cognitively intact. Functional status was setup or clean up for eating, she was dependent for toileting and transfers. She was substantial/maximal assistance for bed mobility. She was frequently incontinent for bowel and bladder. Review of a progress note dated 04/16/25 at 6:00 P.M. for Resident #159 revealed the hospital had called the facility and reported the resident was being admitted due to a fall. She was out of the facility for a follow-up doctor's appointment and during transport, with a company that was an outside service, the resident fell out of her wheelchair and broke her left lower extremity and will be needing surgery. Review of the hospital paperwork dated 04/16/25 revealed Resident #159 presented to the emergency room after a motor vehicle accident with complaints of left leg pain. An X-ray revealed a displaced left tibia and fibula fractures with associated proximal fibula fracture. Review of the investigation for Resident #159 dated 04/17/25 revealed there was a timeline of events, resident interview, and hospital paperwork. Interview with Resident #159 on 05/05/25 at 10:52 A.M. revealed she went out to an appointment on 04/16/25 to see her vascular surgeon. On the way back to the facility, she reported the driver was going the wrong way and she told him he took the wrong exit and he slammed on the brakes and she became unbuckled from her wheelchair and dropped onto the floor and slid on the floor and her left leg jammed underneath the drivers seat in front of her. She revealed she was sent to the hospital and had surgery to repair her leg. Interview with the Director of Nursing (DON) on 05/05/25 at 1:04 P.M. revealed the hospital called and said the resident had been in a motor vehicle accident. He reported the facility received the hospital records and they said Resident #159 had been in a motor vehicle accident. He reported he didn't called the police department to get the details of the accident or get a police report. He confirmed he didn't investigate thoroughly. He reported he didn't try to get a police report to see if another car was involved in the accident he took the word of the hospital paperwork. Review of the policy entitled Abuse, Neglect, Exploitation, and Misappropriation of Resident's Property dated 11/01/19 revealed once the Administrator and the state agency were notified, an investigation of the allegation violation will be conducted. 1. Time frame for investigation The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days 2. Investigation protocol The person investigating the incident should generally take the following actions: Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. 3. If there are no direct witnesses, then the interviews may be expanded. For example, to cover all employees on the unit, or, as appropriate, the shift. For Injuries of Unknown Source, the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well.

2. Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with activities of daily living and had no history of behaviors. Interview with Regional Operations Director #154 on 05/06/25 at 09:29 A.M. revealed no reports of abuse in the last month. Review of the facility's Self Reported Incidents (SRI)s revealed there was no report completed regarding Resident #14 in regards to verbal abuse. Telephone interview on 05/06/25 at 09:43 A.M. with Certified Nursing Assistant (CNA) #51 revealed she witnessed very concerning behavior from CNA #22 a little less than one month ago. CNA #51 stated that she overheard CNA #22 get into a verbal disagreement with Resident #14 and Resident #27 in the TV room/hallway and it escalated when that aide got into Resident #14's face yelling shut up and pointing finger at him. CNA #51 described it as a full-on fight and advised CNA #22 to walk away and ignore Resident #14. Furthermore, CNA #22 was saying offensive things to other residents and making side comments. CNA #51 attested this was full on verbal abuse because CNA #22 was threatening, getting too aggressive, and she believed it was going to turn into something more. CNA #51 stated the incident was reported to Unit Manager Nurse (UMN) #127 by telephone 30 minutes after the incident occurred. CNA #51 confirmed she filled out a paper report and slid it under a staff's door. Interview with UMN #127 on 05/06/25 at 9:52 A.M. confirmed CNA #51 notified her by telephone of the incident and reported residents were getting loud with staff and that residents were yelling at CNA #22. She stated she was unsure what they were yelling about. UMN #127 confirmed CNA #22 was working the evening of the alleged incident and CNA #51 intervened. UMN #127 stated followed up was completed with Resident #14 and Resident #127 and reported there were no issues, however UMN #127 could not recall when the follow up occurred. UMN #127 stated they spoke with CNA #22 who reported residents did get loud on the evening of the incident and there was an argument. UMN #27 confirmed the interviews reveled no indications there was a problem during that night shift. UMN #127 confirmed she did not report the alleged incident of verbal abuse to the Director of Nursing and/or Administrator. Interview with Resident #14 on 05/06/25 at 09:59 A.M. confirmed CNA #22 initially yelled at Resident #27, so Resident #14 stood up for him and that is when CNA #22 got in his face and was screaming and hollering at him. He could not recall exact words. Staff intervened and the incident was over. Resident #14 confirmed he felt threatened and reported it was verbal abuse. Interview with DON on 05/07/25 at 08.56 A.M. confirmed he had not received a report of abuse involving Resident #14 and this was the first time he heard about it. Interview with Administrator on 05/07/25 at 09:00 A.M. confirmed he was not aware of a report of abuse between CNA #22 and Resident #14. He denied having a report from CNA #51, and no SRI had been filed with the State Agency. Review of the policy entitled Abuse, Neglect, Exploitation, and Misappropriation of Resident's Property dated 11/01/19 revealed all incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the State Agency. Based on observation, medical record review, staff and resident interview and policy review the facility failed to ensure an injury of unknown origin for Resident #159 and an allegation of verbal abuse for Resident #14 were reported to the state agency. This affected two (#159 and #14) of three residents reviewed for reporting abuse. The census was 56. Findings included: Medical record review for Resident #159 revealed an admission date of 01/15/25. Medical diagnoses included heart failure, renal insufficiency, diabetes, depression and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #159 was cognitively intact. Functional status was setup or clean up for eating, she was dependent for toileting and transfers. She was substantial/maximal assistance for bed mobility. She was frequently incontinent for bowel and bladder. Review of a progress note dated 04/16/25 at 6:00 P.M. for Resident #159 revealed the hospital had called the facility and reported the resident was being admitted due to a fall. She was out of the facility for a follow-up doctor's appointment and during transport, with a company that was an outside service, the resident fell out of her wheelchair and broke her left lower extremity and will be needing surgery. Review of the hospital paperwork dated 04/16/25 revealed Resident #159 presented to the emergency room after a motor vehicle accident with complaints of left leg pain. An X-ray revealed a displaced left tibia and fibula fractures with associated proximal fibula fracture. Interview with Resident #159 on 05/05/25 at 10:52 A.M. revealed she went out to an appointment on 04/16/25 to see her vascular surgeon. On the way back to the facility, she reported the driver was going the wrong way and she told him he took the wrong exit and he slammed on the brakes and she was unbuckled from of her wheelchair and slid onto the floor and slid on the floor and her left leg got jammed underneath the seat of the driver's. She revealed she was sent to the hospital and had surgery to repair her leg. Interview with the Director of Nursing (DON) on 05/05/25 at 1:04 P.M. revealed the hospital called and said the resident had been in a motor vehicle accident. He reported the facility received the hospital records and they said Resident #159 had been in a motor vehicle accident. He confirmed he didn't report to the state since he took what the hospital paperwork said and the call from the hospital as to what happened on the transport van to Resident #159.

Based on medical record review, review of downloaded ventilator data, review of the policy Invasive Mechanical Ventilation, staff interviews, interview with Respiratory Therapist Specialist (RTS) #600, interview with Police Detective #10, the facility failed to ensure necessary life sustaining respiratory services were provided by timely answering a ventilator's (a mechanical device required for the breathing) alarm after the resident's ventilator tubing had become disconnected from his [CONDITION(S)]. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #04 when the ventilator was found alarming for over an hour, the tubing was not connected to the resident and had gone unnoticed by any of the facility staff. Consequently, Resident #04 was found unresponsive, pale, pulseless and without respirations, requiring Cardiopulmonary Resuscitation (CPR) without success and subsequently being pronounced deceased at the emergency room (ER). This affected one (#04) of three (#01, #04, #08) residents reviewed for respiratory services. The facility identified there were no current residents in the facility utilizing a ventilator. The facility census was 64. On [DATE] at 4:21 P.M., Regional Director of Operations (RDO) #500, Minimum Data Set (MDS) Nurse #400 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 4:30 A.M., when Resident #04 became disconnected from his ventilator tubing which triggered the ventilator alarm to annunciate. At 5:33 A.M., Resident #04 was found by State tested Nurse Aide (STNA) #400 with the ventilator tube disconnected and the ventilator alarm sounding. STNA #400 called for Registered Nurse (RN) #200, who found Resident #04 unresponsive, pale, pulseless, without respirations and the ventilator tubing was disconnected from the resident. CPR was initiated by facility staff. Emergency Medical Services (EMS) were called and found Resident #04 without vital signs, when attached to a monitor. Resident #04 had been transferred to the ER where he passed away from [CONDITION(S)] and respiratory arrest at 6:35 A.M. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: · On [DATE] at 2:21 P.M., all current residents were evaluated for ventilator alarms or any life sustaining alarms by the DON. No other residents requiring a ventilator or life sustaining alarms are currently in the facility. · Resident #01, a ventilator dependent resident, was discharged on [DATE] to the hospital for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] · On [DATE] at 3:30 P.M., Respiratory Therapist (RT) #630, with the ventilator equipment company, was contacted by Vice President of Clinical Services #100 to indicate the facility will not admit a resident without an external monitor in place on the ventilator. The external alarm would sound outside of the room and allow staff to be notified even if the resident's door was closed. · Beginning on [DATE], all new admissions and/or referrals will be reviewed by the DON or designee for the need for life sustaining equipment. An order will be placed for life sustaining equipment through RT #630 and external monitoring will be sent by RT #630 with the life sustaining equipment prior to admission. · On [DATE] at 6:00 P.M., an ad hoc Quality Assurance Performance Improvement meeting was held to discuss ventilator alarms for a root cause analysis with the Quality Assurance team. · On [DATE] at 6:30 P.M., the DON was educated by Vice President of Clinical Services #100 on the external monitor for ventilators. · On [DATE], all nursing staff were educated by the DON or designee on timely response to alarms that are priority for any life sustaining intervention, and the new external monitor system to be used on all new ventilator resident admissions by [DATE] at 11:59 P.M. · On [DATE], audits will be conducted daily on new referrals for life sustaining care to ensure that external monitor is present prior to admission daily by DON or designee for 4 weeks. Audits will also be conducted to ensure the ventilator care policy is being executed correctly daily and that timely response to life sustaining alarms is occurring by DON designee for 4 weeks, then ongoing. · On [DATE], review of in-service records revealed all staff were in-serviced on responding to life sustaining/ventilator alarms. · On [DATE], interviews between 11:53 A.M. and 1:04 P.M., with STNAs (#420, #460, #480), Licensed Practical Nurses (LPN) (#300, #330, #336, #360, #363), Dietary Cooks (#800, #820), Laundry Staff #700, Housekeeper #730, Respiratory Therapist #630, and Front Desk Receptionists (#500, #530) verified they had received the education on responding to life sustaining/ventilator alarms and were knowledgeable about the education given. · On [DATE], Resident #01, the only other resident that was on a ventilator in the facility, was given a discharge notice due to it being necessary to meet the resident's welfare and the needs cannot be met by the facility. · After [DATE], a new external alarm system will be installed for ventilator alarms. When the vent alarm sounds this also sounds an alarm, outside the room and to the nurse's station. No ventilator residents will be admitted until the new alarm system is set up. All staff will be further in-serviced on the new alarm system once installed prior to admission of a resident. · Review of Resident #01 and #08's medical records revealed respiratory services were being documented as being provided per care plans and physician orders. Resident #08's medical record was reviewed due to no other ventilator patients and resident had [CONDITION(S)]. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #04 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #04 had orders for the resident on ventilator continuously every shift, and the resident was a Full Code status. Review of Resident #04's plan of care dated [DATE] revealed the resident is ventilator dependent via [CONDITION(S)] related to respiratory failure due to a gunshot wound to the neck with spinal cord injury. The goals included the resident will maintain a patent airway (the ability of a person to breathe). The interventions included to maintain ventilator settings which was continuous. Review of the Minimum Data Set Assessment for Resident #04 dated [DATE], revealed the resident was assessed as having mild impaired cognition. He was assessed as being totally dependent with all activities of daily living and was a ventilator dependent resident. Review of progress notes dated [DATE] at 5:33 A.M., revealed RN #200 was assisting STNA #400 and STNA #440 with resident care this morning in another room. RN # 200 was called, by STNA #400, to Resident #04's room for Resident #04 being unresponsive and the ventilator alarming. RN #200 noted the ventilator tubing had popped off. Resident #04 had color, with slightly pale lips, and was still warm to the touch. RN #200 started CPR and called out for other staff on duty to come to the room. Additional staff responded. The Ambu bag (a bag used to give rescue breaths) was hooked to oxygen. Rotation of staff for compressions was continued throughout CPR. The bed was deflated, and a back board placed after second round of CPR. Emergency 911 was called at 5:33 A.M. (time resident was found unresponsive). EMS arrived, and CPR was taken over by medics. Report was given to medics. Resident #04's mother was contacted at 5:41 A.M. and notified of the situation. She stated she would meet Resident #04 at the hospital. The DON was called by STNA #400 at 5:39 A.M. The DON arrived at 5:45 A.M. to the facility. The face sheet and medication list were faxed to the hospital. Review of the Emergency Department Encounter dated [DATE] at 7:04 A.M., revealed Resident #04 was a [AGE] year-old male who presents with [CONDITION(S)]. By history, it seems that this was initiated as a respiratory arrest, as the nursing home staff stated he was found with his ventilator alarming and disconnected. Resident #04 was found in asystole and was last seen at 4:00 A.M., with the initiation of CPR at 5:33 A.M. Resident #04 received multiple doses of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. He did not regain pulses. Despite multiple rounds of medications, resident did not have return of spontaneous circulation and resuscitative efforts were terminated at 6:35 A.M. Interview on [DATE] at 1:25 P.M. with RN #200 revealed she had come into work early on [DATE] around 4:07 A.M. RN #200 stated she was helping the STNAs cleanup Resident #08 in a room down the hall and she completed the dressing change and suctioning for Resident #08. The two STNAs (#400 and #440) left the room, while RN #200 finished [CONDITION(S)] care. RN #200 stated she heard STNA #400 yell for her to come to Resident #04's room. RN #200 stated she finished the suctioning on Resident #08 and went to Resident #04's room. RN #200 stated the ventilator was alarming. The ventilator tube was off the resident and the tubing was lying on the floor. RN #200 stated she assessed for a pulse and checked the oxygen level. Resident #04 was unresponsive, pale, pulseless and had no respirations. RN #200 stated she got the Ambu bag and gave two rescue breaths. STNA #400 went out to call 911 and get the other nurse. RN #224 started compressions while RN #200 bagged the resident. The other nurse (RN #220) came and relieved RN #224 from compressions and then RN #224 took over bagging the resident. The emergency squad got there fast and took over CPR. RN #200 stated Resident #04 had a blow call light, he used all the time. RN #200 stated she did not know if Resident #04 had his light on. RN #200 stated she did not pay attention when she went to the room, and she does not know for sure if the door was shut because STNA# 400 was the first one in the room. RN #200 stated Resident #04 did like to have his door shut but when it was shut, you were unable to hear the alarms. RN #200 stated she told Resident #04 when she was on duty, the door had to be cracked so they could hear if there was an alarm. RN #200 stated RT #630 had come in the previous day to complete the weekly ventilator settings checks, provide [CONDITION(S)] care, and alarm systems checks. RN #200 revealed when she got to the facility that morning, she was going to see Resident #04. The other staff informed her, Resident #04 had been up all night and had finally gotten to sleep, so she did not go to the room. Interview with the DON on [DATE] at 2:15 P.M., verified she did not perform a formal investigation. The DON stated she had reviewed the nurse's notes and spoke with the staff on duty and felt they acted appropriately given the information she had. The DON stated she did not have the downloaded ventilator data due to the police calling with instructions for no one to go into the room. When the police got there, they took the ventilator to have the results downloaded. The DON stated she was unaware of the results until the surveyor informed her the police had them. Interview on [DATE] at 3:00 P.M. with Police Detective #10 revealed she was told by RT #630, who downloaded the ventilator records, a piece of the ventilator tubing was missing. RT #630 stated the piece was a swivel piece. RT #630 reported to Police Detective #10 the ventilator was disconnected at 4:30 A.M., which is when the alarm would have started to sound. Police Detective #10 stated during interviews RN #200 and RN #224 both stated they could not hear the ventilator alarm from the nurse's station. The staff told Police Detective #10, the door to the resident's room was closed. RN #200 had stated she had asked for an alarm to be placed at the nursing station but was told it was too expensive. Interview on [DATE] at 3:08 P.M. was attempted with STNA #400. STNA #400 refused to be interviewed and said she told the police everything she had seen. Interview on [DATE] at 6:50 A.M., with agency STNA #440, revealed she was working the 200 Hall the night Resident #04 had coded. STNA #440 stated they were in Resident #08's room completing a complete bed change, while the nurse was doing a treatment and [CONDITION(S)] care. We exited the room and heard the alarm in Resident #04's room but there was no call light on. STNA #440 stated she did not recall if the door was open or closed. STNA #400 went down to the room then and called for STNA #440 to get RN #200. RN #200 instructed STNA #440 to go and get the 200-hall nurse while STNA #400 called 911. STNA #440 stated she then went to the door and waited for the squad and took them back to Resident #04's room as soon as they got there. STNA #440 stated she did not go into Resident #04's room. Interview on [DATE] at 7:00 A.M. with RN #220 revealed at approximately 5:30 A.M., STNA #440 came and got her because they needed her in Resident #04's room for CPR. RN #220 stated she checked the chart to make sure Resident #04 was a Full Code and ran down to the room. RN #224 was doing compressions and RN #200 was using the Ambu bag. RN #220 stated she then took over chest compressions while RN #224 began using the Ambu bag. The squad showed up and took over with a compression vest. Resident #04 was warm with blue tinged lips. Interview on [DATE] at 8:06 A.M. with RN #224 revealed she was on duty this night and was the nurse for Resident #04. RN #224 stated on the night of [DATE], she was in a resident room, with two of the STNAs (#400 and #440) passing medications and completing a wet to dry dressing change on the 200 Hall. RN #200 came into work around 4:00 A.M. and she was in Resident #08's room for just a little while. RN #224 stated she and the STNAs (#400 and #440) left Resident #08's room and RN #224 continued with her medication pass on the 200 Hall. RN #224 stated she was informed by STNA #400, there was a code blue in Resident #04's room. RN #224 went in and started compressions while RN #200 was utilizing the Ambu bag. RN #224 stated the next nurse in the room was RN #220, who took over compressions and placed the backboard once the bed was deflated. Resident #04 was warm to the touch, lips had bluish tinge, but Resident #04 did not look ashen but pale. RN #224 stated she had never seen Resident #04's ventilator hose come off before. RN #224 stated she had seen Resident #04 last at 4:00 A.M. and he was sleeping, and this is when she completed her ventilator checks. RN #224 confirmed she had training on the ventilator but was unsure when it was and stated she used to work critical care in the hospital prior to working here. RN #224 stated she believed his door was open. RN #224 stated she had not heard the alarm prior to being told of the code blue. Interview on [DATE] at 12:30 P.M. with RT #630 verified the ventilator for Resident #04 was disconnected at 4:30 A.M., per the ventilator downloaded information. RT #630 verified the ventilator was set for 20 seconds for the alarm to sound and Resident #04 had 55% of leakage high pressure which was twice his normal leakage. RT #630 stated this could have been from the missing exhalation valve, which would have caused the ventilator hose to come off. RT #630 stated Resident #04 would not have been able to exhale so the pressure would have caused it to come off. Review of the Downloaded Ventilator Data from Resident #04's ventilator for the date of [DATE], starting at 12:00 A.M., revealed the breaths per minute with an average of breaths 24 per minute ceased at 4:30 A.M., the minute ventilation ceased at 4:30 A.M., the resident's triggered breaths ceased at 4:30 A.M., and was not resumed at any time. Interview on [DATE] at 3:45 P.M. with Respiratory Therapist Specialist (RTS) #600, verified the documents which were downloaded from the ventilator, showed the ventilator had been disconnected at 4:30 A.M. The ventilator was set with a 20 second alarm. RTS #600 reviewed the ventilator equipment and found an important part was missing. RTS #600 stated the exhalation valve was missing from the ventilator tubing. This valve allowed the resident to exhale and, if this is not on, the pressure builds up and the tubing will pop off. The two pieces which are both male parts, may have been able to be pushed together. RTS #600 stated he has no way of knowing when the valve went missing. Review of the undated policy for Invasive Mechanical Ventilation revealed the purpose of the policy is to augment the residents' own ventilation and or to provide total ventilatory support for the resident using a mechanical ventilator. The process in training included: ventilator controls, limitations, circuit assembly, power sources and alarm response to assure alarms are set appropriately and are sufficiently audible so corrective actions may be initiated if necessary. This deficiency substantiates Master Complaint Number OH 056 and Complaint Number OH 044.

Based on review of a closed medical record, a facility investigation, personnel records, staff and family interviews, and review of the facility policies related to Advanced Directives, and Emergency Procedure-Cardiopulmonary Resuscitation (CPR), the facility failed to initiate CPR and contact Emergency Medical Services (EMS) for one resident (Resident #200) who was a Full Code status and was found unresponsive. When vital signs ceased the facility did not initiate CPR. Life threatening harm and death occurred when Resident #200 did not receive CPR or EMS services and expired at the facility. This resulted in Immediate Jeopardy for one of three residents reviewed for emergent change in condition and death. Additionally, the facility census of 55 residents were placed at risk for more than minimal harm that is not Immediate Jeopardy when the facility failed to ensure three nurses, Licensed Practical Nurses (LPN) #20, #21 and Registered Nurse (RN) #18 had a current, or approved CPR certification. This affected three of 17 licensed nurses. On [DATE] at 12:29 P.M., Regional Director of Clinical Services (RDCS) #70, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) were notified Immediate Jeopardy began on [DATE] at approximately 6:00 A.M., when Resident #200 was found by RN #18 unresponsive, in bed without her oxygen and [MEDICAL CONDITION] (bilevel positive airway pressure) face mask on. The resident did not respond to verbal cues. The resident's skin was cool to the touch, respirations were shallow, radial pulse was weak and thready. The resident did not respond to a sternal rub (painful stimulation). RN #18 and State tested Nursing Assistants (STNAs) #10 and #75 placed Resident #200's bed into a 45-degree position. RN #18 placed her oxygen on. The resident remained unresponsive. The STNAs remained with the resident while RN #18 reviewed the resident's medical record and determined per physician's orders [REDACTED]. When RN #18 returned to the room the resident's oxygen saturation rate was at 36 percent (%), her blood pressure was dropping, and her respirations remained shallow with periods of apnea (not breathing), her pupils were fixed and unresponsive to light. The resident's fingers were mottling (blotchy, red-purplish marbling of the skin which occurs before death). At 6:15 A.M., Resident #200 had no further respirations or radial pulse for a total of two minutes. LPN #20 came into the room and verified cessation of all vital signs. At 6:25 A.M., the physician was notified, and orders were received to release the body to the funeral home. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · The DON provided education to all licensed nursing staff beginning on [DATE] and was completed on [DATE] at 3:00 P.M. The education consisted of the code status process, placing code status orders, and the new process of identifying resident code status. · On [DATE] at 11:30 A.M., an audit of all resident's medical records was completed by the DON to ensure the correct code status. No discrepancies were found. All residents' code status matched in the medical record, as well as the facility's computer charting system, Point Click Care (PCC). · An audit was completed by the DON on [DATE] to ensure the correct code status was on all residents' care plans. · On [DATE] at 1:30 P.M., color identifiers indicating a resident's code status were placed in all medical records by the DON. · On [DATE] at 3:00 P.M., a color identifier key was completed and hung on the units and medication rooms by the DON. · On [DATE] the DON began daily audits of new admissions to ensure a resident's code status was correct in the binder on the crash cart, as well as resident's care plans. · On [DATE] color identifier of a resident's code status was placed in a binder on the crash cart by the DON. · On [DATE] color identifier dots to indicate a resident's code status was placed on the outside of the medical record by the DON. · On [DATE] weekly audits began of resident's care plans by the DON to ensure a resident's code status was accurate on the medical record and care plan. · On [DATE] the DON will complete audits once a week for four weeks, then monthly times two months, to ensure the resident's code status on the medical record, in PCC, and the binder were correct. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Social Worker (SW) #43's progress note dated [DATE] indicated a Full Code status for Resident #200 with a plan to return to the community after rehabilitation. Review of Resident #200's plan of care dated [DATE] revealed the resident desired to be a Full Code status and planned to return to the community after rehabilitation services. A brief interview for mental status (BIMS) completed on [DATE] revealed a score of 11 indicating Resident #200's cognition was moderately impaired. Resident #200 was a short-term resident admitted for rehabilitation services with the goal of returning to the community. On [DATE] SW #43's quarterly progress notes revealed the resident continued to make her own decisions and stated she wanted to return home with her spouse. The resident's code status remained Full Code. On [DATE] SW #43's review of a progress note revealed during the resident's care conference the resident requested her code status changed to a DNRCC. The resident signed the Advanced Directive paper work and a physician's verbal order was obtained on [DATE] at 2:36 P.M. On [DATE] review of a progress note written by the DON revealed she spoke to Resident #200 regarding her code status. Resident #200 stated, I think I jumped the gun too fast when I asked you guys not to do CPR. I spoke with my sister and we both think the same, if something happens to me I want you to do CPR. The DON notified the physician and a verbal order was obtained at 10:55 A.M. on [DATE], to revise Resident #200's Advance Directives to a Full Code status. On [DATE] SW #43's progress note revealed Resident #200 had been readmitted to the facility after a brief hospital stay. The resident continued to be alert and oriented to person, place and time. The resident's continued plan was to return to the community after rehabilitation. The resident's code status remained a Full Code. Continued review of Resident #200's closed medical record revealed no evidence the resident's code status was changed back to a Full Code status, as she requested on [DATE]. A physician's orders [REDACTED]. Review of Resident #200's nurse progress note dated [DATE] at 6:00 A.M. by RN #18 revealed the nurse went into the resident's room to check on her. The resident was noted to be in bed without her nasal cannula and [MEDICAL CONDITION] face mask on. Her oxygen saturation was at 40 %, blood pressure was ,[DATE] millimeters of mercury (mmHg) and pulse was 45. Resident #200 was unresponsive. The resident's skin was cool to touch, her respirations were shallow, and the radial pulse was weak and thready. Resident #200 did not respond to a sternal rub (painful stimulation across the breastbone). RN #18, STNA #10, and STNA #75 placed Resident # 200's bed into a 45-degree position. RN #18 placed oxygen on the resident and Resident #200 remained unresponsive. The STNAs remained with the resident while RN #18 went to check the medical record for her code status. RN #18 determined per physician's orders [REDACTED]. RN #18 returned to Resident #200's room and noted the oxygen saturation had dropped to 36 %, and respirations remained shallow. Resident #200's pupils were fixed and unresponsive to light. The resident's fingers were mottling. At 6:15 A.M., Resident #200 had no further respirations or radial pulse for a total of two minutes. LPN #20 came into the room and verified cessation of all vital signs. At 6:25 A.M., Resident #200's physician was notified, and orders were received to release the body to the funeral home. Review of RN #18's written statement dated [DATE] revealed the RN entered Resident #200's room on [DATE] for visual rounds. Upon entering the room, the resident was seen lying on the bed. It was noted her nasal cannula (oxygen) and the [MEDICAL CONDITION] face mask was not on. The resident previously had both on an hour before. She called Resident #200's name and she did not respond. The resident's skin was cold to the touch, respirations were shallow and her radial pulse was weak and thready. Resident #200 did not respond to a sternal rub. RN #18 and the STNAs placed the resident's head of the bed in a 45-degree position and placed oxygen on her. The resident remained unresponsive and her oxygen saturations was 40 %. The STNAs remained with the resident while RN #18 went to the resident's medical record and confirmed under the physician's orders [REDACTED]. RN #18 returned to the room and the resident's oxygen saturation was 38 %. The resident's fingers were mottling, and her oxygen saturation and apical pulse were not audible. At 6:15 A.M., the resident had no further respirations or radial pulse for a total of two minutes. RN #18 then had LPN #20 verify cessation of all vital signs of Resident #200. Interview on [DATE] at 9:00 A.M., with Resident #200's sister, the resident's Health Care Power of Attorney (HCPOA) revealed she and Resident #200 went to church, shopping, and had lunch on [DATE]. The resident's sister revealed the resident was showing no signs of not feeling well. She was alert and oriented and in a very good mood. The resident was excited to be leaving the facility soon and be on her own. On [DATE] in the early morning Resident #200's sister stated she received a call from a nurse at the facility stating Resident #200 had passed away. The sister revealed Resident #200 was a Full Code status and she did not know why CPR had not been initiated, or EMS contacted. On [DATE] at 1:16 P.M., interview with the DON, RDCS #70, and the LNHA revealed a full investigation was completed after Resident #200 passed way on [DATE]. The DON confirmed RN #18 did not perform CPR on Resident #200 because her medical record still revealed she was a DNRCC status. The LNHA confirmed his investigation revealed the resident's medical record was not properly marked as being a Full Code status. The LNHA revealed the resident's medical record should have had a green dot on the outside of it, which would have indicated the resident was a Full Code status and CPR should have been initiated. On [DATE] at 2:05 P.M., telephone interview with RN #18 confirmed she was doing her hourly rounds on [DATE] and found Resident #200 unresponsive with shallow breathing, her oxygen was not on and her [MEDICAL CONDITION] face mask was off. RN #18 revealed she called for STNA #10 and STNA #75 to come and help her. They put the resident's head of bed up. Then RN #18 revealed she ran to check the resident's medical record to verify her code status while the STNAs stayed with the resident. RN #18 revealed she found a physician order [REDACTED]. She indicated when she returned to the room the resident's vital signs were less audible. When no respirations were heard RN #18 called for LPN #20 to confirm Resident #200 had passed away. RN #18 notified the physician of the death and received an order to release the body to the funeral home. RN #18 revealed she called the family member and informed the resident's sister, Resident #200 had passed away. RN #18 confirmed no CPR was initiated as her medical record indicated she was a DNRCC. RN #18 confirmed EMS was not notified. On [DATE] at 5:02 P.M., interview with STNA #10 confirmed she helped RN #18 with Resident #200 on [DATE]. She revealed she was called to the resident's room and helped RN #18 put the resident's head of the bed up. STNA #10 stated she and STNA # 75 stayed with the resident while RN #18 went to confirm the code status of the resident. STNA #10 revealed she left the room when RN #18 returned. STNA #10 indicated she was not in the room when Resident #200 passed away. On [DATE] at 2:30 P.M., and 5:10 P.M., attempts via telephone to interview LPN #20 and STNA #75 were unsuccessful. 2. Review of RN #18's personnel file revealed her date of hire was [DATE]. Further review of her personnel file revealed she had completed an online course for CPR on [DATE] that expired on [DATE]. There was no evidence the RN completed a hands-on demonstration to ensure CPR certification. 3. Review of LPN #20's personnel file revealed her date of hire was [DATE]. Further review of LPN #20's personnel file revealed the LPN completed an online course for CPR on [DATE], however there was no evidence the LPN completed a hands-on demonstration to ensure CPR certification. 4. Review of LPN #21's personnel file revealed the LPN's date of hire was [DATE]. LPN #21 was certified for CPR through the American Red Cross on [DATE] and it expired on [DATE]. There was no evidence LPN #21 had renewed her CPR recertification. On [DATE] at 11:30 A.M., interview with HRM #23 confirmed RN #18, LPN #20, and LPN #21 did not have a current CPR certification. HRM #23 further confirmed the on-line course was not valid unless a return demonstration was completed. Review of the facility's Advance Directives Policy and Procedure, dated (MONTH) (YEAR) revealed the following: · Advance Directives will be respected in accordance with state and law facility policy. · Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. · The Plan of Care for each resident will be consistent with his or her documented treatment preferences. · Do Not Resuscitate indicates that, in case a respiratory or cardiac failure, the resident guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. · Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and /or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. · The Director of Nursing or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The Attending Physician will not be required to write orders for which he or she has an ethical or conscientious objection. Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation, dated ,[DATE], revealed the following procedures if an individual is found unresponsive: · Briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR: · Instruct a staff member to activate emergency response system(code) and call 911 · Call code blue over intercom or walkie talkie in facility. · Instruct a nurse to retrieve the automatic external defibrillator · Nurse to verify the DNR or code status of the individual's medical record · Initiate the basic life support (BLS) sequence of events. · Continue with CPR/BLS until emergency medical personnel arrive. This deficiency substantiates complaint number OH 665.

Based on observations, medical record review, resident and staff interview, review of the facility Matrix, review of information from the National Pressure Ulcer Advisory Panel (NPUAP), review of information from Medscape and facility policy review, the facility failed to accurately assess and identify a Stage 4 pressure wound to the coccyx of Resident #13. In addition, the facility failed to ensure weekly assessments, physician notification and physician recommendations were completed for a developing Stage 4 pressure ulcer to the left heel of Resident #19. This resulted in actual harm when both Residents #13 and #19 required surgical removal of necrotic tissue, as well as, development of significant pain to the surgical site on Resident #13. Additionally, the facility failed to accurately assess/identify a pressure wound to the heels of Resident #65. This affected three (#13, #19 and #65) out of four residents reviewed for pressure ulcers. The facility census was 64. Finding include: 1. Medical record review for Resident #13 revealed an initial admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most current comprehensive quarterly Minimum Data Set (MDS) assessment completed 01/11/18 revealed the resident was identified as having moderate cognitive impairment. The assessment revealed the resident was dependent on staff for most activities of daily living. The resident required two-person physical assistance for bathing and bed mobility. The resident was immobile. Continued review of the medical record revealed Resident #13 was discharged to the local hospital on [DATE]. Review of the discharge (MDS) assessment completed 04/01/18 revealed the resident was coded as having no unresolved pressure ulcers. Observation and interview with Resident #13 was conducted on 04/16/18 at 11:06 A.M. The resident was cooperative, alert to person and place. Resident #13 was resting supine in the bed. A wound vac (medical device used to suction drainage from wounds) was observed in operation at the bedside. Tubing from the wound vac was under the bed linens. Therefore, the wound location was not visible to the surveyor. The resident said there was a wound on her 'bottom'. During the interview, Resident #13 reported the wound was painful and required the use of pain medication to make it barely tolerable. Continued review of the medical record for Resident #13 revealed Wound Care Specialist physician initial evaluation of buttock wounds on Resident #13 dated 03/07/18. Review of the physician documentation revealed the resident had a wound to the left buttock measuring 2.0 by 1.2 by 0.1 cm (centimeters) and a wound of the right buttock measuring 3.52 by 2.2 by 0.1 cm of one day duration. The physician documented the areas as moisture-associated skin damage. An order was for use of a house barrier cream to the areas every shift and as needed. In addition, the physician recommended off-loading to the area, reposition per facility policy and weekly follow-up with the wound care specialist. Further record review of Resident #13's progress notes revealed on 03/14/18 the resident preferred not to be seen by a male doctor (wound physician). At that time, the Assistant Director of Nursing (ADON) completed the wound assessment. The nurse documented the left buttock wound was healed. The right buttock measured at 1.5 by 0.5 cm. Barrier cream treatment was continued by the physician. The following wound physician visit was conducted on 03/21/18. Resident #13 allowed the physician to assess the areas. The physician documented measurements to the left buttock of 6.0 by 7.0 by 0.1 cm with 40% slough. The physician measured the right buttock at 4.0 by 7.5 x 0.1 cm with 40% slough. Both areas were noted as deteriorated. The physician did bedside surgical debridement of devitalized tissue on both areas at that time. In description of the procedure the physician described the result of the debridement conducted, healthy bleeding tissue was observed. The physician then ordered the use of Santyl ([MEDICATION NAME] ointment used to remove necrotic tissue and establish granulation tissue for wound healing) daily. (Note: The use of [MEDICATION NAME] ointment is to be terminated when debridement of necrotic tissue is completed and granulation is established for wound healing (reference Medscape Wound Care).) Additional information provided in the physician wound note on 03/21/18 referred to the resident refusal to be seen by that wound physician on 03/14/18 as noncompliance with wound care. The physician documented the resident, resists during repositioning for wound examination and treatment. Review of the treatment record for (MONTH) revealed nursing documentation of the completion of barrier cream and/or Santyl cream as ordered. No indications of noncompliance to treatment were found. In addition, review of the nursing progress notes revealed no documentation of noncompliance to treatments or repositioning from Resident #13. Documentation reviewed revealed periodic documentation of repositioning throughout the shift, however, no mention of difficulty or resistance from the resident was found. Review of the weekly Wound Care Specialist Evaluation dated 03/28/18 revealed continued assessment of two wounds was completed per the wound physician. The physician assessment and exam indicated Resident #13 continued to have a wound to the left buttock (referred to as Site #1) and a wound to the left buttock (referred to Site #2). As with previous physician documentation, the areas were only referred to as wounds. No distinction to the etiology was documented following the initial [DIAGNOSES REDACTED]. Continued review of the medical record for Resident #13 revealed the resident had a change in condition on 04/01/18 demonstrated by lethargy and change in mental status. The physician was notified and Resident #13 was transported to the local hospital emergency room (ER) for treatment. The resident was admitted to the hospital for a urinary tract infection [MEDICAL CONDITION]. Upon arrival to the hospital the emergency room physician identified a Stage 4 sacral decubitus. Review of the hospital physician History and Physical Note upon arrival on 04/01/18 revealed the [DIAGNOSES REDACTED]. The area was described by the physician as, a large stage 4 sacral tunneled necrotic decubitus ulcer. Further record review revealed the resident underwent [REDACTED]. The resident was discharged and returned to the facility on [DATE]. Initially, the resident had wound packing with an ordered solution. The surgeon recommended the use of wound packing with a wound vac to be utilized and changed every Monday, Wednesday and Friday. Findings were verified during interview with the Director of Nursing (DON) on 04/19/18 at 10:46 A.M. The DON indicated at that time, they were not aware of the extent/stage of the pressure ulcer prior to hospitalization . Review of the Wound Care Specialist Evaluation for Resident #13 dated 04/09/18, following readmit to the facility, revealed the wound physician documentation of examination to include three areas. Wound of the left buttock (Site #1), wound of the right buttock (Site #2) and the addition of post-surgical wound sacrum (Site #3). Additional information provided by the physician included the wound initially developed as a moisture-associated excoriation which worsened. Review of the facility matrix on 04/16/18 revealed no facility acquired pressure ulcers and/or worsened pressure ulcers identified for Resident #13. Staff interview with the DON on 04/17/18 at 6:00 P.M. Revealed Resident #13 developed a pressure ulcer in the facility and had been seen by the wound care physician from the time of discovery. During the interview, the DON revealed the resident was hospitalized due to a change of condition. While hospitalized a surgical debridement of the pressure wound was completed. The DON verified Resident #13 now had a wound vac, as well as, a urinary drain catheter not listed on the facility matrix. Observation of wound care to Resident #13 was conducted on 04/18/18 at 12:10 P.M. Licensed Practical Nurse(LPN) #309 was observed to replace the wound packing and change the wound vac on the surgically debrided coccyx wound. A second staff member assisted with turning/holding the resident on the side during the procedure. LPN # 309 reported Resident #13 had been premedicated with a narcotic pain reliever to aid tolerance of the procedure. During the procedure the resident cried out in pain several times during the procedure. When the dressing change was completed the wound vac was restarted. The resident cried out louder until the suction was stabilized. The resident demonstrated grimacing, muscle tightening and verbal cries of pain during the treatment despite premedication. Review of the current physician orders [REDACTED]. Medical record review of the nursing progress notes revealed documentation of Resident #13 crying out in pain, with [MEDICATION NAME] and repositioning ineffective on 04/10/18. Nursing documentation on 04/14/18 revealed the scheduled narcotic was also providing, little relief from pain. 2. Review of Resident #19's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the modification of the annual minimum data set 3.0 assessment dated [DATE] identified the resident as requiring an extensive two person assist with bed mobility, transfer, dressing, toilet use and personal hygiene. It identified the resident as having a stage 4 pressure ulcer that was not present upon admission. Review of the (MONTH) (YEAR) physician orders [REDACTED]. Review of the non-pressure skin condition record indicated on 09/11/17 there was a Stage 2 (partial thickness skin loss with exposed dermis) to Resident #19's left heel measuring 1.75 cm by 0.70 cm. The wound was described as having a pink, pale wound bed and without drainage. Review of the medical record revealed there was no indication of physician notification regarding this newly identified Stage 2 pressure ulcer and there was no new treatment initiated. Review of the nurses note dated 09/21/17 at 3:12 P.M. revealed the resident has a full heel size fluid filled blister to her left heel with a new order to wrap with [MEDICATION NAME] and monitor daily. Review of the treatment administration record (TAR) revealed the ordered treatment to wrap the left heel with [MEDICATION NAME] and monitor daily was not signed off as being completed three times (09/23/17, 09/28/18 and 09/29/18). There was no evidence that weekly skin assessments and weekly measurements were completed from 09/11/18-09/27/17 for Resident #19's pressure area to her left heel. Review of the Wound Care Specialist Evaluation dated 09/27/17 revealed Resident #19 presents with an unstageable deep tissue injury (DTI) defined as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister, of the left, posterior heel of at last one day duration, measuring 4.0 cm by 3.5 cm by depth not measurable. It revealed a dressing order for skin prep and foam once daily. Review of the (MONTH) physician orders [REDACTED]. Review of the Wound Care Specialist Evaluation dated 10/04/17 identified the resident's left heel DTI measuring 1.5 cm by 1.5 cm. It recommended for hydrogel (gel based wound care dressing which protects and provides a moist wound-healing environment and help remove dead tissue from the wound bed during the healing process) daily with a dry protective dressing. Review of a physician's orders [REDACTED]. Further review of the Wound Care Specialist Evaluation notes indicated they had seen the resident weekly. Review of the note dated 10/25/18 identified the DTI to Resident #19's left heel measured 2.5 cm by 1.2 cm. It recommended for air boots and float heels in bed. Further review of the (MONTH) (YEAR) physician orders [REDACTED]. Review of the nurses notes from 10/25/17 to 11/01/17 failed to indicate there was any evidence that the resident refused to wear her boot. Additionally, there was no evidence that a boot was even attempted to be placed on the resident. Review of the Wound Care Specialist Evaluation dated 11/01/17 indicated the DTI had deteriorated and was measuring 3 cm by 2.5 cm by 0.4 cm with 20% necrotic tissue and 80% granulation tissue. It revealed surgical excisional debridement of the left heel was completed, and now the left heel presents as a stage 4. This note indicated the DTI had deteriorated due to the patient non-compliant with wound care because the patient had gone back to not using her air boot and upon examination the boot was not in place. It continued to recommended to off load the wound and for an air boot. Observation on 04/18/18 at 4:00 P.M. revealed Resident #19 has a healing stage 4 to her left heel. LPN #335 measured the area and measured 6.5 cm by 5 cm and she did not measure the depth. The bottom posterior part of the heel had a black necrotic area on the wound and the posterior left side of the heel contained a small circular area of yellow slough. Interview with LPN #335 on 04/18/18 at 4:55 P.M. revealed she would describe Resident #19's wound as a stage 2, because it's pretty open. She confirmed the resident had a black area on her posterior heel and yellow slough present on the posterior left side of the heel. Interview with Registered Nurse (RN) #325 on 04/19/18 at 8:45 A.M. revealed Resident #19 is compliant with everything, and never refuses her boot. Interview with LPN #336 on 04/19/18 at 10:15 A.M. revealed Resident #19 is compliant with wearing her boot. Interview on 04/19/18 at 11:38 A.M. with the DON confirmed on 09/11/17 the resident was found to have a Stage 2 pressure area to her left heel and then on 09/21/17 the resident was observed to have a fluid filled blister to the left heel. The DON confirmed there was no evidence the physician was notified regarding the Stage 2 pressure wound found on the left heel on 09/11/17, and no new interventions were implemented. Additional interview with the DON on 04/19/18 at 4:12 P.M. revealed they were unable to find any evidence of any measurements being completed regarding the stage 2 pressure ulcer after the development on 09/11/17 until the wound physician seen her on 09/27/17. She confirmed there was no evidence of the wound physician recommendations being implemented for 09/27/17 and 10/25/17. 3. Review of Resident #65's medical record revealed he was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status score of 10, indicating a moderate impairment in cognition. The resident required extensive assistance with two plus staff for bed mobility. He was identified as having no pressure ulcers. He was assessed as having [MEDICAL CONDITION]. Observation of wound care on 04/18/18 at 2:30 P.M. revealed the resident had a 1.0 cm by 1.0 cm open pink area to the right heel. Santyl (chemical wound [MEDICATION NAME] agent) was applied to the open area. The resident had a 1.0 cm by 0.5 cm open pink area to the left heel which was also treated with Santyl. The resident was wearing bilateral air boots. Review of the resident's wound notes dated 04/16/18 revealed the resident had a diabetic wound of the left heel for greater than 18 days measuring 0.4 cm by 0.1 cm by 0.1 cm. The resident had a diabetic wound of the right heel greater than 85 days measuring 0.8 cm by 0.4 cm by 0.1 cm. Review of information NPUAP (www.npuap.org) revealed a pressure injury was defined as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. A stage two pressure injury was defined as partial-thickness skin loss with exposed dermis. 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. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Interview with ADON #313 on 04/19/18 at 8:15 A.M. verified the resident's bilateral heel ulcers were over bony prominences, meeting the NPUAP definition for a pressure ulcer. She verified the facility was coding and assessing the resident's bilateral heels as diabetic ulcers. Review of a facility policy titled Pressure Ulcer and Skin Care Management with a revision date of 12/01/15 revealed a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing. The presence of any pressure ulcer, wound or other skin condition is documented weekly on the pressure ulcer or skin condition report form, progress note and the care plan. Prevention and treatment orders are implemented and documented as ordered.

Based on medical record review, observation, resident and staff interview and review of facility policy, it was determined the facility failed to ensure one resident's floor was free from environmental factors that may contribute to falls. This resulted in actual harm for Resident #19 who slipped and fell on a wet floor and sustained a fractured right clavicle and a fractured right hip. This affected one (#19) of three residents identified with falls in the last 30 days. The facility identified 36 residents on fall prevention programs. The facility census was 89. Findings include: Review of Resident #19's medical record revealed an original admission date of [DATE] from an acute care hospital due to increased difficulty breathing. [DIAGNOSES REDACTED]. Surgical history included bilateral hip replacements and a colostomy. Review of the admission minimum data set (MDS) assessment dated [DATE] indicated the resident was alert and oriented, but had some difficulty with higher level problem solving and recall. She transferred and ambulated with a walker and assistance upon admission. The resident was identified upon admission to be at high risk for falls. Review of the physician's history and physical dated 01/02/12 revealed the resident had generalized weakness and decreased energy secondary to her significant hospitalization and was admitted to the facility for physical and occupational therapy prior to her return home. The record noted the resident had lived at home alone prior to the hospitalization . Review of the discharge plan note dated 01/06/12 revealed the resident was to be discharged from the facility and returned home on 01/11/12. Review of Resident #19's care plan revealed the resident was as at risk for falls due to impaired mobility, use of psychotropic and pain medication and limitations in activity tolerance. The care plan was initiated on 12/20/11, upon original admission to the facility. The goals were to minimize risk for injury related to falls and minimize risk for falls. Interventions included: assess for fall risk upon admission and reassess as needed; notify physician and family/responsible party of any falls; observe for and report changes in gait/balance; provide assist to transfer and ambulate as needed. An additional intervention was initiated on 01/10/12, following a fall, to educate the resident to ask for assist when ambulating. Review of Resident #19's medical record revealed the resident fell in her room at the facility on 01/09/12 and complained of right shoulder pain and right leg pain. Initial x-rays of the shoulder and hip were negative. Repeated x-rays of the femur and neck were also negative. Due to intractable pain and an inability to bear weight on her leg, the resident was sent to the hospital for a magnetic resonance imaging (MRI) on 01/12/12. At the hospital, Resident #19 was diagnosed with [REDACTED]. The resident was hospitalized from [DATE] to 01/14/12 for pain control and stabilization of the fractures. The fractures were not dislocated and with the resident's other health issues, the decision was made to manage the injuries without surgical intervention. Resident #19 returned to the facility on [DATE] for further recovery and therapy. Review of the incident report dated 01/09/12 at 10:00 A.M. indicated Resident #19 was using the restroom in her room and a housekeeper was in the room mopping the floor. When the resident came out of the restroom, the staff member warned the resident that the floor was wet. Upon crossing the room to the bedside chair, the resident slipped on the wet floor landing on her right side, bumping her head on her roommate's bed. The physician and family were notified of the incident. The investigation included a written witness statement dated 01/09/12, by the housekeeper referred to in the incident report. In the statement, it was noted that the housekeeper stated, "I did mop a partial section of the floor. I mopped under the beds and the outside by the window. I left the path from the bathroom and the center section dry (un-mopped). The housekeeper noted she told the patient that she left her a dry area so she wouldn't fall when she left the bathroom. The investigation also included a statement from Resident #19 which indicated the housekeeper hollered in and told her that she was going to just mop around the bed and wall and leave a dry path to walk on to get to the bed, but when she came out, the wheelchair was next to the bed so she had to go out around it to get to the bed. Resident #19 noted she must have went off the dry patch and hit a wet spot and went down (fell ). Further review of the investigation details revealed the housekeeping staff was inserviced on 01/10/12 regarding resident safety and mopping resident rooms. Staff instruction was for resident safety and if a resident is in the bathroom or walking around the room, do not mop at that time, go on to another room. Observation and interview with Resident #19 on 02/07/12 at 2:07 P.M. revealed an alert and oriented resident sitting on the edge of the bed, working on a puzzle book and talking with her roommate. The resident was pleasant and easily described the circumstances of her fall on 01/09/12. Resident #19 reported being up in the bathroom when the housekeeper came in to clean the room on that day. When the resident opened the bathroom door to go out, there was a wet floor sign there. The resident said the housekeeper was standing near the window and told the resident that part of the floor was wet, but there was a dry path to her bed. The resident reported that at that time she did not require assistance for ambulation. Resident #19 said she stepped off the dry area and onto the wet floor and her feet went out from under her. The resident protected her left side, as she had a colostomy. The resident landed onto her right side and hit her head on the bottom of the roommate's bed. Resident #19 said she ended up with some fractures, but they weren't immediately found because x-rays did not show them. As the days passed and they were unable to control the pain, they sent her to the hospital and the fractures were found. The resident reported she stayed at the hospital for a few days where she was monitored and received pain control. After a few days, the resident said she was transferred back to the facility. Review of the facility's "Falls Practice Guide" indicated some environmental factors which may be associated with falls or the risk of falling may need to be reviewed and considered as ongoing fall prevention strategies. These factors may include, but are not limited to: loose carpeting or moveable rugs; uneven flooring; and wet floors.

Based on medical record review, observations, resident, staff, physician and nurse practitioner interview, review of facility policy and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), it was determined the facility failed to implement pressure ulcer preventative measures to prevent the development of pressure ulcers. This resulted in actual harm for Resident #102 who developed two avoidable pressure ulcers to the left heel and right outer ankle. This also resulted in actual harm for Resident #18 who developed two avoidable pressure ulcers to the left foot and heel. This affected three (#102, #18 and #15) of six residents reviewed for pressure ulcers. The facility identified two current residents with pressure ulcers upon entrance to the facility. The facility census was 81. Findings include: 1. Review of Resident #102's medical record revealed the resident was admitted to the facility on [DATE] and was later discharged to home on 01/31/12. [DIAGNOSES REDACTED]. Review of the "Patient Admission Screen" dated 12/09/11 documented the presence of a sacral bruise related to a fall; however, there were no pressure ulcers or open areas. The screen further documented a "Braden Scale for Predicting Pressure Score Risk" which revealed a score of "16" indicating the resident was at low risk for skin breakdown. An activity of daily living (ADL)/functional status form dated 12/09/11 documented the resident had a history of [REDACTED]. Review of the initial minimum data set (MDS) assessment completed upon admission, dated 12/16/11, indicated the resident required extensive assist of two persons for bed mobility and transfers. The assessment further noted the resident was at risk for developing pressure ulcers. Review of Resident #102's comprehensive care plans revealed a care plan for at risk for alteration in skin integrity, initiated 12/12/11, related to impaired mobility, cognitive deficits, pain, and decreased intakes. The care plan included interventions to encourage and assist as needed to reposition frequently, pressure redistributing device on the bed and cushion in the wheelchair, reassess skin risks per protocol and notify physician and significant other of any change in skin condition. The care plan did not include specific interventions for pressure relief to the resident's bilateral heels. Further review of the medical record revealed a nurse note entry dated 12/16/11 at 10:00 A.M. which indicated the physician had been in to see the resident and discovered a large fluid filled blister on the left heel. The physician ordered to pad and protect the area. The nurse note did not include any measurements of the blister. Review of nurse note entry dated 12/20/11 at 2:45 A.M. revealed Resident #102 was discovered to have a fluid filled blister on the right outer ankle that measured 1.0 centimeter (cm) by 1.0 centimeter. On 12/19/11, a care plan was initiated to address the left heel blister and on 12/21/11, a care plan was developed to address the right outer ankle blister. Interventions included to administer treatment per physician orders, evaluate and record wound status per facility guidelines until healed and observe for and report any [MEDICAL CONDITION] noted during care. Neither of the care plans included specific interventions for pressure relief to the heels (i.e. off-loading of the heels.). Review of documentation from the National Pressure Ulcer Advisory Panel (NPUAP) revealed a pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. In addition, the NPUAP defines a Stage II pressure ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. The NPUAP further noted "Pressure Ulcer Prevention Points" which consisted of using devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed and for long term care, place heel suspension boots and reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with overall goals of care. During interview on 02/08/12 at 2:30 P.M., Registered Nurse (RN) #8 verified Resident #102 required extensive assist of two persons for most of her ADL's and that she was at risk for pressure and/or skin breakdown. RN #8 stated the resident had [MEDICAL CONDITION] to the lower extremities and did develop skin breakdown to the left heel on 12/16/11 and to the right outer ankle on 12/20/11. RN #8 further stated the blisters on the left heel and right outer ankle eventually popped and the skin became covered with an eschar covering. Interview with Director of Care Delivery (DCD) #1 on 02/08/12 at 6:10 P.M. verified Resident #102 was at risk for the development of pressure ulcers and skin breakdown upon admission, related to a left [MEDICAL CONDITION] and left shoulder dislocation which required extensive assist of two person for bed mobility and transfers. DCD #1 also verified the resident's care plan lacked specific interventions to prevent skin breakdown on the resident's heels upon admission to the facility. She confirmed interventions were implemented after the areas developed. Review of the facility's policy entitled "Skin Practice Guide" dated 07/08 indicated the Braden Scale tool is completed for four (4) weeks total after admission and the Braden Scale Reference Tool may be used in conjunction with the Braden Scale to assist staff with selecting interventions for care delivery. The Braden Scale Reference Tool further documented an intervention guide for residents at very high risk for pressure ulcer development which included to protect the heels. Additionally, the facility's policy referenced the NPUAP. 2. Review of Resident #18's medical record revealed an admission date of [DATE]. Review of the physician's most recent progress noted dated 02/02/12 included current [DIAGNOSES REDACTED]. The resident was also paraplegic and unable to move the left leg. The quarterly minimum data set (MDS) assessment dated [DATE] indicated the resident was alert and oriented and required extensive assist of two or more staff members for bed mobility. The resident was totally dependant for transfers from bed to the wheelchair. The resident was able to self-propel the wheelchair in the halls. Review of the resident's care plan for at risk for alteration in skin integrity related to impaired mobility and [MEDICAL CONDITION], initiated on 05/09/08, included interventions to monitor skin condition daily with ADL care and report abnormalities, encourage consumption of all foods, especially high protein ones, use pillows and positioning devices as needed, encourage and assist resident to reposition as needed based upon needs, air mattress on the bed and cushion on chair and suspend heels. The care plan also included an intervention to limit time up in the wheelchair to two hours; however, notes the resident is non-compliant with this intervention. Review of the most recent physician's progress noted dated 02/02/12 made no reference to wounds. However, during the stage one record review and staff interview, the resident was identified as having an open area, described as "denuded" by the facility staff to the coccyx. The resident was also receiving treatment for two other skin alteration areas on the left foot. Review of the "Skin Alteration Record" dated 09/15/11 revealed the coccyx wound was identified as a "denuded area from moisture on the coccyx". (Medical terminology defines denuded as a loss of some or all of the epidermis (the outer layer) leaving a denuded surface). The coccyx wound measured 1.3 centimeters (cm) in length by 1.2 cm in width, with no depth recorded. The tissue was described as dark pink/red with serosanguinous (thin, red) drainage. The surrounding tissue was reddened and there was no pain noted. Weekly measurements and assessments were noted on the skin record. However, the records reviewed were noted to be missing measurements of depth on two occasions and the amount of drainage and assessment of pain on two occasions. It was also noted that on the third week, 09/23/11, there was an addition of moderate purulent (creamy white to yellow) drainage noted. Measurements had increased to 1.0 cm in length by 2.5 cm in width by 0.1 cm in depth. By week seven, 10/20/11, the documentation noted a further increase in size and the wound bed was documented to have eschar. From 10/20/11 through 02/08/12, the coccyx wound presented with slough and a moderate amount of drainage. On 02/08/12, the coccyx wound measured 2.8 cm in length by 1.2 cm in width with 0.1 cm in depth. Further review of the record revealed a "Wound Management Progress/Procedure Note," written by the certified wound care nurse. The wound care nurse indicated the onset of Resident #18's coccyx wound was 09/01/11, not 09/15/11. The wound on the coccyx at that time was noted as a Stage II area with a pressure component. During interview on 02/19/12 at 11:00 A.M., DCD #2 stated the facility was aware that the wound care nurse had documented Resident #18's coccyx wound as a pressure ulcer. DCD #2 further stated they (the facility) had talked to her (wound nurse) about re-evaluating that documentation. In addition, Resident #18's record contained a nurse note entry dated 01/05/12 which indicated an open area to the left lateral foot was discovered. On 01/06/12, staff also discovered a discolored area to the left lateral heel. Review of the physician's orders [REDACTED]. Review of the "Skin Alteration Record" dated 01/05/12 indicated the left lateral foot was described as dark red tissue with slough (moist yellow or gray necrotic tissue), had a moderate amount of purulent drainage (creamy white to yellow) with a foul odor. The surrounding skin was reddened, [MEDICAL CONDITION] and macerated. On 02/04/12, the left lateral foot wound measured 3.0 cm in length by 3.0 cm in width, with no depth. The area was described had pale pink tissue with a scant amount of serous (clear) drainage. The surrounding skin was macerated (skin softening related to fluid). Review of the "Skin Alteration Record" dated 01/06/12 revealed the left lateral heel area was described as firm and purple and measured 1.7 cm in length by 1.2 cm in width by 0.2 cm in depth. On 02/09/12, the area measured 1.4 cm in length by 1.0 cm in width, with no depth. The area was still described as firm and purple. Review of Resident #18's care plans revealed a care to address the left lateral heel was initiated on 01/11/12. The care plan noted the area was related to "[MEDICAL CONDITION]" and included interventions to administer treatment per physician orders, use pillows and/or positioning devices as needed and evaluate and record wound status per facility guidelines until healed. There were no additional interventions of pressure relief to the area. Additionally, a care plan was initiated on 01/11/12 to address the left lateral foot ulcer. The care plan also noted the area was a "stasis ulcer related to [MEDICAL CONDITION]" and included interventions to administer treatment per physician orders, use pillows and/or positioning devices as needed, evaluate and record wound status per facility guidelines until healed and suspend heels as able. There were no additional interventions of pressure relief to the area. Further review of Resident #18's record revealed no documentation by the physician regarding any of the skin wounds. The record contained no physician documentation of the resident having stasis ulcers as a result of vascular issues. It was further noted that the wound care nurse had no mention or documentation regarding the areas to Resident #18's left foot. Observation on 02/19/12 at 10:00 A.M. of Resident #18 revealed a pleasant, alert and oriented resident lying in bed. The resident was noted to have her right leg amputated and the remaining left leg was observed to be externally rotated, with the left side of her foot lying directly against the bed. Interview with the resident at this time revealed she was unable to move her left leg or feel any sensation in that extremity. Observation of the dressing change to Resident #18's coccyx and the two areas on her left foot was completed on 02/19/12 at 10:00 A.M. Registered Nurse (RN) #7 cleansed and dressed the wounds as ordered by the physician. The unit managers, DCD #1 and DCD #2, were present as they are the lead staff for the facility's wound team. DCD #1 completed the measurements as requested by the surveyor at that time. Observation of the resident's coccyx/sacral (tailbone/low back area) revealed an open area that measured 3.0 cm in length by 2.3 cm in width by 0.2 cm in depth. The wound bed had an area of white slough and black eschar noted. The surrounding tissue was reddened. There was moderate yellow, odorous drainage on the old dressing. Continued observation of the dressing change to Resident #18's foot wounds revealed the staff had to lift the left lower leg/foot off of the bed so the surveyor, RN #7 and DCD #1 could lean over and look up to assess the areas. The areas on the left heel and side of the left foot, down near the toes, were noted to be at pressure points where the resident's foot lays naturally with the external rotation of her leg. Observation of the left outer heel revealed a round brown scabbed (eschar) area that measured 1.4 cm in length by 1.0 cm in width. The surrounding edges were noted with yellow slough. Observation of the wound to the left lateral foot revealed an area that measured 0.7 cm in length by 0.8 cm in width. The staff failed to measure the depth, even after the surveyor requested it. The wound bed was noted with approximately 50% yellow slough and the wound edges were reddened. There was a moderate amount of serous drainage noted on the old dressing. Interview with DCD #1 at the time of the observation revealed she "believed" the foot wounds were caused by vascular issues, but would have to check the chart. Again, DCD #1 verified she and DCD #2 comprised the facility's wound team. DCD #1 further verified the measurements and assessments of Resident #18's foot wounds had been completed by floor nurses not the wound team. It was also noted during the observation that Resident #18's left foot was warm to touch and there was no circulatory discoloration evident. DCD #1 verified Resident #18's left foot was lying directly on the bed prior to completing the dressing changes. Interview with Resident #18's physician on 02/09/12 at approximately 2:00 P.M. revealed the physician has not previously assessed the wounds to the resident's left foot. At the physician's invitation at that time, the surveyor accompanied him to the resident's room and the physician removed the dressings and observed the areas. During the interview, the physician verified the wounds developed on bony areas and that pressure was definitely a factor. However, the physician was notably vague and would not commit to [DIAGNOSES REDACTED]. The physician reported the resident did have some [MEDICAL CONDITION] that "could have played a part" in the development of the wounds. Physician #10 stated, "we'll just call them wounds". The physician then wrote an order for [REDACTED]. 3. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] and later discharged home on[DATE]. [DIAGNOSES REDACTED]. The resident's "Admission Screen" dated 09/23/11 revealed no documentation regarding any concerns with pressure ulcers or open areas. Further review revealed the resident scored a "19" on the "Braden Scale for Predicting Pressure Sore Risk" which indicated she was at low risk for pressure ulcer development. The admission minimum data set (MDS) assessment dated [DATE] indicated Resident #15 required extensive assist of two persons for bed mobility, transfers and walking in the room and corridor. The assessment further noted the resident was at risk for pressure ulcer development; however, there was no unhealed pressure ulcers at the time of the assessment. Review of Resident #15's care plan for at risk for alteration in skin integrity related to impaired mobility dated 09/29/11 included interventions to encourage and assist to reposition as needed based upon patient's needs, encourage consumption of all foods especially high protein ones and all fluids provided, notify physician and significant other of any change in skin condition, and observe skin condition with ADL care daily and report abnormalities. The care plan did not include interventions specific to pressure relief. Review of Resident #15's physician's orders [REDACTED]. The TAR documented the dressing was changed on 10/02/11, 10/05/11, 10/08/11, 10/11/11 and 10/14/11. Further review of the medical record revealed there was no skin alteration form present and no nurses' notes related to the left buttock open area. The facility was unable to provide any wound documentation related to Resident #15's left buttock wound. Further review of Resident #15's care plan for at risk for alteration in skin integrity related to impaired mobility dated 09/29/11, failed to document any information regarding an open area to the resident's left buttock. The care plan did not indicate a treatment was initiated or that pressure relieving interventions were initiated. During interview on 02/08/12 at 9:15 A.M., DCD #1 verified that on 10/02/11, the nurse on duty initiated an order for [REDACTED]. DCD #1 was asked what the left buttock open area was related to and she indicated it was related to friction and shearing; however, it was not related to pressure but verified it met the definition of a pressure ulcer per the NPUAP. DCD #1 also confirmed she was unable to provide any wound documentation with measurements and a description of the open area on Resident #15's left buttock. She verified the care plan did not include pressure relieving interventions and also verified it was facility policy to start a skin alteration sheet for pressure and non-pressure ulcers.