Every finding on record at Promontory Point Rehabilitation

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 9 of 12 residents (Resident #2, # 3, #17, #29, #37, #52, #60, #61 and #66) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include: The facility's Patient's Rights Regarding Treatment and Advance Directive policy, revision date 12/1/22, documented on admission, Promontory Point Rehabilitation will determine if the patient has executed an advance directive, and if not, determine whether the patient would like to formulate and advance directive. Upon admission, should the patient have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the patient wishes to change or continue these instructions. The following resident's records did not include an advance directive or documentation information about an advance directive was provided to the resident or the resident's representative. Resident #2 was admitted to the facility 3/3/26, with multiple diagnoses including nondisplaced fracture of left femur (thigh bone) and chronic respiratory failure. A Social Services note, dated 3/4/26, documented when Resident #2 was asked if he had a POA/Living Will he stated he did. When asked if the facility could get a copy to have on file, Resident #2 stated the facility could. Social Service documented that he would follow up in a couple of weeks for upload or with Resident #2. On 5/27/26 at 11:34 AM, a record review of Resident #2's medical record did not document an advance directive or follow up with Resident #2 or resident representative. Resident #37 was initially admitted to the facility 7/26/23, and readmitted on [DATE], with multiple diagnoses including displaced intertrochanteric fracture (thigh bone) and delirium (disorientation to time and place, usually with hallucinations). A Social Services note, dated 5/12/26, documented when Resident #37 was asked if she had a POA/Living Will she stated she did not. When asked if she would like assistance to make one she stated she would like assistance in making one. Social Service documented that he would assist her and upload a copy when done. On 5/26/26 at 10:55 AM, Resident #37's medical record had documented Resident #37 had been transferred to a local emergency department due to low blood pressure and low oxygen saturation on 5/13/26. Resident #37's transfer document checklist dated 5/13/26, marked Advance Directive had been sent with Resident #37 to the emergency department. On 5/27/26 at 11:39 AM, a record review of Resident #37's medical record did not document an advance directive or follow up with Resident #37. On 5/28/26 at 10:53 AM, the Administrator stated he had assisted Resident #37 on the afternoon of 5/27/26, to complete her Advance Directive. Resident #60 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including diabetes and anxiety. A Social Services note dated 5/20/26, documented when Resident #60 was asked if he had a POA/Living Will he stated he did. When asked if the facility could get a copy to have on file, Resident #60 stated he would let his family know. Social Service documented that he would follow up in a couple of weeks for upload or with Resident #60. On 5/28/26 at 10:04 AM, a record review of Resident #60's medical record did not document an advance directive or follow up with Resident #60 or resident representative. On 5/28/26 at 10:54 AM, the LSW stated they had not received a copy of Resident #60's advance directive from his family. Resident #61 was originally admitted on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple fractures of ribs and atrial fibrillation (irregular, rapid heartbeat). On 5/26/26 at 11:24 AM, a record review of Resident #61's medical record did not document an advance directive. On 5/27/26 at 12:15 PM, Resident # 61's medical record had not documented a Social Services note that Resident #61 had been asked about her advance directive or if she wanted assistance in making an advance directive. On 5/28/26 at 10:57 AM, the LSW stated they had not followed up with Resident #61 about her advance directive and she did not have an advance directive in her medical record. Resident #66 was initially admitted on [DATE], and readmitted on [DATE], with multiple diagnoses including acute embolism and thrombosis (blood clots) and anemia. On 5/26/26 at 9:42 AM, a record review of Resident #66's medical record did not document an advance directive. A Social Services note, dated 5/18/26, documented when Resident #66 was asked if he had a POA/Living Will he stated he did. When asked if the facility could get a copy to have on file, Resident #66 stated he would let his wife know. Social Service documented that he would follow up in a couple of weeks for upload or with Resident #66. On 5/28/26 at 11:04 AM, the LSW stated they had not received a copy of Resident #66's advance directive from his wife or documented a follow up. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including urinary tract infection and discitis (a painful inflammation and infection of the intervertebral disc space in the spine). A Social Services note, dated 3/17/26, documented when Resident #3 was asked if she had a POA/Living Will she stated she did. When asked if the facility could get a copy to have on file, Resident #3 stated she would let her family know. Social Service documented that he would follow up in a couple of weeks for upload or with Resident #3. On 5/27/26 at 2:48 PM, a record review of Resident #3's medical record did not document an advance directive or follow up with Resident #3 or resident representative. On 5/28/26 at 10:47 AM, the Administrator stated Resident #3 did not have an advance directive in her medical record and they did not follow up. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (a life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death) and hypertension. Resident #17's Social Services note, dated 3/24/25, documented, When the patient was asked if she has a POA/Living Will. She says she does. Asked if we could have a copy to have on file at the facility. She says she does not. Resident #17's Initial Care Planning Conference form dated 3/24/26, documented POA/Living Will: Yes (No). Resident #17's Baseline care plan dated 3/24/26, did not address her advance directive status. On 5/28/26 at 10:49 AM, the LSW stated they had not received a copy of Resident #17's advance directive from her family. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including fractured pubis (pelvis bone) and chronic kidney disease. Record review of Resident #29's medical record did not include an advance directive or documentation information about an advance directive was provided and discussed with her or resident representative. On 5/28/26 at 10:50 AM, the Administrator stated Resident #29 had no advance directive and Social Services should have offered to assist Resident #29 formulate one. Resident #52 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including fractured hip and hypertension. Resident #52's Social Services notes dated 2/26/26, documented she has one (advance directive) and will follow up. No follow up note documented in Resident #52's medical record. Resident #52 was discharged [DATE], and readmitted [DATE], and review of her medical record did not have documentation of her advance directive. On 5/28/26 at 10:24 AM, the LSW stated Resident #52 did not have an advance directive in her medical record.

Based on observation, policy review, manufacture's manual review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment for 2 of 2 residents (#57 and #66 ) observed for respiratory equipment use and clean/sanitary laundry rooms. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The facility's Nebulizer Therapy policy revision date [DATE], directed staff to clean the nebulizer after each use. Once completely dry, store the nebulizer cup and the mouthpiece in a ziplock bag.The facility's Laundry policy dated [DATE], documented the laundry equipment will be used and maintained according to manufacturer's instructions.The Top Load Washer Owner's manual provided by the Administrator documented cleaning of the top-loading washer should be performed at a minimum once per month or every 30 wash cycles, whichever occurs sooner.The Electric Dryer Owner's Manual provided by the Administrator documented the lint screen to be cleaned before or after each load.The following was observed for proper laundry handling:-On [DATE] at 1:39 PM, the housekeeper was observed carrying clean bed linens down the hallway, uncovered.On [DATE] at 1:40 PM, the housekeeper stated she was taking the clean bed linens to hall 300 and the linens should have been bagged.On [DATE] at 3:36 PM, the IP stated clean linen should be bagged when going down the hall. The following was observed for nebulizer use:-On [DATE] at 9:56 AM, observed Resident #66's nebulizer mouthpiece and tubing on his bedside table not covered.-On [DATE] at 10:21 AM, observed on Resident #57's bedside table his nebulizer mouthpiece and tubing not covered.The following was observed on the treatment cart:-On [DATE] at 7:19 AM, observed on the hall 100 treatment cart a bottle of hand sanitizer with an expiration date of [DATE].On [DATE] at 7:23 AM, RN #1 stated the sanitizer should not have been on the cart.On [DATE] at 11:21 AM, the DON stated the hand sanitizer should have been discarded by nursing when it had expired.-Observed in the laundry rooms:On [DATE] at 3:48 PM, with CNA #1 present observed in the laundry room used for linens a blue apron and goggles with a light gray fuzzy film.CNA #1 was asked if there were aprons and goggles that were used when placing dirty laundry in the washing machine and she stated there was no apron or goggles that the staff only wear gloves to the load dirty laundry into the washing machine. CNA #1 also stated that the CNAs do the laundry, there were no designated laundry staff.On [DATE] at 3:50 PM, observed above the dryer in the linen laundry room, on the vent and ceiling around vent a gray fuzzy substance.On [DATE] at 3:52 PM, observed the ceiling above the washing machine a splattering of a dry yellow substance.On [DATE] at 3:58 PM, in the laundry room for personal linens observed the small Amana washing machine with a gray fuzzy substance on the back panel of the machine. The soap dispensing compartment of the washing machine was filled with a dry, grainy substance. The machine agitator had a dry, gray substance on the top and down the middle. The inside of the lid, on the bottom lip of the machine, had a dry, gray substance. On [DATE] at 3:59 PM, observed the base of the hole in the wall where the hot and cold-water pipes come out of the wall for the washing machine had a thick layer of a gray fuzzy substance. The pipes from the ceiling above the dryers had a gray fuzzy substance on them.On [DATE] at 4:00 PM, observed the Amana dryer lint filter compartment with a layer of black, fuzzy substance.On [DATE] at 4:04 PM, the floor behind the dryers in the personal linen laundry room were observed to have a layer of gray, fuzzy substance.On [DATE] at 4:06 PM, observed the three vents in the personal linen laundry room with a gray, fuzzy substance on the vents and on the ceiling around the vents.On [DATE] at 7:11 AM, the Maintenance Director stated the floor staff wash the laundry and there were goggles and an apron for the staff to use but they do not always use them when washing laundry, and they should.When the Maintenance Director was asked who was responsible for cleaning the laundry rooms, he stated it was his and the housekeeper's responsibility to keep the laundry rooms clean and they cleaned them weekly.Review of the Weekly Laundry Cleaning/Audit documented:-Leaks in chemical hoses-Washer machine no leaking-Washer Drain free of obstruction-Dryer lint vacuum-Dryer running properly-Laundry room floor clean and room organizedReview of the weekly cleaning schedule did not document cleaning of the laundry machines or other areas of the laundry rooms.On [DATE] at 1:58 PM, the Administrator stated there was no cleaning schedule for the personal size washing machines or dryers.

Based on policy review, record review, and staff interviews it was determined the facility failed to ensure transferring information and documentation, notice of bed-hold policy, and notice to the State Long-Term Care Ombudsman for 2 of 12 residents (#37 and #47) and the facility reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner, allowed to return to the facility, or protected from inappropriate transfers and discharges. Findings include: The facility's Bed Hold Notice Before/Upon Transfers revision date 12/1/22, documented, 1. When a patient is transferred to the hospital or goes on therapeutic leave, facility will provide to the patient and/or representative written or verbal information that specifies: a. The duration of the state bed-hold policy, if any, during which the patient is permitted to return and resume residence in the nursing facility. 2. In the event of an emergency transfer of a patient, the facility will provide within 24 hours written or verbal notice of the facility's bed-hold policies.5. Facility will keep a signed and dated copy of bed-hold notice information given to the patient and/or representative in the patient's file.1. Resident #37 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including displaced intertrochanteric fracture (thigh bone) and delirium (disorientation to time and place, usually with hallucinations).On 5/26/26 at 1:53 PM, review of Resident #37's medical record had documented on 5/13/26 at 2237, resident had been transferred to the local emergency department due to low blood pressure and low oxygen saturation. On 5/26/26 at 1:56 PM, Resident #37's medical record had not documented a bed-hold policy had been reviewed with the resident or her representative. On 5/28/26 at 11:09 AM, the Administrator stated Resident #37 had not been presented with a bed-hold policy and should have been.2. Resident #47 was admitted to the facility on [DATE], with multiple diagnoses including weakness and recent sepsis (a serious condition in which the body's response to an infection causes injury to its own tissues). On 5/27/26 at 10:24 AM, review of Resident #47's medical record documented Resident #47 had been transferred to the local emergency department on 4/7/26 at 17:57, for increased cough, shortness of breath, and low oxygen saturations. On 5/27/26 at 11:32 AM, Resident #47's medical record had not documented required pertinent medical information including care plan goals, medication list, and advance directive was provided to the receiving hospital. On 5/27/26 at 11:34 AM, Resident #47's medical record had not documented a bed-hold policy had been presented to the resident or resident's representative.On 5/28/26 at 1:11 PM, the Administrator stated Resident #47's medical record had not documented the required transfer information and should have. 3. On 5/28/26 at 12:07 PM, the surveyor requested six months of the facility's Ombudsman notifications of transfers and discharges.On 5/28/26 at 12:33 PM, the Administrator stated the facility did not have documentation of notifications to the Ombudsman as requested.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident's call light was within reach for 1 of 37 residents (Resident #9) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's Call Lights Accessibility and Timely Response policy, no version date, documented. 5. Staff will ensure the call light is within reach of resident and secured, as needed. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including displaced trimalleolar fracture (ankle fracture), major depressive disorder, and diabetes. On 5/26/26 at 11:17 AM, observed Resident #9 sitting in her recliner with her legs propped up. The recliner was positioned with the back against the bed and the call light plugged into the wall and the cord hanging down the wall and under the foot of her bed and not within her reach. Resident #9 unable to independently reach call light. On 5/28/26 at 2:32 PM, the DON stated resident's call light should be within reach and had not been.

Based on observation, staff interviews, and the State Operations Manual, Appendix PP it was determined the facility failed to ensure nurse staffing information was accurate and included scheduled and actual hours. This failed practice had the potential to affect the 37 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:State Operations Manual, Appendix PP -.the facility posts the following information on a daily basis: facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff, and resident census. On 5/27/26 at 11:14 AM, the daily posted staffing sheets were reviewed for the months of December 2025 - May 2026, the following was observed:No actual licensed and unlicensed staff hours documented on the sheets for the 6 months reviewedOn 5/27/26 at 1:41 PM, the Administrator stated the facility had not documented the actual licensed and unlicensed staff hours on the daily posted staffing sheets and the facility daily staff schedules are not kept as time adjustments are only made on the staff time sheets.

Based on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 1 of 1 resident (Resident #60) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications. Findings include:Resident #60 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including anemia (a condition in which there is a reduced number of circulating red blood cells) and diabetes. A physician order dated 5/19/26, documented Resident #60 was to start Bupropion HCl oral tablet 100 mg two times a day. On 5/27/26 at 10:06 AM, review of the May 2026 medication administration record had documented Resident #60 received Bupropion HCl 100 mg on 5/19/26, at bedtime. On 5/27/26 at 10:24 AM, Resident #60's signed Psychotropic Medication Administration Disclosure dated 5/20/26, listed Bupropion for a diagnosis of major depressive disorder. On 5/28/26 at 11:26 AM, the DON stated, Resident #60 should have signed the psychotropic medication administration disclosure prior to administration of Bupropion HCl but had not.

Based on observation, resident and staff interviews, record review, and policy review it was determined the facility failed to assess whether residents had the ability to self-administer their medications for 1 of 1 resident (Residents #66) reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident. Findings include: The facility's Self-Administration of Medication policy revised 10/22/22, documented residents may self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . 3. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the patient's medical record . 10. The care plan must reflect patient self-administration and storage arrangements for such medications. Resident #66 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute embolism and thrombosis (blood clots) and anemia. On 5/26/26 at 9:12 AM, observed in Resident #66's room one Albuterol inhaler lying on the bed linen next to the resident. On 5/26/26 at 9:39 AM, review of Resident #66's medical record included physician orders dated 5/15/26, for Albuterol Sulfate HFA Inhalation Aerosol Solution. On 5/27/26 at 2:10 PM, Resident #66's medical record had not documented an interdisciplinary team assessment, care plan update for self-administration of medication for Albuterol inhaler to be self-administered. On 5/28/26 at 2:28 PM, the DON stated Resident #66 had not been assessed by the interdisciplinary team for self-administration of medications and should not have had the albuterol inhaler at his bedside.

Based on observation, interview, and the FDA Food Code, the facility failed to ensure food was appropriately stored, distributed, and labeled. This deficient practice had the potential to affect all residents and staff who received meals prepared in the facility's kitchen. This placed residents and staff at risk for potential contamination of food and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code Section 3-305.11 Food Storage documented, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.The FDA Food Code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding documented bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 degree C to 57 degree C (41 degree F to 135 degree F) too long. On 5/26/26 at 5:52 AM, observed in the kitchen with the Administrator present three uncovered plates of food on the serving counter (tray line area): - one plate filled with cooked peas and carrots - one plate filled with cooked mashed sweet potato-looking orange substance - one plate filled with meat and gravy-like off white thick substanceOn 5/28/26 at 2:28 PM, the Dietary Manager stated the three plates of food had been left out from the prior dinner meal for the night shift staff and should have been discarded but had not been.On 5/27/26 at 3:43 PM, the following was observed in the 100 Hall resident unit refrigerator with RN #2 present:Multiple Ensure bottles - not dated or labeled with resident nameMultiple soda bottles - labeled with resident room number and residents' initials onlyThree cans of drinks - labeled with staff initials On 5/27/26 at 3:45 PM, RN #2 stated the refrigerator contents should be labeled with the resident name and the date and staff drinks should not have been in the refrigerator.On 5/27/26 at 4:13 PM, the following was observed in the 200 & 300 Hall resident unit refrigerator with staff present:One large bottle of Gatorade - not dated or labeled with resident name On 5/28/26 at 11:22 AM, the DON stated the unit refrigerators are for resident items only and items should have been dated with the resident's room number, first name and last name initial and had not been.

Based on observation and staff interview it was determined the facility failed to ensure resident's privacy was maintained during medication administration and medical information was protected. This was true for 1 of 2 medication carts reviewed for privacy and confidentiality. This deficient practice placed residents at risk of embarrassment and loss of control over their personal information. Findings include: The facility's Patient Rights policy, revision date 12/1/22, documented the resident has the right to have personal and clinical records kept current and private. On 2/11/25 at 7:46 AM, observed on the south hall medication cart, the computer had the screen open to Resident #23's medical information. On 2/11/25 at 7:54 AM, observed on the south hall medication cart, the computer had the screen open to Resident #8's medical information. On 2/11/25 at 7:57 AM, observed on the south hall medication cart, the computer had the screen open to Resident #19's medical information. On 2/11/25 at 8:02 AM, LPN #1 stated she should have shut the screen to the computer before she left the medication cart.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for 1 of 12 residents (Resident #1) reviewed for quality of care. Resident #1 was at risk for adverse outcomes when she did not have a physician's order to provide oxygen as needed. This failed practice had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice. Findings include: The facility's Oxygen Administration policy revision date 10/13/22, documented oxygen was to be administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Resident #1 was admitted to the facility on the 1/21/25, with multiple diagnoses including fracture of the right femur (thigh bone) and hypertension. On 2/10/25 at 9:00 AM, observed Resident #1 in her room with oxygen at 1 liter per minute via nasal cannula. Review of Resident #1's medical record did not document an order for oxygen. On 2/11/25 at 11:22 AM, LPN #2 stated Resident #1 did not have an order for the oxygen and she should have because she has been on a low flow oxygen since she was admitted .

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately, this was true for 1 of 2 medication storage rooms inspected and 1 of 2 medication carts audited for labeling and storage of medications. This failure created the potential for residents to receive the wrong medication and to receive expired medications with decreased efficacy. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices, dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. The facility's Medication Storage policy revision date 10/12/22, documented the facility was to ensure all medications housed on the premises are stored in medication rooms or cart according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. On 2/11/25 at 10:07 AM, the facility's south side medication cart was inspected with LPN #1 present, observed in the third drawer on the left, a cup with multicolored tablets in it with a piece of tape across the top labeled Tums. On 2/11/25 at 10:12 AM, LPN #1 stated they did not have a container for the Tums, and they should have. On 2/11/25 at 10:16 AM, the facility's north side medication room was inspected with LPN #2 present, observed in the resident medication refrigerator, a vial of Tuberculin purified solution (a clear colorless solution used for detection of tuberculosis infection) vial with no opened date. On 2/11/25 at 10:17 AM, LPN #2 stated there was no open date on the bottle of Tuberculin purified solution or the box the solution was in. She stated the vial should have been dated when it was opened.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and maintained to provide a safe and sanitary environment. This was true for 2 of 4 residents (#116 and #133) observed for infection control. This failure created the potential for harm by placing residents at risk for cross-contamination and infection. Findings include: 1. Resident #133 was admitted on [DATE], with multiple diagnoses including aftercare following total knee replacement. The facility's Personal Protective Equipment Policy (PPE), dated, 7/8/23, stated personal protective equipment appropriate to specific task requirements would be utilized per CDC guidelines. The policy stated equipment included but was not limited to: -gowns -gloves -masks -eyewear (googles and/or face shields The CDC website for isolation and standard precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last reviewed 7/11/23, and accessed 3/14/24, states: Handwashing should be performed before having direct contact with patients; after contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; after contact with a patient's intact skin; if hands will be moving from a contaminated-body site to a clean-body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; after removing gloves. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. 1. On 3/4/24 At 5:35 PM, LPN #1 placed unopened testing supplies for admission testing of COVID-19, influenza, and PPD (purified protein derivative - skin injection to test for silent tuberculosis infection) on Resident #133's overbed table in front of her. LPN #1 then administered a nasal COVID-19 testing swab, a nasal influenza swab, and a PPD test to Resident #133. LPN #1 did not perform hand hygiene or wear PPE prior to administering the admission tests to Resident #133. On 3/4/24 at 5:55 PM, LPN #1 confirmed she did not perform hand hygiene or put on PPE during admission testing for COVID-19, influenza, and PPD. On 3/7/24 at 10:32 AM, the IP stated the facility policy was staff should be gowning and using PPE prior to completion of COVID-19 tests for all new admissions of unknown COVID-19 status. The IP further stated it was the facility's policy to use PPE for all new admissions. 2. On 3/4/24 at 5:35 PM, meal tray passes were observed in the facility's North Hall. a. LPN #1 entered Resident #133's room and placed a meal tray on her overbed table in front of her. LPN #1 did not perform hand hygiene prior to delivering Resident #133's meal. On 3/4/24 at 5:55 PM, LPN #1 confirmed she did not perform hand hygiene prior to delivering Resident #133's meal tray b. The Administrator delivered a meal tray to Resident #116. Resident #116 was not offered hand hygiene prior to receiving his meal tray. On 3/7/24 at 4:24 PM, the Administrator was asked if all residents should have hand hygiene offered prior to receiving their meal tray. The Administrator stated all residents should be offered hand hygiene prior to receiving their meal tray. The Administrator was asked if he offered hand hygiene to Resident #116 for his evening meal on 3/4/24. The Administrator stated he did not. 49552

Based on policy review, record review, and resident, and staff interview, it was determined the facility failed to ensure a residents' advance directive or POST were obtained and documented in their record. This was true for 4 of 12 residents (Resident #1, 130, #7, and #182) whose advance directives were reviewed. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes regarding their advanced care plans were not followed or documented. Findings include: The facility's Residents' Rights Regarding Treatment and Advanced Directives policy, undated, stated: It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. 'Advance directive' is a written instruction such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when an individual is incapacitated (unable to speak for themselves). 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident's representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed in the chart as well as communicated to the staff. 4. Any decision-making regarding resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. The State Operation Manual Appendix PP defined an advance directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law [whether statutory or as recognized by the courts or the State], relating to the provision of healthcare when the individual is incapacitated. Physician Order for Life-Sustaining Treatment, [POST], paradigm form is a portable form designed to improve patient treatments the patient wants in the event of a medical emergency, taking the patient ' s current medical condition into consideration. A POST is not an advance directive. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following placement of drain tubes post gallbladder surgery for blockage due to gallstones. An MDS assessment, dated 2/14/24, documented Resident #1 was cognitively intact. Resident #1's record did not include a copy of an advance directive, or documentation he was offered assistance to formulate an advance directive. On 3/7/24, at 10 AM, the SW confirmed Resident #1 was not offered assistance to formulate an advance directive and his record did not include documentation of further requests or follow up regarding an advance directive. 2. Resident #130 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (when your immune system has a dangerous reaction to an infection). and chronic pressure ulcers of the buttocks. Resident #130's record did not include a copy of an advance directive, or documentation he was offered assistance to formulate an advance directive. On 3/5/24 at 11:34 AM, Resident #130 and his spouse stated they were interested in Resident #130 having an advance directive. Resident #130 and his spouse both stated they had not received information regarding advance directives since admission. On 3/7/24 at 10 AM, Resident #130's record was reviewed with the SW. The SW confirmed there was no documentation Resident #130 had an advance directive or that he was offered assistance in formulating one. 49552 3. Resident #7 was admitted on [DATE], with multiple diagnosis including respiratory failure and hypertension. An MDS admission assessment, dated 1/31/24, documented Resident #7 was cognitively intact. Resident #7's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her. 4. Resident #182 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and sepsis (when your immune system has a dangerous reaction to an infection). A MDS admission assessment, dated 3/1/24, documented Resident #182 was cognitively intact. Resident #182's record did not include an advanced directive or documentation information about an advanced directive was provided and discussed with her. On 3/6/24 at 11:38 AM, the SW stated he asked residents if they have had an advanced directive on admission and if they had one, he asked for a copy. If the resident did not have an advanced directive, he offered to help the resident formulate one or find a lawyer to help them formulate an advanced directive. The SW stated he did not document in the resident's chart if they had an advanced directive or if he offered to help them formulate one.

Based on record review, policy review and resident staff interview, it was determined the facility failed to ensure a baseline care plan was reviewed and provided to residents' and their representative. This was true for 5 of 12 residents (#7, #16, #130, #181, and #184) whose records were reviewed. This failure placed residents at risk of not having their goals for care and services met. Findings include: A facility policy titled, Baseline Care Plan, undated, documented the facility would develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care that met professional standards of quality care. The guidelines stated the baseline care plan was developed within 48 hours of admission and included a minimum of healthcare information necessary to care for the patient and included the following: -initial goals based on admission orders -physician orders -dietary orders -therapy services -social services -PASARR [Preadmission Assessment and Resident Review) recommendation, if applicable -initial goals of resident -special needs, services, health or safety risk, wound care The guidelines further stated all care should be summarized and reviewed and signed by the patient and patient representative if applicable. a. Resident #16 was admitted to the facility 2/15/24, with multiple diagnoses including stroke and a post-surgical head wound. Resident #16's record did not include documentation a baseline care plan was provided and discussed with her. On 3/6/24, at 10:30 AM, Resident #16 stated she was uncertain of her plan of care. She stated she did not believe she had papers telling her what her care needs were at the facility. b. Resident #130 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (when your immune system has a serious reaction to an infection) and chronic pressure ulcers of his buttocks. Resident #130'ss record did not include documentation a baseline care plan was provided and discussed with him. On 3/5/24, at 11:34 AM, Resident #130 and his spouse stated they remembered signing papers when he was admitted but did not remember what those papers stated. 49552 c. Resident #7 was admitted on [DATE], with multiple diagnosis including respiratory failure and hypertension. Resident #7 's record did not include documentation a baseline care plan was provided and discussed with her. d. Resident #181 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and thyroid cancer. Resident #181's record did not include documentation a baseline care plan was provided and discussed with him or his wife. On 3/4/24 at 4:24 PM, Resident #181 stated no one had discussed the plan for his care and he did not remember signing a paper about it. e. Resident #184 was admitted on [DATE], with multiple diagnosis including respiratory failure, renal (kidney) failure, and congestive heart failure. Resident #184's record did not include documentation a baseline care plan was provided and discussed with him. On 3/4/24 at 4:59 PM, Resident #184 stated he did not receive papers about how the facility planned on caring for him. During an interview on 3/6/24 at 11:18 AM, the DON stated the baseline care plan was initiated when the patient was admitted . She stated there was no documentation the baseline care plan was reviewed with the above residents or their representative and there was no documentation one was signed by the residents' or their representative.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital. This was true for 1 of 2 residents (Resident #8) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include: The facility's policy, Bed Hold Notice Before/Upon Transfer, revised 12/1/22, stated, Promontory Point Rehabilitation will provide the receiving provider the following: - Contact information of the practitioner responsible for the care of the patient. - Patient representative information, including contact information. - Advance Directive information. - All special instructions or precautions for ongoing care, as appropriate. - Comprehensive care plan goals. - All other necessary information including a copy of the patient ' s discharge summary, as applicable, and any other documentation to ensure a safe and effective transition of care. Resident # 8 was admitted to the facility on [DATE]. with multiple diagnoses including dementia and hypertension. A nurse's note dated 3/6/24 at 8:14 PM, documented Resident #8 was sent to the hospital earlier that day. The note documented there was no update and Resident #8 had not yet returned and his family and provider were aware. On 3/7/24 at 8:38 AM, RN #2 stated a transfer sheet and a medication list were sent with residents when they transferred to the hospital and the provider, family, and EMS were called. RN #2 stated this should have been documented in the progress note. On 3/7/24 at 8:48 AM, the DON and the ADON stated when a resident transferred to the hospital, the nurse notified and gave the physician a report, then made a progress note. They stated the facility sent a medication list, labs, and face sheet with the resident to the hospital. They further stated report was called to the hospital and family and should be documented in a progress note. Resident #8's record did not include documentation pertinent medical information was provided to the receiving hospital.

Based on policy review, observation, record review, and, resident and staff interview, it was determined the facility failed to ensure a resident was assessed for safety to self-administer medication. This was true for 1 of 1 resident (Resident # 2) reviewed for self-administration of medications. This failure created the potential for adverse outcomes if Resident #2 received too much or too little of the medication. Findings include: The facility's Self- Administration of Medication policy, revised 10/12/22, stated the interdisciplinary team will determine which medication may be self-administered. The results of the interdisciplinary team assessment will be recorded on the Medication Self-Administration Assessment in the patient ' s medical record. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including Hypertension and removal of her pancreas. On 3/4/24 at 1:42 PM, Fluticasone Propionate nasal spray (nasal spray used to treat allergies) was observed on Resident #2's bedside table. Resident #2's care plan, dated 2/12/24, had no documentation Resident # was able to self-medicate. There was no Medicatioon Self-Adminisration Assessment in Resident #2's record. On 3/4/24 at 1:45 PM, Resident # 2 stated the medication on her bedside table was a nasal spray that she used for her allergies. On 3/5/24 at 9:06 AM, RN # 1 stated medications were not allowed to remain at a resident's bedside unless the resident was persistent on taking their own medication then an assessment was completed.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure there was an on-going activity program designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This was true for 2 of 12 residents (#8 and #180) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lack meaningful activities throughout the day. Findings include: The facility's Activities policy, revised 10/25/22, documented Promontory Point will provide an ongoing program to support patients in their choice of activities based on their preferences and include the following:. -Scheduled activities will be posted throughout the facility. - Special considerations will be made for developing meaningful activities for patients with dementia and/or special needs. - All staff will assist patients in and from activities when necessary. 1. Resident #180 was admitted to the facility on [DATE], with multiple diagnosis including fracture of the left tibia (the larger of the two bones in the lower leg) and hypertension. A care plan created on 2/21/24, documented Resident #180 was to be invited to scheduled activities, she was to be provided with an activities calendar, and she was to be assisted/escorted to activity functions. On 3/4/24 at 3:15 PM, Resident #180 was observed sitting in her wheelchair in her room. There was no activity calendar observed in her room. On 3/4/24 at 3:21 PM, Resident #180 stated she was not offered activities except therapy. She stated she had not received a calendar of the activities that were offered in the facility. 2. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. Resident #8's care plan, revised 2/6/24,documented he liked to watch TV. The care plan documented Resident #8 was to be provided with simple, short activities, an activity calendar and reminded of upcoming activities. On 3/4/24 at 4:44 PM, Resident #8 was observed awake and sitting in his room. The TV was not on. On 3/4/24 at 4:50 PM, Resident # 8's wife stated he did not like activities other than watching TV. On 3/5/24 at 1:16 PM, the Administrator stated the activity director was let go, so activitties were not being offered according to resident care plans/preferences. He stated staff were going room to room offering activities. He stated Bingo wass offered at 2:00 PM in the dining room and there were no activity calendars in the Resident's rooms.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' dressing care was provided according to professional standards of nursing practice for 2 of 2 residents (#181 and #182) reviewed for quality of care. This failed practice had the potential to create infection in wounds or to Intravenous line sites. Findings include: The facility's Clean Dressing Change policy, revised 11/2/22, stated after securing a resident's dressing, staff were to mark the dressing with their initials and date. Dressing were to be changed per physician's order. The facility's PICC/Midline/CVAD (intravenous[IV] lines) Dressing Change policy revised 5/14/22, stated after the transparent semipermeable dressing was applied to the insertion site, staff were to label the dressing with the date and time the dressing was changed and their initials. 1. Resident #181 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and thyroid cancer. On 3/4/24 at 4:34 PM, Resident #181 was observed lying in bed with an IV dressing on his left upper arm without a date or initials. The edges of the dressing were loose and light brown in color. On 3/4/24 at 4:40 PM, Resident #181 stated he could not remember the last time the dressing was changed. 2. Resident #182 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and sepsis (when your immune system has a dangerous reaction to an infection). a. On 3/4/24 at 2:51 PM, Resident #181 was observed sitting in a chair in his room. The dressing to his left elbow did not have a date, time or initials. His IV site dressing on his left forearm did not have a date, time, or initials. b. On 3/6/24 at 9:42 AM, Resident # 182's IV site dressing on right hand was observed without date, time, or initials. On 3/6/24 at 12:09 PM, RN #2 stated all IV and wound dressings should be dated and initialed by the nurse, when they were changed. On 3/7/24 at 1:16 PM, the ADON stated all IV dressings and wound dressings should be dated and initialed when changed.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #181) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practice. Finding include: The facility's Verifying Placement of feeding tube (a flexible plastic tube placed into the stomach to provide nutrition) policy, revised 6/14/21, directed staff to verify tube placement by gently tugging on the tube and taking note of the marking on the tube. A physician's order, dated 2/20/24, directed staff to change, date, and initial Resident #181's feeding bag and tubing every night shift. On 3/6/24 at 12:05, Resident #181 was observed in his room receiving Jevity 1.5 (a type of feeding formula that provides complete, balanced nutrition) via his feeding tube. The bottle of Jevity 1.5 was not labeled with Resident #181's name, start date or time, or rate of feeding to be delivered per hour. On 3/6/24 at 12:08 PM, RN #2 stated the bottle of Jevity 1.5 should have been labeled with Resident #181's name, the date it was started, along with the time and the rate it should be flowing at. On 3/6/24 at 12:11 PM, Resident #181 was lying in bed, with the head of the bed elevated. RN #2 was observed giving Resident #181's medication through his feeding tube. The feeding tube placement was not checked prior to giving the medication. On 3/6/24 at 12:17 PM, RN #2 stated she should have checked for tube placement.

Based on policy review, observation, record review, and staff interview, it was determined the facility failed to follow physician orders for the maintenance of supplemental oxygen This was true for 3 of 4 residents (#7, #181, and #182) reviewed for supplemental oxygen use. This placed residents at risk for respiratory infections when the supplemental oxygen and nebulizer tubing and humidifier bottle were not dated when changed. Findings include: The facility's Oxygen Concentrator policy revised 5/1/22, documented it was the nurse's responsibility to change the oxygen tubing weekly and as needed if it became soiled or contaminated. a. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure. A physician's order, dated 1/28/24, documented to change Resident #7's oxygen tubing and bag, clean the filter, and change the water (humidifier) bottle weekly. The order stated the staff were to initial and date the tubing when they were changed. A physician's order, dated 1/28/24, documented to change Resident #7's nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) tubing weekly and as needed and initial and date the tubing every day shift, every Sunday. On 3/4/24 at 3:02 PM, Resident #7's oxygen concentrator tubing, water bottle, and nebulizer tubing were observed without dates. b. Resident # 81 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and thyroid cancer. A physician's order, dated 2/20/24, documented to change Resident #182's oxygen tubing and bag, clean the filter, and change the water bottle weekly. The order directed staff to initial and date the tubing. On 3/4/24 at 4:28 PM, Resident #181 was observed lying in bed with his oxygen mask on. The oxygen mask and tubing were not dated. c. Resident #182 was admitted to the facility on [DATE], with multiple diagnosis including respiratory failure and sepsis (when your immune system has a dangerous reaction to an infection). A physician's order, dated 2/26/24, documented to change Resident #182's oxygen tubing and bag, clean the filter, and change the water bottle weekly. The order directed staff to initial and date the tubing. A physician's order, dated 2/26/24, documented to change Resident #182's nebulizer tubing set weekly and as needed and to initial and date the tubing every day shift, every Sunday. On 3/4/24 at 4:01 PM, Resident #182 was observed sitting in a chair with oxygen on. The oxygen tubing was not dated. The nebulizer set and tubing in his room were also not dated. On 3/5/24 at 12:54 PM RN #1 stated the oxygen tubing should be changed once a week and tubing is to be dated.

Based on observation, Interview, and record review, the facility failed to operationalize all components of their infection prevention and control program and Centers for Disease Control and Prevention (CDC) recommendations for COVID-19 (COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste and/or smell, and in severe cases difficulty breathing that could result in severe impairment or death) when 1) new admissions were not quarantined for 14 days pending COVID-19 testing and/or asymptomatic, and 2) residents were not asked and/or encouraged to wear masks when out of their rooms. These failures placed all residents and staff at risk for exposure to COVID-19 resulting in an Immediate Jeopardy (IJ-a situation of non-compliance that has placed the health and safety of residents at risk for serious injury, serious harm, serious impairment or death). On 6/18/2020 at 4:00 PM, the Administrator, Infection Preventionist (IP), Corporate Nurse, and two other administrative staff were notified of the Immediate Jeopardy. On 6/18/2020 at 5:20 PM, the facility provided an acceptable removal plan that addressed the findings that resulted in the Immediate Jeopardy. The plan included an immediate action to place all residents who were admitted in the past 14-days in quarantine pending a COVID-19 test, and future new admissions would be quarantined in a private room until COVID-19 test results were obtained. In either case, if the resident had gone 14 days without signs and symptoms of COVID-19 they would be removed from quarantine. The plan also included an immediate action to encourage all residents to wear a mask when outside of their room and during cares. Training would be provided to staff and residents regarding these procedures. On 6/25/2020, a follow-up survey was conducted to verify the implementation of the facility's 6/18/20 removal plan. The survey found that the facility had successfully implemented the Immediate Jeopardy removal plan. Findings include: The facility's policy entitled COVID-19 Admission and Re-admission Policy (undated) indicated the following: Promontory Point Rehabilitation has a plan for managing new admissions and readmissions whose COVID-19 status is unknown or patients with signs or symptoms of COVID-19. Policy Interpretation and Implementation, New Admissions 1. New admissions will be tested for COVID-19. Patients will remain quarantined to their private room until results for COVID-19 are received. 2. Patient will be asked to wear a mask during therapy or when cares are provided .4. If the COVID-19 test is negative, quarantine restrictions for patients will be lifted. 5. If the COVID-19 test results are positive, following provider will be notified and patient will be sent back to the ER of the hospital they were admitted from . CDC recommendations include the following: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare provider) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents .Implement Source Control Measures .Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. 1. On 6/18/20, the facility had 25 residents, only one resident (Resident (R)6) was on isolation precautions (quarantined). R6 was admitted to the facility on [DATE]. R6's [DIAGNOSES REDACTED]. The resident was on droplet precautions, which indicated that staff entering the resident's room needed to wear (don) personal protection equipment (mask, gloves, gowns, and a face shield/goggles). A Nursing Progress Note dated 6/17/20 documented the Pt (patient) continues on COVID Precautions until COVID test returns. An interview regarding R6 was conducted with the IP on 6/18/20 at 11:00 AM. The IP indicated that R6 had a fall at home and she injured both arms. When she was discharged from the hospital she returned home; however, her husband was unable to provide the needed care of her so their physician arranged admission to the facility. The IP further explained that because R6 did not have a current negative COVID-19 test R6 was placed on isolation precautions. The IP stated that the facility was awaiting the results from a COVID-19 test that the facility had completed. The IP was asked about residents coming from the hospital. The IP stated that if the resident had a negative COVID test at the hospital, the facility did not place the resident in isolation/quarantine. Resident 1: R1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. R1 had a physician's orders [REDACTED]. The results of the test were still pending on 6/18/20. There was no other COVID test results or documentation of a previous COVID test. The resident's medical record did not indicate that the resident had been on any isolation precautions at the beginning of his stay at the facility. The resident's COVID status was unknown at the time of his initial admission. Resident 2 R2 was admitted to the facility on [DATE]. R2's [DIAGNOSES REDACTED]. There was no documentation of the resident's COVID-19 status at admission or that the resident had been on isolation precautions at admission. On 6/12/20, R2 was sent to the hospital for altered mental status. The resident was admitted to the hospital for treatment of [REDACTED]. R2 returned to the facility on [DATE]. There was no documentation of the resident's current COVID status at the time of readmission. The resident was not placed on isolation precautions after returning from the hospital. Resident 3 R3 was admitted to the facility on [DATE]. R3's [DIAGNOSES REDACTED]. There was no documentation that the facility knew the resident's COVID status at admission or that the resident had been placed on isolation precautions following admission. Resident 4 R4 was admitted to the facility on [DATE]. R4's [DIAGNOSES REDACTED]. There was no documentation indicating what R4's COVID status was at admission or that the resident had been placed on isolation precautions following admission. An interview was conducted with the IP on 6/18/20 at 1:05 PM to clarify the facility's process for determining new admission's COVID-19 status. The IP stated the facility required each new admission to have had a negative COVID-19 test during their hospital stay and no symptoms of COVID. The IP indicated that the facility did not necessarily get a copy of the COVID test but a verbal confirmation from the hospital that the resident had had a negative test. The IP was asked about the time frame for the COVID-19 test, the IP stated just a negative test anytime during the hospitalization . It was pointed out that the resident could have had the test at or before their hospitalization . The IP acknowledged that the test could have been completed early on in the resident's hospitalization , which made it possible that the resident could have been exposed to COVID-19 between testing and admission to the facility. 2. On 6/18/20 at approximately 9:15 AM, therapy staff were observed ambulating with residents in the hallways of the facility. The staff were wearing masks; however, none of the residents were observed wearing a mask. At approximately 10:20 AM, a resident was seen ambulating in the hallway without staff; the resident was not wearing a mask. At 11:20 AM, observations in the therapy gym revealed four residents working with therapy staff. The therapy staff were all wearing masks; however, none of the residents were wearing masks. At no time during the survey were residents seen wearing masks. Resident 8 R8 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS-assessment tool) dated 4/28/20 revealed a Brief Interview for Mental Status (BIMS-a test for measuring cognitive status) score of 9 (Moderate cognitive impairment) for R8. During an interview on 6/18/20 at approximately 2:35 PM, R8 was asked about wearing a mask while in the facility. R8 stated I don't need to wear a mask because you are wearing one, so that protects me. R8 was asked if he had a mask and he indicated he did not have one. Resident 9 R9 was admitted to the facility for surgery aftercare and had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS-assessment tool) dated 6/2/20 revealed a Brief Interview for Mental Status (BIMS-a test for measuring cognitive status) score of 15 (no cognitive impairment) for R9. An interview with R9 on 6/18/20 at 2:50 PM was conducted. R9 had a surgical mask lying on her bedside table, which R9 indicated she wore when she went out of the facility for doctor's appointments. R9 stated she did not wear a mask when in the facility. Resident 7 On 6/18/20 at approximately 3:15 PM, R7 was interviewed. R7 explained that she was in the facility for therapy, which she needed after having surgery. R7 was asked about her stay at the facility and COVID-19. R7 stated that she was never isolated during her stay at the facility. In her description of her stay at the facility, R7 indicated that she had never worn a mask when she worked with therapy or when she was out of her room. R7 did state that she had gone out of the facility to a doctor's appointment that morning and her daughter made her wear a mask. On 6/18/2020 at 4:00 PM, a meeting was held with the facility's Administrator, Infection Preventionist (IP), Corporate Nurse, and two other administrative staff. The facility's COVID-19 procedure for admitting new residents and mask use were discussed. The staff confirmed that resident's being admitted from the hospital only had to have a negative COVID-19 test sometime during their hospitalization . The facility staff acknowledge that between the time of the COVID-19 test and the time the resident was admitted to the facility; a resident could have been exposed to COVID-19. Therefore, the facility did not really know the COVID status of residents when they were admitted to the facility. The staff also acknowledge that the resident should be wearing a mask when out of their rooms. The facility's policy was reviewed and it was confirmed that the facility staff were not following the facility policy regarding COVID-19. These failures resulted in an Immediate Jeopardy situation.

Based on record review, staff interview, and review of facility policies, it was determined the facility failed to ensure implementation of interventions to prevent the worsening of a pressure ulcer and that the pressure ulcer prevention interventions were followed. This was true for 1 of 1 resident (Resident #73) reviewed for pressure ulcers. This deficient practice caused harm to Resident #73 when the pressure ulcer on her coccyx worsened to an unstageable wound. Findings include: The 2014 guidelines for staging wounds from the National Pressure Ulcer Advisory Panel, Prevention and treatment of [REDACTED]. * A Stage I pressure ulcer is defined as a nonblanchable (skin that remains red in color after pressure is applied) intact redness to skin over a bony area. * A Stage II wound is partial skin thickness loss (affects the top two layers of the skin) with red and/or pink in the wound bed without slough (a mass of dead tissue that separates from a wound bed). * A Stage III wound is full skin thickness loss (affects the layers of skin and subcutaneous tissue of fat) with possible slough present in the wound bed; however, the base of wound is visible. * A Stage IV wound is a full thickness tissue loss with exposed muscle, bone, or tendon. The guideline documented slough or eschar (dark dead tissue) could be present in parts of the wound bed. * An unstageable wound is of unknown depth due to the base of the wound being covered by slough or eschar. The facility's undated Pressure Ulcer Treatment Policy documented: * Interventions for a Stage I pressure ulcer included the following: evaluating the resident's skin until the redness was no longer persistent, determining the cause of the pressure, initiating appropriate interventions, notifying the physician, initiating a skin grid and care plan, and providing a turning schedule. * Interventions for a Stage II pressure ulcer included the following: protecting the wound, managing drainage, cleansing the wound, following physicians' orders for dressing changes, and consulting the physician for order changes as needed. * Interventions for a Stage III pressure ulcer included the following: protecting the wound, managing drainage, cleansing the wound, promoting moist wound healing, managing pain, following physicians' orders for dressing changes, and consulting the physician for order changes as needed. * Interventions for a Stage IV pressure ulcer included the following: filling in the dead space, managing drainage, [MEDICATION NAME] slough or eschar if ordered, consulting with a wound clinic, irrigating the wound, following the physician's orders for wound care, and consulting the physician for order changes as needed. Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #73 was discharged on [DATE]. Resident #73's Hospital History and Physical, dated 7/20/18, documented she had a sacral (low back/upper buttock area) pressure sore which was not a full thickness skin loss and was mostly a reddened area. a. Resident #73's Nursing Admission Assessment, dated 7/23/18, documented she had a 0.6 cm long by 0.6 cm wide open area to her sacrum. The nursing assessment did not include an assessment of the wound bed or include staging of the wound. Based on the description of the wound in the admission assessment, Resident #73's wound was a Stage II and no slough was documented as present. Resident #73's admission orders [REDACTED]. An admission MDS assessment, dated 7/30/18, documented Resident #73 was cognitively intact and documented she required extensive assistance of two staff members for transfers, bed mobility, toilet use, and dressing. The MDS assessment documented Resident #73's had a stage I pressure ulcer or greater. The MDS did not describe the wound in further detail. Resident #73's Total Skin and Body Assessment, dated 7/31/18, documented she had a 1 cm red, excoriated (damaged rubbed off skin) open area to her coccyx. The pressure ulcer was 0.6 cm by 0.6 cm on 7/23/18 and increased in size to 1 cm as of 7/31/18. The assessment did not document a description of the wound bed or stage the wound. A Wound Clinic Note, dated 8/2/18, documented Resident #73's sacrum was initially evaluated, and she had an unstageable pressure ulcer covered with slough. The assessment documented she had three small, bridged, slough-covered open areas and the area of the wounds measured 0.4 cm long by 1 cm wide by 0.1 cm deep. The note documented she had a dressing in place upon arrival. A Wound Clinic order, dated 8/2/18, documented an order for [REDACTED]. and PRN. Resident #73's physician order, dated 8/3/18, 11 days after Resident #73's admission, documented an order for [REDACTED]. The order did not include the use of Iodosorb as a cleansing agent, as documented in Resident #73's Wound Clinic orders. Resident #73's (MONTH) (YEAR) MAR documented staff were to cleanse Resident #73 sacrococcygeal wound with normal saline and gauze, apply skin prep to the intact area, and cover the wound with [MEDICATION NAME] every two days, beginning on 8/3/18 and discontinued on 8/24/18. The dressing was changed as ordered with the exception of 8/22/18 and 8/24/18. The care plan area addressing Resident #73's pressure ulcer, initiated on 8/6/18, documented Resident #73 had a chronic pressure ulcer to her coccyx. The care plan documented staff were to encourage and assist Resident #73 to with repositioning every two hours. The care plan documented Resident #73 was to receive wound care per orders and facility protocol. The care plan documented staff were to monitor and documented the location, size, and treatment of [REDACTED]. Resident #73's Total Skin and Body Assessment, dated 8/7/18, documented she had a 1 cm red, excoriated, open area on her coccyx. The assessment did not document a description of the wound bed or the stage of the wound. A Wound Clinic Note, dated 8/9/18, documented Resident #73 had an unstageable sacral pressure ulcer which measured 0.4 cm by 0.5 cm by 0.1 cm. The note documented Resident #73's wound was a single open area with slough covering the wound bed and some localized redness to the tissue surrounding the wound edges. The note documented Resident #73's wound and surrounding tissue was tender when touched. The note documented the Wound Clinic applied a topical agent using Iodosorb. Resident #73's Total Skin and Body Assessment, dated 8/14/18, documented Resident #73's coccyx was healing without redness. The assessment did not document wound measurements, a description of the wound bed, or staging of the wound. A Wound Clinic Note, dated 8/16/18, documented Resident #73's unstageable sacral pressure ulcer measured 0.3 cm by 0.3 cm by 0.1 cm. The note documented Resident #73's wound bed was covered with slough and there was blanchable redness to the tissue surrounding the wound edges. The note documented Resident #73's wound and surrounding tissue was tender when touched. The note documented the wound care orders still included the Iodosorb. Resident #73's Total Skin and Body Assessment, dated 8/21/18, documented Resident #73's coccyx was healing without redness. The assessment did not document wound measurements, a description of the wound bed, or staging of the wound. A Wound Clinic Note, dated 8/23/18, documented Resident #73's unstageable sacral pressure ulcer measured 0.4 cm by 0.2 cm by 0.2 cm. The note documented Resident #73's wound bed was covered with slough and there was no evidence of Iodosorb on the wound or the dressing. The note documented Resident #73's wound and surrounding tissue were tender when touched. The note documented the wound care orders still included the Iodosorb and a tube of it was sent with Resident #73 to the facility. Resident #73's (MONTH) (YEAR) MAR documented staff were to cleanse Resident #73 sacrococcygeal wound with normal saline and gauze, apply a topical agent using Iodosorb, and cover the wound with [MEDICATION NAME] every other day and PRN, beginning on 8/24/18. Between 8/3/18 and 8/23/18 Resident #73's physician's order did not include the use of Iodosorb. The dressing was changed as ordered by the physician during that time frame. Resident #73's Total Skin and Body Assessment, dated 8/28/18, documented Resident #73's coccyx was healing without redness. The assessment did not document measurements for the area, a description of the wound bed, or staging of the wound. A Wound Clinic Note, dated 8/30/18, documented Resident #73's unstageable sacral pressure ulcer was evaluated with slough and measured 0.4 by 0.3 by 0.1 cm. A Wound Clinic order, dated 8/30/18, documented an order for [REDACTED]. The film was moisture vapor permeable, waterproof, and impermeable to liquids, bacteria, [MEDICAL CONDITION].) Resident #73's (MONTH) (YEAR) MAR documented staff were to cleanse her sacrococcygeal wound with normal saline and gauze, apply skin prep to the intact area, and cover the wound with [MEDICATION NAME] or similar dressing every three days and PRN, beginning on 8/31/18 and discontinued on 9/17/18. The dressing was changed as ordered except when Resident #73 refused on 9/6/18 and 9/15/18. Resident #73's Total Skin and Body Assessment, dated 9/4/18, documented she had a 1 cm red, excoriated, open area on her coccyx. The assessment did not document a description of the wound bed or staging of the wound. Resident #73's Total Skin and Body Assessment, dated 9/11/18, documented her sacrum was healing. The assessment did not document measurements of the area, a description of the wound bed, or staging of the wound. A Wound Clinic Note, dated 9/13/18, documented Resident #73's sacral pressure ulcer was evaluated as improved and classified as a Stage III wound pressure ulcer with slough and measured 0.4 cm by 0.2 cm by 0.1 cm. A Wound Clinic order, dated 9/13/18, documented an order for [REDACTED]. Resident #73's physician orders, dated 9/17/18, four days after the wound clinic order, documented an order for [REDACTED]. The Iodosorb was discontinued on 8/30/18 by the Wound Clinic, 18 days prior. Resident #73's (MONTH) (YEAR) MAR documented staff were to cleanse Resident #73 sacrococcygeal wound with normal saline and gauze, apply skin prep to intact skin, apply Iodosorb to the wound bed, and cover the wound with [MEDICATION NAME] every Monday and Thursday dayshift and PRN, beginning on 9/17/18 and discontinued on 9/25/18. The dressing was changed as ordered except on 9/17/18. Resident #73's Total Skin and Body Assessment, dated 9/18/18, documented Resident #73's sacrum was healing. The assessment did not document measurements of the area, a description of the wound bed, or staging of the wound. A Wound Clinic Note, dated 9/18/18, documented Resident #73's sacral pressure ulcer was evaluated as improved and was classified as a Stage III wound with slough. The wound measured 0.4 cm by 0.2 cm by 0.1 cm. A Wound Clinic order, dated 9/18/18, documented an order for [REDACTED]. Resident #73's facility physician orders did not include the collagen gel to Resident #73's sacral pressure ulcer treatment between 9/18/18 and the next new order on 9/25/18. Resident #73's Total Skin and Body Assessment, dated 9/25/18, documented she had an open area to her coccyx. The assessment did not document measurements of the area, a description of the wound bed, or staging of the wound. A Wound Clinic Note, dated 9/25/18, documented Resident #73's sacral pressure ulcer was a healing Stage III wound with [MEDICATION NAME] cells (new cells) and measured 0 cm by 0 cm by 0 cm. A Wound Clinic order, dated 9/25/18, documented an order for [REDACTED]. Resident #73's Total Skin and Body Assessment, dated 10/2/18, documented Resident #73's sacrum was healing. The assessment did not document measurements for the area, a description of the wound bed, or staging of the wound. Resident #73's Total Skin and Body Assessment, dated 10/9/18, documented Resident #73's coccyx/sacrum was healed. A Wound Clinic Note, dated 10/9/18, documented Resident #73's sacral pressure ulcer was healed. The facility failed to implement pressure ulcer treatments as ordered by the Wound Clinic in a timely manner, and some were not implemented. The facility also failed to consistently assess and document the status of Resident #73's sacral pressure ulcer. b. Resident #73 was not repositioned consistently as follows: The care plan area addressing Resident #73's pressure ulcer, initiated 8/6/18, documented Resident #73 had a chronic pressure ulcer to her coccyx. The care plan documented staff were to encourage and assist Resident #73 with repositioning every two hours. The Wound Clinic Notes, dated 8/2/18, 8/9/18, 8/16/18, 8/23/18, 8/30/18, 9/13/18, 9/18/18, 9/25/18, and 10/9/18, documented Resident #73 required repositioning every 2 hours. Resident #73's (MONTH) (YEAR) ADL Turning and Repositioning record documented the following: - There was no documented evidence she was turned/repositioned between 7/23/18 through 7/30/18 (7 days). - It was documented Resident #73 was turned/repositioned once each shift on 7/30/18 and 7/31/18. Resident #73's (MONTH) (YEAR) ADL Turn and Reposition record documented the following: - There was not documented evidence she was turned/repositioned on 8/1/18. - There was not documented evidence she was turned/repositioned the night shift of 8/2/18. - On 8/3/18 it was documented Resident #73 was turned/repositioned three times on the dayshift and four times on the night shift. There was no documented evidence she was turned/repositioned on evening shift on 8/3/18. Resident #73's ADL Turn and Reposition record, dated 8/4/18 through 10/10/18, was changed to document when staff repositioned her every two hours. The facility failed to ensure Resident #73 was turned/repositioned prior to the pressure ulcer worsening into an unstageable wound. On 3/15/19 at 8:45 AM, the DON stated the facility initiated a low air loss mattress when Resident #73 was admitted due to her pressure ulcer. The DON stated she could not find admission treatment orders for the wound on Resident #73's coccyx. She stated the earliest order she found was from 8/3/18. The DON stated the wound was at least a stage II based on the description in the Nursing Admission Assessment. The DON stated nurses staged wounds if they were comfortable doing so. She stated if nurses were not comfortable staging a wound, they should ask for assistance. The DON stated the nurses should document the location of the wound, describe the wound's appearance, size, the wound bed, drainage, and more. The DON stated the wound treatment orders should be entered into the computer system by the nurse in charge of the resident's care. The DON stated the nurses should enter the orders as soon as possible, and if the orders were not sent with the resident, the nurses should contact the Wound Clinic to get the orders faxed. She stated nurses entering new orders were to ensure the orders were accurate. The DON stated if an order was unclear the nurse should contact the physician for clarification. The DON stated she could see there was inconsistency with the documentation of the wounds. The DON stated the CNAs were not documenting turning and repositioning accurately during the first part of July. The DON stated Resident #73 refused to reposition at times and the CNAs were not documenting that. The DON stated the staff should reposition Resident #73 minimally every 2 hours, and she could see that was not documented as completed.

Based on record review and staff interview, it was determined the facility failed to ensure timely treatment was provided for a resident with a urinary tract infection [MEDICAL CONDITION] and residents with signs and symptoms of infection. This was true for 2 of 10 sampled residents (#s 10 & 8) and 2 of 2 random residents (#s 11 & 12). Resident #10 was harmed when staff failed to recognize signs and symptoms of pneumonia; the physician was not notified until the next day, and a chest x-ray was not done to rule out pneumonia. Additionally, the resident complained of chest pain, the physician was not notified, and the resident was sent to the emergency room with a resulting [DIAGNOSES REDACTED].#11 was harmed when he had blood tinged urine and pain at the catheter site and no treatment was provided. The resident was sent to the emergency room with a resulting [DIAGNOSES REDACTED]. Resident #12 was harmed when the urine color changed from yellow to dark brown mucous, the physician was not notified and a urine analysis was not performed to rule out a UTI. The resident was transported to a local hospital the next day where she was diagnosed with [REDACTED]. Resident #8 had the potential for harm caused by a delay in treatment when the resident used her call light and told the CNA she was having trouble breathing. The nurse did not assess the resident but passed the information in her report to the oncoming nurse. Findings included: 1. Resident #10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent admission MDS assessment, dated 4/2/14, documented Resident #10 was rarely/never understood and unable to complete the mental status interview, required extensive assistance of 2 or more people for bed mobility and transfers, did not ambulate and had range of motion impairment to bilateral lower extremities. The following information for Resident #10 was gathered from Progress Notes (PN) and Physical Therapy Notes (PT) and were as follows: * (PT) 4/7/14 - "...Pt seems to be weaker today than he was yesterday. He required frequent rest breaks and was not able to perform exercises as well as he usually does. Pt recognized this and became a little discouraged. Pt was educated and reassured about the progress that he has made;" * (PT) 4/8/14 - "...he did not do as well today for standing tolerance. pt. had c/o (complained of) pain and fatigue;" * (PT) 4/9/14 - "...Pt very limited with transfers at this time, requiring 2 therapists for transfers, and CNA's on the hall are using the hoyer...;" * (PT) 4/13/14 - "...Pt willing to try exercise, pt tolerated tx (treatment) well with multi(ple) rests due to SOB (shortness of breath);" * (PN) 4/14/14 at 12:01 PM - "...Lungs clear to all lobes...;" * (PT) 4/14/14 - "...he was very fatigue and did not do as well /c (with) standing activities...;" * (PN) 4/15/14 at 12:27 PM - "...Lung sounds clear, patient continues to have quick short breathes. Continues to wear O2 (Oxygen) at 2L (Liters) per nasal canula (sic), sats (saturations) above 90%." (NOTE: this was the first time oxygen was documented); * (PT) 4/15/14 - "...Discussed in detail with pt about his progress. Asked him what is (sic) plan is and he stated 'I have to be able to walk'. Asked him what the plan is if we don't get to that as it has been 3 wks (weeks) and no walking has been performed. His standing tolerance is still really struggling. He thinks we are doing everything we can to get him better, but it is very slow progress. Talked with SW (Social Worker) about pt as well;" * (PN) 4/15/14 at 8:30 PM - "Pt c/o (complains of) shortness of breath and coughing up a minimal amount of clear sputum with a reddish tinge after changing positions in bed and attempting to have a BM (bowel movement). Pt's oxygen is 94% at this time while using 4.5L O2. Pt states he is not in any pain. Will continue to monitor pt." (The resident required an additional 2.5 L of O2); * (PN) 4/15/14 at 9:08 PM - "Pt states is 'feeling much better' and is no longer short of breath. Pt is still coughing but no longer has sputum at this time. Pt's oxygen sats are 90% on 4.5L per NC (Nasal Cannula). Pt states he is comfortable and does not wish to take further action at this time. NOC (nighttime) nurse notified of pt's previous complaint, will continue to monitor. Pt states he will notify staff of any changes or concerns...;" * (PN) 4/16/14 at 1:17 PM - "...Lung sounds clear, patient continues to have quick short breathes. Continues to wear O2 at 2L per nasal canula (sic), sats above 90%...;" * (PT) 4/16/14 - "...2 rests d/t (due to) fatigue and SOB...;" * (PN) 4/16/14 at 10:15 PM - "Pt with productive cough this evening, sputum is clear with a pinkish tinge. Pt states he has been coughing throughout the day but that it was non-productive. Pt states he is not in pain at this time and has no difficulty breathing. Pt's VS: BP: 97/59, oxygen is 94% on 4L per NC, HR: 74, Temp: 97.1 oral, RR:16. Lung sounds were clear in all lobes bilat(erally) upon auscultation, somewhat diminished in bases. Notified (Physician's name) per fax, notified NOC nurse. Will continue to monitor pt and await new orders from (Physician's name)...;" * (PN) 4/17/14 at 10:42 AM - "...Lung sounds clear to all lobes, patient continues to have quick short breathes. Continues to wear O2 at 2L per nasal canula (sic), sats above 90%...;" * 4/17/14 (PO) - [MEDICATION NAME] DM ([MEDICATION NAME]-Gualfenesin) Syrup 100-10 MG/5ML by mouth for cough every 4 hours as needed; * (PT) 4/17/14 - "...pt able to perform ex(ercise) on his own but fatigues quickly /p (after) 5reps not able to complet(e) 10 reps in a row;" * (PT) 4/17/14 - "...he was very fatigued at end of treatment and required increased assistance for transfer;" * (PN) 4/18/14 at 8:32 AM - [MEDICATION NAME] administered; * (PN) 4/18/14 at 12:31 PM - "...Lung sounds clear to all lobes, patient continues to have quick short breathes. Continues to wear O2 at 2L per nasal canule (sic), sats above 90%...;" * (PN) 4/18/14 at 3:11 PM - [MEDICATION NAME] administered; * (PN) 4/18/14 at 8:52 PM - [MEDICATION NAME] administered; * (PT) 4/18/14 - "...Pt. very fatigued and struggled to stay awake this afternoon...;" * (PN) 4/19/14 at 2:16 PM - [MEDICATION NAME] administered: "Patient requested for c/o cough;" * (PN) 4/19/14 at 4:01 PM - "Patient stated medication was effective;" * (PN) 4/19/14 at 8:26 PM - [MEDICATION NAME] administered: "pt requested for cough;" * (PT) 4/19/14 - "...he did fatigue easier today than he has during previous therapy sessions...Pt was disappointed that he couldn't do better today;" * (PN) 4/20/14 at 7:18 AM - [MEDICATION NAME] administered: "Patient requested for c/o cough;" * (PN) 4/20/14 at 8:53 AM - "Patient stated medication was effective;" * (PN) 4/20/14 at 2:33 PM - "...Lungs noted to be clear x4 lobes...;" * (PN) 4/20/14 at 8:32 PM - [MEDICATION NAME] administered: "given at pt request for c/o cough;" * (PN) 4/20/14 at 10:26 PM - "pt's cough has decreased;" * (PN) 4/21/14 at 12:26 PM - "...Lungs noted to be clear x4 lobes...;" * (PN) 4/21/14 at 7:55 PM - [MEDICATION NAME] administered: "Pt asked for cough medicine due to cough;" * (PN) 4/21/14 at 10:13 PM - "Patient complaint of chest pain. Pt stated that he did not feel any pain in his left arm, but it did feel like someone was sitting on his chest. Pts vitals were taken BP:109/66 P (Pulse):83 O2:95 (percent).Pt has had persistent cough throughout shift, which only seems to get better when sitting up. Pt was given cough medicine to relieve cough. Will continue to monitor pt;" * (PT) 4/21/14 - "...Pt. required several interim rest breaks...;" * (PT) 4/21/14 - "...Pt fatigued easily with these exercises and required rest breaks between sets and exercises...Pt continues to fatigue easily with the exertion...;" * (PN) 4/22/14 at 12:55 AM - "Cough has decreased;" * (PN) 4/22/14 at 8:40 AM - [MEDICATION NAME] administered; * (PN) 4/22/14 at 10:37 AM - "...Lungs noted to be clear x4 lobes...;" * (PN) 4/22/14 at 5:16 PM - [MEDICATION NAME] administered; * (PN) 4/22/14 at 8:02 PM - [MEDICATION NAME] administered; * (PN) 4/22/14 at 11:01 PM - [MEDICATION NAME] administered: "Per pt request due to cough;" * (PT) 4/22/14 - "...Pt. very fatigued today, and had very low O2 levels, requiring frequent VC (Verbal Cues) to avoid deep breathing. Pt. unable to stand up complete;y (sic) d/t fatigue;" * (PT) 4/22/14 - "...needing rests secondary to SOB, fatigues quickly...Education given in pursed lip breathing /p education in breathing and following activity again, pt showing much improved O2 sats at 91%...;" * (PN) 4/23/14 at 11:07 AM - "...Lungs noted to be clear x4 lobes...Cough Syrup given with good results...;" * (PT) 4/23/14 - "...pt fatigued quickly and becomes SOB, many vc's for proper breathing techniques, pt tends to breath (sic) through his mouth and not his nose...Pt reports some SOB and fatigues during tx, pt on 4 L on O2, had difficulty time getting the oximeter to read correctly, measuring 75-85%, reported numbers to NSG (Nursing), also instructed pt in proper breathing technique..." * (PN) 4/23/14 at 10:47 PM - "Patient, after having been moved from the wheel chair (sic) to the bed experienced an episode of shortness of breath and difficulty breathing. Patient also stared off into the distance, seemingly looking nowhere in particular. During this phenomena patient was unresponsive and did not respond to questions asked. Patient would jerk a bit when touched on the arm. Patient became responsive after a few minutes, without any intervention. Patient then expierenced (sic) the same episode after sitting upright in bed for a period of time. VS at this time were WNL (Within Normal Limits) and BG (Blood Glucose) 212. A few hours later patient repeated the same process as before. Patient was asked if he would like to go to the hospital, patient declined. Daughter came to see patient. Daughter reported that patient's wife was going to come stay with patient. Patient wife and son came to see patient. Wife requested that we call the EMT's (Emergency Medical Technicians)and have him transferred to (local medical center). Non-emergent transport notified. patient transferred to (local medical center) via ambulance, family followed patient to hospital in car. Called report into (local medical center) but patient had already arrived to hospital and report was declined;" * (PN) 4/24/14 at 5:05 AM - "Contacted ER (emergency room ) department and staff states pt is being admitted ." There was no documented evidence PT and Nursing had communication about Resident #10's symptoms. On 3/12/15 at 1:12 PM, the DON was asked what day the physician was notified of Resident #10's "reddish tinged sputum," and she stated, "The next day," He should have been notified, "right away." The DON was asked if the physician was notified of the resident's complaints of chest pain on 4/21/14, and she stated, "I'm not seeing anything." There was a delay in treatment on 4/15/14 when Resident #10 had a productive cough with reddish tinged sputum and the physician was not notified until an order was received for cough syrup on 4/17/14, and on 4/21/14 when the resident complained of chest pain and the physician was not notified. This affected his ability to participate in therapy and discouraged the resident. Additionally, the resident continued to display symptoms of illness with no further physician notification or diagnostic work-up. 2. Resident #11 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Care Plan for Resident #11, dated 4/16/14, documented the resident had a suprapubic catheter related to [MEDICAL CONDITION]. The interventions included monitoring for signs and symptoms of discomfort on urinary frequency, monitoring and documenting pain or discomfort due to the catheter, and monitoring/recording/reporting to physician signs and symptoms of a UTI such as pain and blood tinged urine. The following information was gathered for Resident #11 from physician's orders [REDACTED]. * 4/14/14 at 2:43 PM (PN) - "...Pt was admitted ...with the [DIAGNOSES REDACTED]. Pt is alert to self only. Unable to determine year, place, or items about self such as if he wears dentures, allergies [REDACTED]. * 4/16/14 (PO) - "Supra-pubic cath care Q (every) shift and PRN;" * 4/21/14 (PO) - "UA (Urinary Analysis) microscopic/ C&S (Culture & Sensitivity) if indicated;" * 4/21/14 at 12:05 PM (PN) - "...Patient to see (Physician's name) this am. New orders for [MEDICATION NAME] 500mg po daily. Administered apon (sic) arival (sic). New orders for UA (Urinary analysis) collection, sent to lab, waiting for results. Patient to see (Urologist's name) this afternoon...cath site cleansed with NS gauze surrounding cath(ether). Draining dark colored urine...;" * 4/21/14 at 10:30 PM (PN) - "Supra-pubic cath care Q shift and PRN. Pt would not comply to recieve (sic) cath care. Will pass information on to next nurse to see if he will comply with the next nurse;" * 4/22/14 at 10:33 AM (PN) - "...New orders for [MEDICATION NAME] 500mg po daily...cath site cleansed with NS gauze surrounding cath. Draining dark amber colored urine...;" * 4/22/14 (PO) - "Urology Note: post op (operative) TURP (Transurethral Resection of the Prostate) (and) s-pubic (supra-pubic) cystotomy - Have asked nurses to clamp S-P tube and have him void - they will then open the S-P tube to measure residual urine volume;" * 4/23/14 at 11:04 AM (PN) - "Phoned (Urologist's name) office about pt. Pt is still incontinent. Tried to clamp off urianry (sic) tubing and pt would urinate in his pants. Pt has no clue when he needs to go. Waiting for new orders;" * 4/23/14 (PO) - "Check bladder residual twice a shift. Document ML residual and on 4-25-14 fax results to (Urologist's name);" * 4/25/14 at 8:12 PM (PN) - "...Pt has had blood tinged urine this evening, faxed information to (Physician's name), waiting for further orders. Bladder residual taken throughout shift, information faxed to (Physician's name), waiting for further orders...;" * 4/25/14 (FS) - "Pt has blood tinged urine 4/25/14. Please inform of any new orders. Pt's urine residual today 4/25/14 was @ 0800 (8:00 AM) - 0 mL, @ 1200 (12:00 PM) - 1.5 mL(,) @ 1600 (4:00 PM) - 2 mL;" * 4/27/14 at 11:28 AM (PN) - "...Suprapubic catheter in place, draining amber colored urine. Patient enocuraged (sic) to drink fluids and requires frequent reminders to drink. Fresh ice water provided and placed with in reach. Continues on [MEDICATION NAME] daily for UTI. Patient denies suprapubic pain upon palpation...;" * 4/27/14 at 6:35 PM (PN) - "Urine residual information sent via fax to (Urologist's name) 4/27/14. Waiting for further orders;" * 5/3/14 at 12:02 PM (PN) - "...Pts suprapub cath care done today and gauze dressing changed. Pt stated pain during change. Pt coughing today, cough is productive. Pt advised to sit up in bed to help with cough...;" * 5/3/14 at 3:09 PM (PN) - "[MEDICATION NAME] order recieved (sic) today 5/3/14 from (Physician's name)...due to pts cough. Order placed in physicians orders;" * 5/4/14 at 10:54 AM (PN) - "Patient is drownsy (sic), disoriented to time, place, situation. Patient has expiratory wheezing...Heart rate iregular (sic). While administering medications observed patient was clammy, red, and lethargic. Patient vitals WNL, temp was 101.7, patient window opened, jacket taken off, applied cold wash cloth to forehead. Patients grandaughter in room with patient. Reports 'This is how he was before he went to the hospital, I think he needs to go to the hospital now.' Encourage family to wait to reevaluate patient when patient is more awake and let tylenol take effect. Family verbalized understanding. Patient assessed aprox (sic) 1 1/2hr later, patient continues to be very letheragic, unable to recognize grandaughter unble (sic) to answer questions appropriately. Agreed to send patient to ER, via facility van, family to meet patient there, MD notified, Paperwork sent with patient, Reports given to ER nurse...Will follow up;" and, * 5/4/14 at 6:31 PM (PN) - "Pt admitted to (local medical center) today 5/4/14 @ 1700 (5:00 PM) for UTI..." On 3/12/15 at 12:53 PM, the DON was interviewed about Resident #11. She said the resident had a UA done on 4/21/14 which came back positive for a UTI of Streptococcus agalactise, and was started on [MEDICATION NAME] for 7 days on 4/22/14. When asked about the physician's response to the fax regarding blood tinged urine, the DON said she was, "Not seeing anything." When asked about the physician's response to the urine residual information, the DON stated, "Judging from this (the computer system) there wasn't any" order or physician response. She said there was nothing indicating there was follow-up with the physician. The DON was asked when the physician should have been notified of the resident's signs and symptoms of infection displayed on 5/4/14, she stated, "Right away when they found them," and the nurse who waited 1.5 hours no longer worked in the facility. On 3/13/15 at 8:10 AM, the DON said generally if a resident was alert and was able to sit in the van, the facility van would transport the resident to the hospital, otherwise the non-emergent ambulance would be called. In the case of Resident #11, the DON did not know why the resident was transported via the facility van when he was not alert or strong enough to do so. Resident #11 was harmed when he had blood tinged urine on 4/25/14, and the physician was notified with no response and treatment was not provided. The resident had pain at the catheter site on 5/2/14 and the physician was not notified and treatment was not provided. On 5/4/14, the resident displayed a temperature of 101.7, expiratory wheezes, disorientation, lethargy, was red and clammy, yet the LN waited 1.5 hours before sending the resident to the hospital and admitted for treatment of [REDACTED]. On 3/13/15 at 9:40 AM, the Administrator and DON were informed of the delay in treatment concerns. No further information was provided. 3. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The 6/11/14 admission MDS assessment documented the resident was cognitively intact, had lower extremity impairment on both sides and needed extensive assistance of 2+ persons for bed mobility, transfers, dressing and toileting. Review of the resident's Order Summary Report for June of 2014 documented the following orders with a start date of 6/4/14: *16 French foley catheter with 10 cc balloon. Change Q (every) month (on the 4th) and PRN and, *Foley cath care Q shift and PRN. Resident #12's care plan for indwelling catheter care, with a start date of 6/4/14, documented, "Note any changes in amount, frequency, color or odor. Report any abnormalities to Registered Staff." On 6/17/14 at 11:47 AM, a Progress Note (PN) documented the resident's foley catheter was in place with clear yellow colored urine. Later that day at 3:25 PM, a PN documented there was "...noted urine draining past foley catheter today...urine is brown/yellow in color. There was also dark brown mucous in the cath bag." NOTE: No documentation was found the foley catheter was changed or the physician was informed of the change of the color of the urine from clear yellow to dark brown mucous. On 6/18/14 at 12:41 PM, a PN documented, "...observed attend to be wet with urine/bloody discharge. Cath in place, changed catheter with 16F, without difficulty. Cath draining red tinged urine. Notified (name of physician). Reports to watch if patient c/o (complained of) fullness, any clots noted to notify." The PN documented the resident had worked with therapy, became unresponsive with shallow breathing and was transported to a local hospital. The local hospital's Emergency Provider Report, dated 6/18/14 at 1:03 PM, documented in the Diagnosis, Assessment & Plan the resident had a syncopal event with no recurrence or lightheadedness in the hospital; dehydration and intravascular volume depletion; and, urinary tract infection, growing 40,000 colonies of [MEDICATION NAME], and ID (identification of medication sensitivity) was pending. The report documented the resident was afebrile (did not have a fever), white count was down with recommendations to continue the [MEDICATION NAME] with the assumption it was sensitive to [MEDICATION NAME]. The hospital discharge summary, dated 6/21/14, documented multiple final [DIAGNOSES REDACTED]. On 3/12/15 at 3:50 PM, the DON was asked about the documentation in the 6/17 PN regarding the change in urine color from clear yellow to dark brown mucous. She stated it didn't look like a urine analysis had been done. When asked what should have been done, the DON stated she would have "expected staff to have changed the catheter or there could have been a clog in the catheter." When asked about flushing the catheter for clogs, the DON stated they would need a doctors order. When asked if they should have gotten an order to flush the catheter, the DON stated, "I would think so or change the catheter." The DON stated the resident's physician should have been contacted, since she was seeing a urologist. When asked if a urine analysis should have been done, the DON stated, "Yes." 4. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS assessment, dated 3/2/15, documented the resident was cognitively intact with a BIMS score of 15. On 3/11/15 at 4:10 PM, Resident #8 was observed in her room sitting in a lounge chair with her feet elevated. The resident was coughing and when questioned stated, "I coughed all night long." She stated she used her call light and when the CNA came in she told her, "I can't breathe, I'm just having trouble." The CNA told her she would tell the resident's nurse, but no one came in until around 7:00 AM. The resident stated she went to bed around 10:15 PM but couldn't sleep due to coughing. She stated she had to hold her chest because it felt heavy and it was hard to breathe. The resident stated she was placed on oxygen about 1:00 PM, which had helped her breathing and wished she would have been started on oxygen the previous night. On 3/11/15 at 4:25 PM, LN #3 stated she was told, by LN #4, in report this morning that Resident #8 was coughing last night. LN #3 stated when she checked on the resident that morning, her sats (saturations) were fine. However, the resident's sats dropped to 88% around 11:00 AM and crackles were noted in the resident's left lower lobe. She stated she obtained an oxygen order for 1-4 LPM (liters per minute) PRN to maintain oxygen saturation above 89%. No documentation by a nurse was found in the PN (Progress Notes) for the evening of 3/10/15 after 7:44 PM. No documentation by LN #4 was found in the PN for the evening shift of 3/10/15. On 3/12/15 at 8:15 AM, LN #3 stated the resident had started antibiotic therapy the previous night at 8:00 PM and would have a CXR (Chest X-Ray) that day. She stated the resident reported she felt better after being placed on oxygen and her cough had decreased. On 3/12/15 at 10:30 AM, the DON stated she had some issues with LN #4's documentation, which she felt was lacking, and had discussed her concerns with LN #4 several times. When told about the lack of documentation for the evening shift on 3/10, the evening LN #4 worked, the DON stated, "That's my issue, her not documenting things, as in this case." Resident #8 was observed to continue coughing throughout the survey process on 3/12/15 at 11:30 AM, 1:15 PM and 3:00 PM. On 3/12/15 at 3:15 PM, LN #3 called the local hospital to obtain findings of the CXR taken that morning. LN #3 stated the technician told her the X-Ray looked fine and she would fax over the results. The Radiology report documented the X-Ray was taken on 3/12/15 at 10:15 AM, and, "Marked hyperinflation of the lungs is noted along with maybe [MEDICAL CONDITION] changes in the lungs. There are no foci of consolidation. There is no evidence of an acute [MEDICAL CONDITION] or infectious process." On 3/13/15 at 9:00 AM and 10:00 AM, Resident #8 was observed to continue coughing. On 3/13/15 at 8:40 AM, the DON provided signed statements from LN #4 and CNA #5, night shift staff who worked 3/10/15 on the resident's hall. However, this information did not resolve the concern related to delay of treatment. On 3/13/15 at 10:30 AM, the Administrator and DON were made aware of the above mentioned concerns. No further information was provided by the facility.

Based on record review, Policy & Procedure review and staff interview, it was determined the facility failed to provide the necessary nursing care and services to prevent the development of pressure ulcers. This was true for 1 of 10 (#10) sampled residents. This deficient practice created the potential for more than minimal harm when the facility failed to implement preventative measures and a resident developed a Stage II pressure ulcer. Findings included: The facility's Comprehensive Admission Skin Assessment Policy, revised 8/2008, documented, "...3...Although a patient may be asessed to be 'no risk' or 'low risk' per the Braden Scale Assessment, the individual areas of the Braden scale should be considered when developing interventions and care plan...The care plan is updated whenever a resident has a change in condition either progression or regression. Care plans must be updated no more than 72 hours after change in condition occurs...5. Identified skin areas should have weekly documentation using the wound/skin healing assessment that includes measurements and how the wound is progressing towards healing...7. When a wound develops and is identified through skin checks or routine care, procedures should include the following: a. Nurse [MEDICATION NAME] the wound...and completes...a skin assessment...d. An assessment/investigation...that assesses how this happened, and identification of the type of ulcer it is and what are plan interventions now need to be implemented, if any to prevent further problems...8. Weekly analysis performed by the DON to assess progress towards healing of the new wounds in the facility..." Resident #10 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent admission MDS assessment, dated 4/2/14, documented Resident #10 was rarely/never understood and unable to complete the mental status interview, did not display behaviors, required extensive assistance of 2 people or more for bed mobility and transfers, did not ambulate, had range of motion impairments to his bilateral lower extremities and did not have any unhealed pressure ulcers or [MEDICAL CONDITION]. A Nursing Admission Assessment, dated 3/26/14, documented Resident #10 had a "discolored area" to the right buttock measuring 3.5 cm x 4 cm with no depth. Resident #10 had three Braden Scale for Predicting Pressure Ulcer Risk assessments and were as follows: * 4/2/14 - Low risk with a score of 17.0; * 4/9/14 - Low risk with a score of 15.0; and, * 4/16/14 - Low risk with a score of 16.0. An Incident Report, dated 4/6/14, documented the description, "Upon taking Pt (Patient) TED hose off, a blister was noted to Pt left heel. The blister measures approx.(imately) 4.5cm x 6.2cm and is intact, peri-wound area noted to have some non-blanching redness toward posterior heel. Pt states he didn't even know it was there, he states there is no pain. Pt states it might be because he sits in his chair and slides his feet back and forth to straighten his legs and bend them to get comfortable." The Immediate Action taken documented, "The area was measured, cleansed and dressed with skin prep and a bordered gauze. (Physician's name) notified of new skin issue, orders received to treat as necessary and call with complications. Pt spouse was notified of issue. Pt educated to avoid sliding heels on the carpet. Pt states it (sic) hard because of the pain in his knees. Pt educated to elevate feet while up in chair, Pt refused stating that it is not comfortable. Pt then educated to lay down during the day for brief periods to help relieve some pressure to the area, Pt states he does not like to lay down during the day. The Pt was educated on the risks of not relieving pressure to the area and refusing interventions. Pt verbalized understanding. Pt is alert and oriented x3. Pt spouse reports that he has had trouble with that heel in the past. The pt does not wear any shoes or slippers, he just wears his non-slip socks. The pt also has a wound surface mattress/bed...d/t (due to) his height. We will refrain from putting Pt TED hose on that leg to avoid any friction it may cause during don/doff of the TED hose. We will monitor the area closely and notify the physician of any immediate concerns." The following information was gathered from Physician's Orders (PO), Care Plan (CP), Wound/Skin Healing Assessment (WHA), Progress Notes (PN), Physical Therapy Notes (PT) and Wound Clinic Notes (WC): * 3/26/14 (PO) - "Weekly skin check - document on progress note;" * 4/1/14 (PO) - "Low air loss mattress to offload pressure and promote skin integrity;" * 4/6/14 (PN) - "Upon removal of TED hoes, Pt left heel is bruised possibly blistered. Skin is non-blanchable. Contacted (LN's name) to inform him if (sic) pt condition. Border guaze (sic) placed on Left heel. Pt reports no pain at this time, no furhter (sic) issues needed at this time...;" * 4/8/14 (PN) - "Weekly skin check - document on progress note: Skin check completed, open blister noted to R(ight) heel, DON aware..." (Note: Right heel was incorrect); * 4/11/14 (PT) - "...Pt was lim(ited) by significant R knee pain and NWB (Non-Weight Bearing) precautions on L heel d/t open wound...Pt's wound on L heel has no opened and NWB on the L heel, although no physician's orders have been received for this change in WB status;" * 4/12/14 (PN) - "...large blister in L(eft) heel. dressing changed, no s/s (signs and symptoms) of infx (infection) scant serous drainage...;" * 4/14/14 (CP) - Focus, "Pressure ulcer stage II to left heel R/T (Related To) immobility and Diabetes. Interventions, "...turn/reposition at least every 2 hours, more often as needed or requested; Administer treatments as ordered and monitor for effectiveness; He uses (2) 1/4 side rails to assist with turning while in bed; Left Heel PU (Pressure Ulcer): Cleanse with NS (Normal Saline) skin prep surrounding tissue, cover with [MEDICATION NAME]. Change dressing QD (Every day) and PRN for dressing failure (revised on 4/16/14); Weekly skin check - document on progress note;" * 4/15/14 (PN) - "...R heel dressing changed. area is beefy red with small dark area on the edge. Notified wound care nurse. Will be looked at again this afternoon;" * 4/15/14 (PN) - "Pt's bandage on left heel changed d/t inadequate adhesion. Area cleansed with gauze and NS, wound surrounded with sureprep skin wipe, [MEDICATION NAME] applied. Wound did not have any foul odor, pt states is not painful. No redness noted, minimal serosanginous (sic) drainage noted...;" * 4/16/14 (CP) - "Low air loss mattress to offload pressure and promote skin integrity;" * 4/16/14 (PN) - "...R heel dressing changed. area is beefy red with covered with eschar. Pressure sore is unstagable (sic) at this time. dark area on the edge. (DON) notified of change in wound. PT education done with patient to keep pressure off of the heels...;" * 4/16/14 (PN) - "IDT Nutrition Meeting r/t pt with new pu to left heel (3.2cm x 4.5cm)...Current nutrition plan and meal intakes adequate to aid in wound healing and skin integrity...Review for skin monitoring in IDT x 2weeks (sic);" * 4/17/14 (PN) - "Pt dressing changed to left heel. Blistered area is now opened. Wound bed is granular with a small amount of slough. Pt denies pain. New dressing orders received. Pt educated on elevating his feet while up in his chair again and agreed this time...;" * 4/17/14 (WHA) - Left heel pressure measuring 6.2 cm x 4.5 cm x 0.1 cm at a Stage III. Wound bed with granulation tissue and slough, surrounding skin macerated. "Blistered area is now open, wound bed is granular, Pt denies pain. New dressing ordered-dermanet AG and [MEDICATION NAME]. Pt agreed to elevate legs while in chair." * 4/17/14 (PO) - "Left Heel pressure ulcer: Complete new 'Wound/Skin Healing' assessment Q (every) week until resolved;" * 4/17/14 (PO) - "Left Heel: Cleanse with normal saline, skin prep surrounding tissue, cover with [MEDICATION NAME] AG and [MEDICATION NAME]. Change dressing Q3 Days and PRN for dressing failure;" * 4/20/14 (PN) - "...Dressing changed to left heel per MD order. No s/sx of infection noted. Noted when patient sits up her (sic) prefers to stretch his legs out and rest his feet upon his heels, noted patient sliding his heels across (sic) the floor to reposition in wheelchair. Education provided to patient about using call light and notifying staff is (sic) he needs assistance with repositioning as to not place friction to heels while trying to reposition. Patient verbalized understanding of education, will continue to monitor...;" * 4/21/14 (PO) - "Podus boot to left foot as resident allows;" * 4/21/14 (CP) - "Podus boot to left foot as resident allows to offload pressure;" * 4/21/14 (PO) - "Remove podus boot and check skin integrity four times daily;" * 4/22/14 (PN) - "...Encourage patient to elevate extremeties (sic), Currently resting in room with feel elevated, podus boot removed and skin checked. no new issues...;" * 4/22/14 (PN) - "Pt dressing changed to pressure ulcer on left heel. PU measuring 5.4cm x 5.6cm x 0.1cm. Moderate amount of serosang drainage noted. Wound is slightly malodorous and periwound in (sic) slightly macerated. Wound bed is granular with a dark area approx. 1.5cm x 2cm toward the upper left wound bed (approx. 10 o'clock). Wound was cleansed with NS, skin prep applied to periwound, dressing applied per MD orders. Pt cont(inues) to wear podus boot to left foot with nursing removing to check skin integrity 4 times daily. Pt also con on ...wound surface bed. Pt re-educated again to elevate feet while up in chair and call for assistance if he needs to reposition. Pt has an appt (appointment) with (local medical center A) wound care on Thursday, 4/24/14 @ 0900 (9:00 AM). Per Pt request we will try to get Pt in to (local medical center B) wound care instead. Will f/u (follow-up) with (local medical center B) wound care for appt;" * 4/22/14 (PO) - "Pt to (wound care center) on 4/23/14 @ 0800 (8:00 AM);" * 4/23/14 (PN) - "...Encourage pt to elevate extremeties (sic), Currently resting in room with feet elevated, podus boot removed and skin checked. no new issues. Pt to (local medical center B) Wound Care for pressure sore on L Heel. Awaiting orders...;" and, * 4/23/14 (WC) - "...Approximately 3 weeks ago he developed a blister on the the (sic) left heel presumably from pressure while at (the facility)...The Stage II pressure ulcer located on the left heel has been present for approximately 14 days. The pressure ulcer is thought to be related to immobility. The pressure ulcer measures 6.5 cm x 4 cm x 0.3 cm. The patient scores the pain as 3 on a scale of 0 to 10. There is a minimum amount of serosanguinous exudate draining from the pressure ulcer. The pressure ulcer bed has exposed partial thickness and eschar tissue. The skin around the pressure ulcer is epithelizing and [MEDICAL CONDITION] pressure ulcer does not show signs of symptoms of infection...Pain Assessment...Status worsening; Duration three weeks; Causes/Aggravates standing..." On 3/12/15 at 1:12 PM, the DON was interviewed about Resident #10 and the pressure ulcer. She said the interventions in place to prevent pressure ulcers included a low air loss mattress, due to the resident's height on 4/1/14, and weekly skin assessments. The DON said the Wound/Skin Healing Assessments were initiated, "Once a problem is identified," and there was not a WHA for the blister noted on 4/6/14 because the assessment was included with the incident report. The DON was asked when the blister opened, and she stated, "The 17th (of April 2014)." After the surveyor informed the DON it had opened prior to that date, she reviewed progress notes and stated, "The 15th (of April 2014)." When asked about the pressure ulcer staging, she said it was a Stage III by definition with some slough in the wound. The DON was asked why 11 days went by before another WHA was done, and she stated, "I do not know why. There should have been one done on the 13th (of April 2014)." Resident #10 developed a pressure ulcer while residing in the facility. Per the Wound Clinic it was a Stage II, but per the facility it was a Stage III. The only preventative interventions in place were the air mattress and weekly skin checks, and the skin care plan was not initiated until 4/14/14, 7 days after the resident developed the pressure ulcer. The blister opened 4 days after it was noted, on 4/8/14, but further assessments were not completed for another 9 days, on 4/17/14. In addition, Progress Notes documented the resident was to utilize his call bell to be repositioned, despite his [DIAGNOSES REDACTED]. On 3/12/15 at 5:10 PM, the Administrator and DON were informed of the pressure ulcer concerns. No further information was provided.

Based on observation, staff interview, record review, and policy and procedure review, it was determined the facility failed to ensure a care plan/interventions for pressure ulcers were in place on admission and that new pressure ulcers did not develop for a resident admitted with multiple stage II pressure ulcers. This was true for 1 of 3 residents (#5) reviewed for pressure ulcers. Resident #5 was harmed when 2 new stage II pressure ulcers developed (coccyx and right buttock) three days after admission; an unstaged left upper thigh pressure ulcer developed 4 days after admission; and one unidentified PU progressed to stage III. In addition, the facility failed to ensure the thigh pressure ulcer was staged, measured, and characteristics were monitored and tracked; and, that the characteristics and status of each pressure ulcer was monitored and tracked. Findings include: Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 5-Day MDS, dated [DATE], coded, in part: * Intact cognition, with a BIMS score of 15; * Extensive assistance of 2 or more people for bed mobility , transfers, and toileting; * Extensive assistance of 1 person for dressing, personal hygiene, and bathing; * At risk for pressure ulcers (PU); and, * Three unhealed stage II PU. The resident's "All Active Orders for December 2013" included: * "Left Buttock: Complete a new "Wound/Skin Healing" assessment weekly until resolved...Tue(sday)." * Low air loss mattress to promote skin integrity and offload pressure; and, * "Weekly skin check-document on a progress note...Tue." Note: There order/start date was not given for any of the orders. The resident's Nursing Admission Assessment documentation, dated 11/26/13, included: * Section IV: Skin Condition - Six skin problems were listed, 3 of which were stage II PUs on the left buttock. Two of the PUs measured 1 centimeter (cm) by 1 cm each, the 3rd PU measured 3 cm by 2 cm. The "site" for the each of the listed skin problems included the anatomical location and a number that correlated to numbers on a front and a back body diagram. The "site" for each of the 3 stage II PUs was, "32) Left buttock" which correlated to the left buttock on the back body diagram. * Braden Scale For Predicting Pressure Sore Risk - total score = 16, or low risk. The resident's Care Plan included, "Focus area(:) Potential/Actual Alteration in skin integrity r/t (related to) stage II pressure ulcer on left buttock." Interventions for this focus area were, "Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of [REDACTED]. Monitor/document location, size and treatment of [REDACTED]. to MD (physician)." This part of the care plan and all of its interventions were initiated/created 11/29/13, 3 days after admission. The resident's Wound/Skin Healing Records (W/SHR) dated 11/29/13, 12/3/13, 12/10/13, and 12/17/13 were reviewed. The W/SHR included 3 pages with the following instructions at the top of each page, "USE SEPARATE ASSESSMENT FOR EACH PRESSURE ULCER SITE(;) Identify and describe site." Page 1 contained a front and a back body diagram with numbered areas, such as 32 for left buttock, 31 for right buttock, 53 for the lower back along the spinal column, and 23 for the coccyx; PU definitions, which included, "Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough..." and "Stage III - ...Slough may be present but does not obscure the depth of tissue loss..."; and, multiple lines on which to list skin conditions and the site, type, and measurements, in centimeters, for each condition. Page 2 contained areas to document the description of the wound bed and surrounding tissue/wound edges. PThe left upper thigh PU was not mentioned at all in the PN and the facility did not provide any documentation regarding the left thigh PU.age 3 asked about pain experienced related to the wound and included an area for comments. The resident's W/SHR documentation included: *11/29/13 - 2 PU listed on page 1: - Coccyx (noted as 23 which correlated to the tailbone area on the back body diagram), 0.5 by 0.5, depth blank, stage II; and, - Right buttock (noted as 31 which correlated to the right buttock on the back body diagram), 4 by 2, depth blank, stage II. Pages 2 and 3 documented no exudate, odor, normal periwound skin, and no pain. Note: There was no indication as to which PU, the coccyx or right buttock, the information on pages 2 and 3 applied. *12/3/13 - 5 PU listed on page 1: - Sacrum (noted as 53 which correlated to the lower back area on the back body diagram), 2 by 1.2, depth blank, stage II; - Left buttock (noted as 32 which correlated to the back body diagram), 3 by 1, depth blank, stage I; - Left buttock (noted as 32), 1 by 1, depth blank, stage II; - Left buttock (noted as 32), 1 by 2, depth blank, stage II; and, - Right buttock (noted as 31 which correlated to the right buttock on the back body diagram), 1 by 2, depth blank, stage II. Pages 2 and 3 noted small amount of exudate, rolled edges, "Hurts a Little Bit," and "...Wounds appear to be less inflammed (sic) and healing well since I last observed them..." Note: There was no indication as to which PU, the sacrum, one of the 3 left buttock, or the right buttock, the information on pages 2 and 3 applied. And, a new PU, on the sacrum was listed while the coccyx PU was not mentioned. *12/10/13 - 5 PU listed on page 1: - Sacrum (noted as 53), 2 by 1.3 by 0.2, stage II; - Left buttock (noted as 32), 2 by 1 by 0, stage I; - Left buttock (noted as 32), 1 by 1 by 0, stage I; - Left buttock (noted as 32), 1 by 2 by 0, stage I; and, - Left buttock (noted as 32), 1 by 1 by 0, stage I. Pages 2 and 3 noted [MEDICATION NAME] tissue, granulation tissue, and slough, scant amount of serous exudate, normal color/tissue of the surrounding skin, "Hurts a Little Bit," and, "Wounds have improved overall..." Note: Again, there was no indication as to which PU the information on pages 2 and 3 applied. And, 4 left buttock PUs were listed while the coccyx and right buttock PUs were not mentioned. *12/17/13 - Only 1 PU listed on page 1: - Left buttock (noted as 32), 0.9 by 0.7 by 0, stage I, with [MEDICATION NAME] tissue, no exudate, normal color/tissue of surrounding skin, no pain, and no comments on pages 2 and 3. Note: None of the other previously noted PU were mentioned. The resident's Progress Notes (PN), dated 11/26/13 - 12/17/13, included: * 11/26/13 at 11:37 p.m. - "...new admit...arrived at (6:00 p.m.)...Pt (patient) has 3 pressure wounds on left glute (buttock)...All wounds showed broken skin, no odor, no drainage, no s/s (signs/symptoms) of infection. (C)overed with 2 [MEDICATION NAME] bandages...not painful..." * 11/29/13 at 1:42 p.m. - "...2 new pressure ulcers noted, see wound assessment. Pt received an air mattress..., pt is to be turned Q (every) 2 hours..." * 11/30/13 at 9:54 a.m. - "...New pressure ulcer noted on L (left) upper thigh. [MEDICATION NAME] placed..." Note: The left upper thigh PU was not included on the aforementioned W/SHRs. * 12/3/13 at 1:36 p.m. - "...Weekly skin assessment completed. See assessment for wound measurements..." * 12/5/13 at 10:27 a.m. - "...Pt coccyx wound dressings changed, all are healing well and no longer draining. New pink tissue is forming and there are no s/sx (signs/symptoms) of infection..." * 12/10/13 at 12:33 p.m. - "...Wound healing assessment completed, weekly skin check completed..." * 12/17/13 at 10:06 a.m. - "...Skin check completed, no new issues noted. Barrier cream applied to pressure sores on left buttock..." Note: The left upper thigh PU was not mentioned again in the PN. In addition, the facility did not provide W/SHR or any other documentation regarding the stage, size, or condition of left thigh PU. Resident #5 was observed lying in bed as follows: * 12/16/13 at about 3:20 p.m. - asleep on back, head of bed (HOB) up 25-30 degrees; * 12/17/13 at 8:35 a.m. - awake on back and turned slightly to right, HOB up about 30 degrees; * 12/17/13 at 10:25 a.m. - same as above; * 12/17/13 at 12:10 p.m. - awake on back, HOB up about 35 degrees; * 12/17/13 at 2:30 p.m. - awake on back, HOB up 35 degrees; and, * 12/17/13 at 3:00 p.m. - awake on back, HOB up about 30 degrees. On 12/17/13 at 3:00 p.m., the resident's lower torso and thighs were observed when LN #8 and CNA #6 provided incontinence care and the following was noted: * An intact, dark reddened area, about 4 cm by 3 cm near the center of the left buttock; * An intact, slightly reddened rounded area, about 1 cm by 1 cm on the left buttock and about 2 inches below the larger area noted above; * An intact, scaly, slightly reddened rounded area, about 1.5 cm by 1.5 cm on the right buttock; * An intact, reddened area at the coccyx, about 0.5 cm by 1 cm; and, * Intact skin on the left thigh. On 12/18/13 at 9:30 a.m., the DNS, who said she used to be a wound nurse, was interviewed about the resident's PU and documentation. The DNS reviewed the 11/26/13 Nursing Admission Assessment and the aforementioned W/SHRs and PNs, then stated, "They are not doing it right. There should be a description for each one (PU) but there's only one each time." She added, "They are using coccyx and sacrum interchangeably." When asked which PU had slough in the wound bed, the DNS said, "I don't know which PU it is." When asked what, if any, interventions were in place when the resident was admitted to the facility, the DNS said that a regular facility mattress was used initially and an air mattress on put in place on 11/29/13. When asked if there was any other documentation about the resident's PUs, the DNS stated, "No." Resident #5, who was admitted with 3 stage II left buttock PU, developed 2 new stage II PU 3 days after admission and a left thigh PU (which was not staged, sized, or described) 4 days after admission when the facility failed to implement a pressure ulcer care plan and interventions on admission. The facility failed to identify which PU had slough in the wound bed, which by definition meant it had progressed to stage III. The facility also failed to document the characteristics of each PU and used different anatomical site terminology (coccyx and sacrum) interchangeable, which confused the issue even more. On 12/18/13 at about 5:30 p.m., the Administrator and DNS were informed of the findings and the facility's P&P regarding PU were requested at that time. On 12/19/13 at about 11:05 a.m., the DNS provided 3 policies and procedures (P&P), which included Pressure Ulcer Risk Assessment, Pressure Ulcer Treatment, and Support Surface Guidelines. The PU Risk Assessment P&P documentation, under Assessment, included, "Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches." The PU Treatment P&P documentation included, "Preparation 1. Review the resident's care plan to assess for any special needs of the resident..." This P&P also provided definitions and descriptions of different stages of PU, which included, "Stage II...Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough... Stage III...Slough may be present..." The Support Surface Guidelines P&P documentation, under Interventions/Care Strategies, included, "Any individual at risk for developing pressure ulcers should be placed on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattresses when lying in bed. (and) ...If resident has a Stage I or above pressure ulcer, q (every) 2 hour turning is inadequate." The facility did not provide any other information or documentation regarding the PU issue for Resident #5.