Every finding on record at Regency Florence

Based on observation, interview, and record review it was determined the facility failed to follow physician orders for 1 of 2 sampled residents (#38) reviewed for skin conditions. This placed residents at risk for re-opening of closed wounds. Findings include: Resident 38 was admitted to the facility in 12/2025 with diagnoses including multiple sclerosis and a history of cellulitis of the right lower leg.A 12/22/25 Initial Non-Pressure Skin Condition Evaluation indicated the presence of a four centimeter by four centimeter right lower leg venous ulcer on admission with a small amount of serosanguineous exudate (blood-tinged fluid drainage).A 1/5/26 Weekly Non-Pressure Skin Condition Evaluation indicated the right lower leg ulcer had resolved. Treatment continued for the right lower leg skin.On 4/21/26 at 2:04 PM, Resident 38 stated she/he was concerned about the condition of her/his right lower leg. The 4/22/26 physician order for treatment of Resident 38's right lower leg stated right lower extremity dressing changes-Primary Treatment: Cleanse with wound cleanser. Apply Xeroform, ABD pad, wrap with kerlix and secure. In the evening every Mon, Wed, Fri.An observation of treatment of Resident 38's right lower leg occurred on 4/22/26 at 3:11 PM, with Staff 6 (RN) and Staff 7 (LPN) completing the treatment. The existing dressing had already been removed when the observation began. No open areas were observed on the right lower leg. The skin was flaking and yellowed in color. Staff 6 performed the treatment and verbalized the process to the resident and surveyor. After cleansing the resident's right lower leg, Staff 6 indicated she was doing light debridement by running gloved hands up and down the right lower leg. Staff 7 then applied Xeroform to the lower leg, followed by covering the area with ABD pads and Kerlix wrap.On 4/24/26 at 8:33 AM, Staff 2 (DNS) was asked if it was appropriate for a nurse to lightly rub Resident 38's right lower leg to remove skin during treatment and refer to this as 'debridement'. Staff 2 indicated this was not part of the physician ordered plan of care for this resident. Staff 2 further indicated staff should never rub the fragile skin around a healed or healing wound because it is unknown what is under the skin, and doing so would increase the risk of re-opening a closed wound.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed infection control procedures for wound care for 1 of 3 sampled residents (#7) reviewed for pressure wounds and 1 of 1 facility reviewed for medication administration. This placed residents at risk for cross contamination and worsening wounds. Findings include: Based on a medication administration observation on 4/22/26 at 8:05 AM, Staff 11(RN) prepared medications for a resident in room [ROOM NUMBER]. Staff 11 entered the room without performing hand hygiene. Staff 11 grasped the resident's water cup and handed it to her/him. Staff 11 provided eye drops and nasal spray to her/him. Staff 11 moved multiple cups on the overbed table and handled the medication cup, eye drops, and nasal spray. Staff 11 failed to sanitize the bottles after usage. Staff 11 returned to the medication cart and logged onto the computer without performing hand hygiene. Staff 11 stated she should perform hand hygiene before entering and exiting a resident's room.During a medication administration observation on 4/22/26 at 4:11 PM, Staff 12 (CMA) prepared medication for the resident in room [ROOM NUMBER]. Staff 12 utilized a pill cutter to cut one of the medications. Staff 12 placed the pill cutter back into the medication cart drawer without sanitizing the equipment. When asked when the pill cutter required sanitization, Staff 12 stated, after every use. Staff 12 failed to sanitize the pill cutter. Staff 12 entered and exited room [ROOM NUMBER] without performing hand hygiene. Staff 12 accessed the computer and medication cart without hand hygiene.On 4/24/26 at 10:52 AM, Staff 1 (Administrator), Staff 2 (DNS), and Staff 10 (Regional Nurse Consultant) stated staff should sanitize their hands before entering and after exiting a resident's room. Staff 2 stated staff should sanitize all equipment after each use, including the pill cutter. Staff 2 stated staff are to clean resident inhalers, eye/ear drops, and nebulizers after each use.

Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 2 of 7 sampled residents (#s 6 and 7) reviewed for unnecessary medications and skin conditions. This placed residents at risk for unmet needs. Findings include: 1. Resident 6 admitted to the facility in 2/2026 with diagnoses including surgical wound infection and adjustment disorder with depressed mood. Resident 6's 2/27/26 admission MDS revealed Resident 6 had a history of depression, took medication for anxiety, and had a wound VAC (a non-surgical treatment that applies controlled suction to a wound to accelerate healing). A review of Resident 6's physician orders revealed orders for care for a wound VAC, hydroxyzine (an antianxiety medication), and duloxetine (an antidepressant). Resident 6's comprehensive care plan revealed no interventions related to her/his wound VAC. Resident 6's comprehensive care plan also did not have target behaviors or interventions for mood or anxiety related to her/his use of hydroxyzine and duloxetine. On 4/22/26 at 2:31 PM Staff 5 (SSD) stated Resident 6 was often tearful and recently started taking duloxetine. Resident 6 took hydroxyzine for anxiety, and Staff 5 knew to let other staff know if there were any changes in the resident's symptoms. Staff 5 reviewed Resident 6's care plan and stated there were no target behaviors or interventions related to the use of duloxetine or hydroxyzine. On 4/23/26 at 10:40 AM Staff 3 (LPN Resident Care Manager) reviewed Resident 6 and her/his care plan. Staff 3 stated there were no specific interventions related to Resident 6's wound VAC. On 4/23/26 at 11:16 AM Staff 2 (DNS) stated she expected the care plan to included information related to the wound VAC and target behaviors and interventions for the hydroxyzine and duloxetine. 2. Resident 7 was admitted to the facility in 7/2025 with diagnoses including a pressure wound and malnutrition. Resident 7's 7/26/25 admission MDS revealed Resident 7 had a wound VAC (a vacuum assisted closure of a wound to promote wound healing). A review of Resident 7's physician orders revealed orders for care for a wound VAC. The 1/26/26 revised care plan revealed no interventions related to her/his wound VAC. On 4/24/26 at 10:11 AM Staff 1 (Administrator), Staff 2 (DNS), and Staff 10 (Regional Nurse Consultant) acknowledged there was no information in the care plan related to Resident 7's wound VAC.

Based on interview and record review it was determined the facility failed to follow physician orders for therapy, failed to provide incontinence care and failed to ensure a call light was accessible for 2 of 3 sampled residents (#s 102 and 104) reviewed for quality of care and treatment. This placed residents at risk for unmet care needs. Findings include: 1. Resident 102 was admitted to the facility in 2024, with diagnoses including stroke and diabetes. Resident 102's Admission Orders dated 9/12/24 included orders for Physical and Occupational Therapy. On 3/25/25 at 1:34 PM, Staff 15 (OT/Therapy Manager) stated the resident was not seen for therapy as they had not received therapy orders. On 3/26/25 at 3:40 PM, Witness 1 (Family Member) stated the resident was admitted to the nursing facility for Respite Care (temporary relief for caregivers of individuals with chronic illness, disabilities, or special needs) in 9/2024. The resident's PCP included orders for PT and OT but the resident did not receive any therapy while at the facility. On 3/27/25 at 3:36 PM, Staff 1 (Administrator) indicated she was unable to locate any documentation to explain why the resident did not receive the ordered therapy during the nine days the resident was at the facility. 2. Resident 104 was admitted to the facility in 2024, with diagnoses including a Stage 4 pressure ulcer (most severe pressure wound with skin and tissue loss and exposed underlying structures like muscle, tendon, or bone) and quadriplegia-incomplete (partial paralysis of all four limbs resulting from a spinal cord injury or disease). A Facility Reported Incident dated 6/17/24 for an incident which occurred on 6/15/24 indicated Resident 104 was not provided incontinence care during the night shift, was found soiled in the morning, and her/his call light was on the floor out of the resident's reach. An investigation was conducted which determined the resident was left without cares through the night by Staff 16 (CNA). Staff 16 was terminated. Staff 16 did not respond to interview attempts on 3/24/25 and 3/25/25. On 3/24/25 at 11:58 AM, Staff 8 (CNA) indicated she went in to bring the resident breakfast on 6/16/24 and found the resident hanging half way off the bed and covered in feces. Staff stated she cleaned the resident and took her/him to the shower. Staff 8 stated the resident told her Staff 16 and another CNA had started to change her/him last night and had taken off her/his brief. Staff 8 stated the resident told her the CNAs would be back to finish changing her/him but no one ever came back. Staff 8 stated she found the wipes and a brief still on the bed. Staff 8 stated the resident stated Staff 16 had not been back to the room for the rest of the night shift. On 3/24/25 at 2:10 PM, Staff 2 (DNS) indicated their investigation determined Staff 16 did not provide appropriate care to Resident 104.

Based on interview and record review it was determined the facility failed to obtain consent prior to administration of a vaccine for 1 of 5 sampled residents (#1) reviewed for immunizations. This placed residents at risk for lack of informed consent. Findings include: Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A 12/4/24 review of immunizations revealed Resident 1 received a COVID-19 vaccine on 5/9/24. A 12/4/24 review of Resident 1's medical record revealed no evidence of a COVID-19 vaccine consent. On 12/6/24 at 10:46 AM Staff 2 (DNS) stated she was unable to locate a signed consent for the COVID-19 vaccine Resident 1 received on 5/9/24.

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 2 of 5 sampled residents (#s 1 and 20) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include: 1. Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A review of Resident 1's orders revealed a 5/7/24 order for a comprehensive metabolic panel (laboratory test) to be completed on the next lab day and every six months. A review of Resident 1's laboratory test results revealed a comprehensive metabolic panel completed on 9/7/24. On 12/4/24 at 2:05 PM Staff 2 (DNS) acknowledged Resident 1's comprehensive metabolic panel was ordered on 5/7/24 but not completed until 9/7/24. Staff 2 stated the test was not completed timely. 2. Resident 20 admitted to the facility in 8/2024 with diagnoses including depression. A review of Resident 20's orders revealed an 8/9/24 order for a lipid panel (laboratory test) to be completed the next lab day and every 12 months. A review of Resident 20's laboratory test results revealed a lipid panel completed on 9/5/24. On 12/4/24 at 2:05 PM Staff 2 (DNS) acknowledged Resident 20's lipid panel was ordered on 8/9/24 but not completed until 9/5/24. Staff 2 stated the test was not completed timely.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 2 of 5 sampled residents (#s 1 and 24) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions and unnecessary medications. Findings include: 1. Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A review of Resident 1's pharmacy consultation reports revealed a 9/3/24 recommendation to attempt a gradual dose reduction on citalopram (an antidepressant medication). A review of Resident 1's medical record revealed no evidence of a signed physician order to attempt a gradual dose reduction on citalopram in 9/2024. A review of Resident 1's pharmacy consultation reports revealed a 10/1/24 recommendation to attempt a gradual dose reduction on citalopram. A review of Resident 1's medical record revealed a 10/8/24 order to decrease citalopram from 20 mg to 10 mg. On 12/4/24 at 1:47 PM Staff 8 (LPN Resident Care Manager) stated pharmacy recommendations should be addressed within a week of receiving the recommendations. Staff 8 confirmed Resident 1's pharmacy recommendation to attempt a gradual dose reduction on citalopram was not completed timely. 50897 2. Resident 24 admitted to the facility on [DATE] with diagnoses including heart disease. A pharmacist review completed 9/2024 instructed the facility to clarify Resident 24's order for carvedilol (a medication to treat hypertension) to administer the medication with food. A record review of Resident 24's MAR and physician orders completed 12/4/24 revealed Resident 24's orders were not updated with the instruction to administer her/his carvedilol with food. In an interview on 12/4/24 at 4:00 PM Staff 2 (DNS) acknowledged Resident 24's orders were not updated to reflect her/his carvedilol needed to be given with food.

Based on interview and record review it was determined the facility failed to ensure provision of trauma-informed care for 2 of 2 sampled residents (#s 11 and 30) reviewed for behavioral needs. This placed residents at risk for unmet trauma needs and a decreased quality of life. Findings include: 1. Resident 11 admitted to the facility in 1/2017 with diagnoses including bipolar disorder, mood disturbance, communication deficit and post-traumatic stress disorder (PTSD). An 10/21/24 Annual MDS revealed Resident 11's BIMS score was five which indicated she/he had severe cognitive impairment. Resident 11 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble with sleep, felt tired, had eating difficulties, felt bad about herself/himself, trouble concentrating and moving and spoke slowly. A review of Resident 11's 11/8/24 care plan revealed areas which discussed trauma. All areas listed a history of trauma from the Vietnam War with history of a gunshot wound. There were no specific triggers related to Resident 11's PTSD or interventions included in her/his care plan. On 12/3/24 at 9:40 AM Resident 11 stated loud noises make her/him upset and scared and she/he experienced bad dreams. On 12/4/24 at 9:51 AM Staff 10 (CNA) and Staff 11 (CNA) stated Resident 11 could become upset and could be combative. Staff 10 and Staff 11 stated they did not know the resident had PTSD or what her/his triggers were. On 12/5/24 at 8:02 AM Staff 2 (DNS) stated Resident 11 had PTSD from the war and getting shot and she/he was not care planned for her/his specific trauma triggers or interventions. 2. Resident 30 admitted to the facility in 11/2021 with diagnoses including post-traumatic stress disorder (PTSD), stroke, depression, mood disorder, and suicidal ideations. A 11/15/24 Annual MDS revealed Resident 30's BIMS score was 15 which indicated she/he was cognitively intact. A review of Resident 30's 11/20/24 care plan revealed areas which discussed depression and self-harm. No areas spoke of Resident 30's history of abuse. There were no specific triggers or interventions included in her/his care plan. On 12/3/24 at 9:43 AM Resident 30 stated she/he had a history of abuse and her/his triggers included people yelling, or when male staff members came into her/his room. Resident 30 stated nobody asked her/him what her/his triggers were. On 12/4/24 at 9:51 AM Staff 9 (CNA) and Staff 11 (CNA) stated they were not aware Resident 30 had PTSD or what her/his triggers were. On 12/5/24 at 8:02 AM Staff 2 (DNS) stated Resident 30 had PTSD from a history of abuse and she/he was not care planned for her/his specific trauma triggers or interventions.

Based on interview and record review it was determined the facility failed to monitor residents at risk for elopement and follow care plans related to safety for 2 of 6 sampled residents (#s 8 and 93) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 8 admitted to the facility in 2/2019 with diagnoses including dementia. A 3/24/24 Quarterly MDS indicated Resident 8 had severe cognitive deficits. A 3/28/24 Elopement Evaluation indicated Resident 8 was at risk for elopement. A 5/5/24 Progress Note indicated Resident 8 attempted to leave the facility four times in the evening before eloping at approximately 5:30 PM. Resident 8 was found outside, on the side of the road near the facility. Resident 8 fell out of her/his wheelchair and was assisted by individuals that were passing by. On 12/5/24 at 1:13 PM Staff 6 (CNA) stated Resident 8 was an active exit seeker prior to her/his elopement on 5/5/24. Staff 6 stated Resident 8 figured out the door code and attempted to leave the facility by entering in the door code. On 12/5/24 at 2:00 PM Staff 5 (LPN) stated on 5/5/24 Resident 8 stated she/he wanted to go out and feed her/his dog and during the evening of 5/5/24 Resident 8 continued to exit-seek between the front door and the back door trying to get out of the facility. Staff 5 stated facility staff attempted to keep an eye on Resident 8, but she/he successfully eloped from the facility and Staff 5 found Resident 8 on the sidewalk after she/he fell out of her/his wheelchair. On 12/5/24 at 2:01 PM Staff 7 (CNA) stated on 5/5/24, prior to Resident 8's elopement, he observed Resident 8 enter the door code and attempt to exit the facility. Staff 7 was able to intervene and keep Resident 8 from exiting the facility. On 12/6/24 at 10:46 AM Staff 1 (Administrator) acknowledged Resident 8 was an active exit seeker prior to the elopement on 5/5/24 and stated Resident 8 should have been placed on one-to-one supervision to prevent the elopement. 2. Resident 93 admitted to the facility in 7/2024 with diagnoses including diabetes. A 7/8/24 Care Plan revealed Resident 93 was care planned for one person assist while showering. A 7/25/24 public complaint indicated Resident 93 was left alone while taking a shower. On 12/3/24 at 5:06 PM Resident 93 stated a nurse left her/him alone in the shower which caused Resident 93 to feel frightened of falling. On 12/6/24 at 8:18 AM Staff 3 (Social Service Director) stated Resident 93 informed her she/he was left alone in the shower, but she/he declined to fill out a grievance form. On 12/6/24 at 11:06 AM Staff 4 (Agency LPN) acknowledged she left Resident 93 in the shower alone for approximately 10 minutes. On 12/6/24 at 10:46 AM Staff 1 (Administrator) stated residents were not to be left alone in the shower unless they were independent and approved by therapy to be left alone in the shower. Staff 1 acknowledged Resident 93 was not approved to be left alone in the shower.

Based on observation, interview, and record review it was determined the facility failed to assess and monitor pressure ulcers for 2 of 2 sampled residents (#s 11 and 94) reviewed for pressure ulcers. This placed residents at risk for unassessed and unmet treatment needs. Findings include: 1. Resident 11 admitted to the facility in 1/2017 with diagnoses including dementia. a. An 10/18/24 New Pressure Injury Incident Report indicated Staff 15 (LPN) was completing wound care for Resident 11 and noticed a new pressure injury to the left heel. The heel tissue was purple in color, soft to the touch, and the skin was intact. Staff 15 stated Resident 11 did not have her/his feet elevated with a pillow. Staff 11 (NA) reported the resident was upset and kicked the pillow off the bed. An 8/28/24 Care Plan revealed staff were to float Resident 11's heels with pillows while she/he was in bed as she/he allowed. A review of Resident 11's medical record revealed a left heel facility-acquired pressure ulcer. There was no documentation in the resident's medical record the left heel wound was assessed or monitored. On 12/2/24 at 3:14 PM Resident 11 was observed lying in bed without a pillow under her/his feet. On 12/3/24 at 9:40 AM Resident 11 was observed lying in bed without a pillow under her/his feet. On 12/4/24 at 9:31 AM Resident 11 was observed lying in bed without a pillow under her/his feet. On 12/5/24 at 7:58 AM Resident 11 was observed lying in bed without a pillow under her/his feet. A review of Resident 11's medical record revealed no Skin and Wound Evaluations documents. On 12/5/24 at 9:51 AM Staff 10 (CNA) and Staff 11 (CNA) stated they were aware Resident 11 had bruising to her/his left heel. Staff 10 and Staff 11 stated they keep the resident's heels off the bed mattress by placing a pillow under her/his feet. Staff 11 stated the left heel bruise was new but he was not aware if nursing was treating the wound. On 12/6/24 at 10:00 AM Staff 2 (DNS) acknowledged there were no Skin and Wound Evaluation documents for the left heel pressure injury. 2. Resident 94 admitted to the facility in 3/2024 with diagnoses including diabetes. The 3/11/24 Admission MDS indicated Resident 94 was cognitively intact and had no pressure injuries. An 4/16/24 New Skin Issue Incident Report revealed Resident 94 complained of pain in the back of her/his left thigh. Staff 16 (LPN) observed an area approximately 2 cm below the left buttocks approximately 0.3 cm x 0.4 cm. The area was red in color and the surrounding tissue was red. The root cause appeared to be Resident 94 had her/his catheter tubing under her/his thigh because that was where she/he thought the tubing was supposed to be placed. The tubing was readjusted and the resident was educated on placement of the tubing. No Skin and Wound Evaluation was initiated regarding the wound. A 5/4/24 Initial Skin Ulcer/Injury Measurement and Evaluation indicated Resident 94 had an unstageable (full thickness wound covered by a layer of dead tissue) facility-acquired pressure ulcer to her/his right heel. There was no incident report or investigation for the above incident. A 5/15/24 Progress Note indicated Resident 94 developed a pressure injury to her/his coccyx (tailbone). There was no incident report or investigation for the above incident. A review of Resident 94's medical record revealed no Skin and Wound Evaluation documents relative to the above new pressure-related skin injuries. On 12/3/24 at 1:10 PM Resident 94 stated she/he had a left hip pressure ulcer which was painful, and staff did not assist her/him to reposition in bed. Resident 94 stated after the pressure wound developed staff assisted her/him with repositioning in bed. On 12/5/24 at 1:57 PM Staff 7 (CNA) and Staff 14 (CNA) stated the resident developed pressure wounds to the buttocks and hip area and to her/his heels. Staff 7 stated he repositioned the resident often and placed pillows under Resident 94's feet while in bed but the resident had leg spasms and accidentally kicked the pillows off the bed. On 12/6/24 at 10:00 AM Staff 2 (DNS) acknowledged there were no Skin and Wound Evaluations for the new left thigh and buttocks injury, right heel injury, and the coccyx injury, the new skin injuries were not investigated, and Resident 94's care plan was not updated

Based on interview and record review the facility failed to follow doctor's orders for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 24 admitted on [DATE] with diagnoses including heart disease. A review of Resident 24's medication orders revealed orders for Ipratropium-Albuterol Inhalation Solution (a medication to treat shortness of breath) for five days beginning 11/22/24. A review of Resident 24's 11/2024 and 12/2024 MARs also revealed the medication should be discontinued after five days on 11/27/24, however the MAR indicated the medication was administered through 12/4/24. In an interview on 12/4/24 at 4:00 PM Staff 2 (DNS) acknowledged the record showed Resident 24 continued to be given doses of Ipratropium-Albuterol Inhalation Solution for seven days past the date the medication was ordered to be discontinued.

Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of abuse for 1 of 7 sampled residents (#94) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 94 admitted to the facility in 3/2024 with diagnoses including failure to thrive. On 9/23/24 a public complaint was received which alleged on 9/12/24 Resident 94 stated Staff 17 (Former Agency LPN) indicated she was going to administer her/him an extra dose of oxycodone beyond what was prescribed, laughed and walked out of the resident's room. Resident 94 stated she/he felt threatened, verbally abused, and the incident caused her/him increased anxiety. Resident 94 stated Staff 17 came to her/his room later and indicated she gave the resident an extra dose of oxycodone. Resident 94 stated she/he was extremely upset and scared. Resident 94 stated a couple hours later Staff 17 came back to her/his room and explained she administered an extra dose of oxycodone to another resident and not her/him, laughed, and walked out of her/his room. On 12/5/24 at 1:57 PM Staff 7 (CNA) stated on 9/12/24 Staff 17 explained to the resident she/he administered an extra dose of oxycodone. Resident 94 started to panic, became upset, and she/he thought she/he was going to die. Staff 7 stated after a couple hours Staff 17 came and told the resident she/he did not administer the extra dose of oxycodone to her/him but to another resident. The investigation for the above incident did not include witness statements, other resident interviews or interview of the alleged perpetrator. On 12/5/24 at 2:45 PM Staff 2 (DNS) acknowledged there was no witness statement for the 9/12/24 incident. Staff 2 acknowledged a thorough investigation was not completed for the incident that occurred on 9/12/24.

Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 1 of 3 sampled residents (#30) reviewed for advance directives. This placed residents at risk for not having health care decisions honored. Findings include: Resident 30 admitted to the facility in 10/2021 with diagnoses including stroke. 5/23/23, 2/8/24, 2/22/24, 5/23/24 and 8/22/24 Interdisciplinary Care Conference notes revealed Resident 30 did not have an advance directive, but wanted one offered. Review of Resident 30's electronic record revealed no advance directive. On 12/3/24 at 9:43 AM Resident 30 stated she/he attended Care Conferences, but was not offered an advance directive. On 12/4/24 at 9:47 AM Staff 3 (Social Service Director) stated she offered advance directives at care conferences, and had the resident sign an Admission Assessment document to verify they received the advance directive. Staff 3 stated she did not conduct follow up related to provision of advance directives. On 12/5/24 at Staff 1 (Administrator) stated she expected staff to follow up before quarterly care conferences regarding advance directives.

Based on interview and record review it was determined the facility failed to address orders for corrective lenses for 1 of 2 sampled residents (#1) reviewed for vision. This placed residents at risk for unmet vision needs. Findings include: Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A 6/3/24 Encounter Summary revealed Resident 1 saw an optometrist on 6/3/24 and a prescription was written for glasses. On 12/2/24 at 2:51 PM Resident 1 stated she/he went to an eye exam about six months previously and was supposed to get glasses, but did not. On 12/4/24 at 8:48 AM Staff 3 (Social Service Director) stated Resident 1 had her/his eyes checked on 6/3/24 but was unaware of the order for new glasses. On 12/4/24 at 2:04 PM Staff 2 (DNS) stated Resident 1 had an order for glasses but did not receive new glasses. Staff 2 acknowledged Resident 1 did not receive timely follow up for new glasses.

Based on interview and record review it was determined the facility failed to make a dental appointment for 1 of 2 sampled residents (#1) reviewed for dental needs. This placed residents at risk for unmet dental needs. Findings include: Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. On 12/2/24 at 2:48 PM Resident 1 stated the facility informed her/him they were going to make a dental appointment for new dentures at her/his last care conference approximately two to three months ago, but no dental appointment was scheduled. On 12/4/24 at 2:19 PM Staff 8 (LPN Resident Care Manager) stated during the 10/17/24 Care Conference Resident 1 indicated she/he needed to see the dentist and Staff 8 stated the appointment was not scheduled. Staff 8 acknowledged Resident 1 did not have timely follow up for her/his dental appointment needs.

Based on observation, interview and record review it was determined the facility failed to provide incontinence care for 3 of 3 dependent residents (#s 101, 102 and 103) reviewed for incontinence care. This placed residents at risk for unmet care needs. Findings include: 1. Resident 101 was admitted to the facility in 2020, with diagnoses including dementia and Traumatic Brain Injury (TBI). Resident 101's 2/2/24 Annual MDS CAA for Urinary Incontinence revealed Resident 101 was frequently incontinent of urine and required extensive assistance for toilet use and total dependence for transfers. Resident 101 was dependent on staff for toileting hygiene and was always incontinent of bladder. The resident had mixed incontinence (urge and functional). The resident has a terminal illness. Staff were directed to maintain pride and dignity while giving personal care. Resident 101's care plan indicated the resident was at risk for ADL deficits related to weakness, decreased mobility, impulse disorder, dementia with behaviors and traumatic brain injury. Resident 101 was on a Check and Change toileting program. Staff were to check the resident every two hours and assist with toileting as needed. A Facility Reported Incident dated 5/18/22, claimed Staff 8 (CNA) failed to provide timely incontinent care and repositioning for Resident 101 on 5/18/22 between 9:10 AM and 12:30 PM. The facility's investigation dated 5/18/22, indicated Staff 8 failed to provide incontinence care and repositioning for the resident who was dependent on staff for ADL care. Staff 8 initially stated she had provided care but then changed her statement and stated no staff answered her call for assistance. Staff interviews revealed she did not call for assistance on the walkie-talkies and did not ask anyone in person. The facility concluded Staff 8 failed to provide the required assistance to the resident. A written statement dated 5/18/22, by Staff 3 (RCMA/LPN) indicated at 9:10 AM, she placed an audit cared under Resident 101's left hip area. At approximately 12:30 PM she asked Staff 8 when did she last change and reposition Resident 101. Staff 8 stated at 10:50 AM. Staff 3 checked the resident and found the audit card was still in place under the resident and the resident was soaked. Staff 8 had not provided care for the resident. On 4/23/24 at 2:15 PM, Staff 3 (RCMA/LPN) stated she was the charge nurse on 5/18/22 and Staff 8 told her she had changed the resident but Staff 3 stated the evidence showed she had not. Staff 3 stated Staff 8 did not ask her for assistance with the resident or she would have helped her. On 4/23/24 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed the lack of incontinence care for Resident 101 on 5/18/22. 2. Resident 102 was admitted to the facility in 2016, with diagnoses including cerebral palsy (congenital disorder of movement, muscle tone, or posture), left sided hemiparesis (partial paralysis) and need for assistance with personal care. Resident 102's 12/3/23 Annual MDS CAA for Urinary Incontinence revealed at-risk diagnoses included: muscle weakness, lack of coordination, reduced mobility, general weakness, abnormality of gait and mobility. The resident had mixed urinary incontinence (urge, functional and overflow). The resident was always incontinent of bowel and bladder and was a 1-person staff assist with toilet hygiene. Resident 102's care plan dated 3/4/22, indicated the resident was on a Check and Change Toileting program. Staff were to check the resident every two hours and assist with toileting as needed. A Facility Reported Incident dated 5/13/22, claimed Staff 9 (NA) failed to provide appropriate ADL care to Resident 102 on 5/7/22. Staff 9 put a bath blanket under the resident instead of changing her/his wet bed sheets. Resident 102 was found with a wet spot under the bath blanket. No harm was found to the resident and an investigation was started. The facility's investigation dated 5/13/22, indicated Staff 4 (PCA) stated she worked the night shift (10:00 PM to 6:00 AM) on 5/7/22 and received report from Staff 9 who stated he had changed the resident at 9:15 PM. When she checked on the resident around 10:30 or 11:00 PM, she found the resident with the blanket underneath her/him which was wet and there was a wet spot under the blanket. The facility determined Resident 102 did not receive incontinence care appropriately or timely. On 4/24/24 at 11:04 AM, Staff 4 (PCA) stated it was not correct procedure to put a blanket underneath the resident instead of changing the resident's soiled bedding. The material of the blanket could cause skin breakdown. Staff 4 stated when she saw Resident 102's condition she went and got the charge nurse to assess her/him. Staff 4 and two other aides cleaned the resident up and changed the bedding. Resident 102 was soaked with urine and had dried bowel movement on her/his behind. On 4/23/24 at 11:43 AM, Resident 102 stated she/he did not remember the incident. Resident 102 said the staff took very good care of her/him. On 4/23/24 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed the lack of incontinence care for Resident 102 on 5/13/22. 3. Resident 103 was admitted to the facility in 2018, with diagnoses including dementia and Traumatic Brain Injury (TBI). Resident 103's 11/24/2021 Admission MDS CAA for Urinary Incontinence indicated the resident was on end-of-life Hospice care. Factors contributing to the resident's incontinence included: anxiety, increased weakness, decreased mobility, increased need for ADL support, death and the dying process. The resident's incontinence appeared to be functional in nature with a decline expected. Resident 103's care plan dated 11/17/22, indicated the resident was on a Check and Change Toileting program. Staff were to check the resident every two hours and assist with toileting as needed. The resident was a 1-person staff assist for toileting. A Facility Reported Incident dated 5/13/22, claimed Staff 9 (NA) failed to provide appropriate ADL care to Resident 103 on 5/7/22. Staff 9 put a bath blanket under the resident instead of changing her/his soiled bed sheets. Resident 103 was found with wet spots under the bath blankets. No harm was found to the resident and an investigation was started. The facility's investigation dated 5/13/22, indicated Staff 4 (PCA) stated she worked the night shift (10:00 PM to 6:00 AM) on 5/7/22 and received report from Staff 9 who stated he had changed the resident at 9:15 PM. When she checked on the resident around 10:30 or 11:00 PM, she found the resident with the blanket underneath her/him which was wet and there was a wet spot under the blanket. The facility determined Resident 103 did not receive incontinence care appropriately or timely. On 4/24/24 at 11:04 AM, Staff 4 (PCA) stated it was not correct procedure to put a blanket underneath the resident instead of changing the resident's soiled bedding. The material of the blanket could cause skin breakdown. Staff 4 stated when she saw Resident 103's condition she went and got the charge nurse to assess her/him. Staff 4 and two other aides cleaned the resident up and changed the bedding. Resident 103 was soaked with urine and had dried bowel movement on her/his behind. On 4/23/24 at 11:15 AM, Resident 103 was found not to be interviewable for this investigation. The resident was lying in bed asleep. The resident was clean and groomed, there was clean bedding on the bed and there were no odors detected in the room. On 4/23/24 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed the lack of incontinence care for Resident 103 on 5/13/22.

Based on interview and record review it was determined the facility failed to complete a thorough investigation within five working days related to potential narcotic medication misappropriation for 1 of 4 sampled residents (#2) reviewed for medications. This placed residents at risk for misappropriation of property. Findings include: Resident 2 was admitted to the facility in 3/2021 with diagnoses including a stroke. Review of a physician order dated 3/21/21 the resident was to receive morphine(narcotic pain medication) 0.25 ml as needed for pain. A physician order dated 9/22/21 revealed the resident was to receive morphine 0.25 ml daily. Review of a narcotic log dated 10/9/23 revealed the last dose of morphine was administered to the resident on 10/20/23 and indicated 4 ml remaining. The unused quantity in the bottle was 0.25 ml and was verified by Staff 2 (DNS) and Staff 3 (DNS/RNCM) on 10/24/23. A note on the log indicated the bottle was greater than five months old and some is likely evaporated/stuck in bottle neck. Review of an incident report dated 10/24/23 at 11:07 AM revealed Resident 2 was missing 2.5 ml of morphine during a medication count. Review of an incident investigation dated 11/2/23 at 11:35 AM revealed Resident 2 was missing 2.5 ml of morphine during shift change. The medication cart was audited for any other missing medication and none were found. Upon investigation the bottle was five months old and had some liquid staff were not able to suction out which amounted to 0.5-0.7 ml. The investigation concluded there was no drug diversion because staff were unable to remove all of the medication in the bottle. The investigation did not include interviews with the alleged victim, potential perpetrators or possible witnesses. In an interview on 11/2/23 at 10:39 AM Staff 2 said she was aware of the missing medication and there was no documented investigation at this time. In an interview on 11/2/23 at 11:05 AM Staff 5 (CMA) said on 10/18/23 she identified Resident 2's morphine bottle contained less than indicated on the narcotic log. Staff 5 said she reported the shortage to Staff 3 and left a note for Staff 4 (LPN). Staff 5 said there was 0.25 ml left in the bottle but there should have been 4 ml. Staff 5 said she was not interviewed by the administration regarding the missing medication. In an interview on 11/3/23 at 8:08 AM Staff 4 said she was informed by Staff 5 about Resident 2's missing morphine on 10/19/23. Staff 4 said she did not notify Staff 3 until a few days later and brought the morphine bottle to Staff 2. Staff 4 said she was not interview by the administration regarding the missing medication. In an interview on 11/7/23 at 9:15 AM Staff 2 acknowledged the investigation for Resident 2's missing medication was not completed within five working days.

Based on interview and record review it was determined the facility failed to ensure medications were available per physician orders for 6 of 6 sampled residents (#s 2, 3, 4, 9, 13 and 14) reviewed for medications. This placed residents at risk for medication-related adverse consequences. Findings include: The facility's 8/2023 Medication Administration Audit Report revealed the following sample of residents with missed medications: -Resident 3's 8/26/23 physician order for Carbidopa-Levodopa, two tablets, three times a day for Parkinson's Disease. The Medication Administration Audit Report revealed the resident did not receive the scheduled dose on 8/26/23 at 10:00 AM. -Resident 14's 8/17/23 physician order for a scheduled dose of Warfarin Sodium (blood clot prevention). The Medication Administration Audit Report revealed the resident did not receive the dose on 8/17/23 at 7:00 AM. On 9/18/23 at 3:12 PM Witness 13 stated there was an Azithromycin (antibiotic) medication error for Resident 9. There was no pharmacy satellite available and no medication was pulled from the Omnicell. On 9/18/23 at 3:15 PM Witness 13 stated Resident 9 did not receive Doxycycline (Antibiotic) when she/he readmitted from the hospital on 6/26/23. On 9/19/23 at 1:17 PM Staff 6 (Nurse Practitioner, NP) indicated there was a problem with Dilaudid (opioid pain reliever) not being available for Resident 3 admitted following shoulder replacement surgery. He needed to prescribe Ibuprofen for the resident which was not the best choice for pain relief. Staff 6 stated he was not happy the facility did not administer the resident's Dilaudid. On 9/19/23 at 1:17 PM Staff 6 (NP) indicated Resident 2 did not receive her/his morning dose of MS Contin (morphine/opioid) medication on 8/28/23. On 9/19/23 at 1:17 PM Staff 6 (NP) said there were medication errors with the Plavix medication for Resident 4. He was initially told the resident was likely double dosed but later told she/he was underdosed. He was very concerned the resident did not get the medication. Staff 6 stated, You cannot make that mistake with that medication. On 9/29/23 5:06 PM Witness 11 indicated there were Plavix (blood thinner) medication errors for Resident 4 even though there were four doses of the medication in the Omnicell. The facility did not receive the order until 9/4/23 because the pharmacy never got the order. The resident did not receive the Plavix medication for three days after admission following heart surgery with stent (tubes to assist with blood flow) placement. On 10/4/23 at 4:12 PM Witness 10 stated two weeks ago Resident 13 was out of the medication Tegretol (anticonvulsant) and it was a Friday so the pharmacy could not get it to the facility. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) and this Surveyor discussed the situation with medications. No additional documentation was provided.

Based on observation, interview, and record review it was determined the facility failed to ensure weekly skin and wound assessments were completed and completed timely and appropriate wound care treatment was provided for residents with wound vacuum systems for 2 of 2 residents (#s 5 and 6) reviewed for appropriate wound care and assessments. This placed residents at risk for delayed wound healing. Findings include: 1. Resident 5 was admitted to the facility in 8/2023 with diagnoses including Fournier's gangrene (rare but deadly infection of the genital and perineum) and Vacuum Assisted Closure wound therapy (wound vac) for a perirectal abscess wound. A hospital Wound Consult note dated 8/22/23 indicated a recommendation for wound vac therapy to encourage granulation tissue formation (development of new tissue and blood vessels), to increase the rate of healing, and to decrease the chance of complications including infection. There was enough skin between the wound edges and the anus to seal the wound vac dressing and withstand the presence of stool if loose stools occurred. There were multiple options for vac placement to avoid the dressing from being close to the anus and it would be very difficult to keep the wound clean without the vac's airtight waterproof dressing. Other therapies were ruled out related to the resident's presence of co-morbidities, high risk of infection, need for accelerated granulation tissue and history of delayed wound healing. An 8/31/23 at 5:52 AM Alert Charting Note for New Admit indicated Resident 5 was alert and oriented and able to make needs and wants known. The resident's wound vac was in place and the resident tolerated it well. An 8/31/23 at 2:52 PM Progress Note by Staff 9 indicated the resident's wound vac continuously came unsealed. Staff 9 (LPN) called the on-call provider, told the provider multiple nurses were unable to get the wound vac to seal, and she obtained new orders for a standard dressing. No documentation was found in the medical record to indicate any nurses, except Staff 9, attempted to place the wound vac. Seven of the nine members of the licensed nursing floor staff were interviewed and indicated they did not attempt to place the wound vac as described by Staff 9. The information provided to the on-call provider was not accurate. On 9/4/23 at 4:46 AM Witness 11 indicated the Nurse Practitioner (NP) was very worried about Resident 5's wound and the treatment which was provided. He stated unless the facility got the wound vac on quickly, he wanted the surgeon to be contacted to find out what else could be done for Resident 5 or the resident may need to discharge to a place where they could do the wound care the resident needed. He stated the wet-to-dry was not appropriate for the trype of wound and was only meant to be temporary while the facility was waiting for wound vac supplies, as with the other wound vac resident (currently out of supplies, too). On 9/19/23 at 1:17 PM Staff 6 (NP) stated Resident 5 was diagnosed with Fournier's gangrene which was a serious infection. The resident had a long-term perineum wound which needed negative pressure (wound vac). The wet-to-dry would not assist in wound healing because there was a massive cavity. Staff 6 said he requested a surgeon consult because the wet-to-dry was not effective for the type of wound involved. Staff 6 said he was told multiple nurses tried to obtain a seal but could not. On 9/19/23 at 9:15 AN Staff 2 (DNS) indicated she understood the concerns related to wound care and she was working on the ordering process for supplies. On 9/25/23 at 10:12 AM Witness 8 stated Resident 5's wound vac care stopped because the facility did not have the wound vac care supplies to provide the care. The NP really wanted the wound vac placed. Witness 8 looked in the supply closet in the DNS's office but there were no wound vac supplies. Witness 8 said staff could not do wound vac care without the correct supplies and the DNS was responsible for ordering supplies for the facility. On 9/25/23 at 11:26 AM Staff 6 (NP) was notified there was not an issue with the wound vac not sealing as he was informed by Staff 9, there was an issue of the facility not having the necessary wound vac supplies to manage the wound care and some nursing staff might not have adequate training to manage the wound vac treatments. Staff 6 stated if there was an intervention used at the hospital but not in the SNF then there was a competency issue at the facility. Staff 6 stated groins and abdomens needed negative wound pressure for the greatest healing outcomes. On 9/25/23 at 1:10 PM Resident 5 indicated she/he started on the wound vac at the hospital and it was working great. The wound vac at the facility was smaller than the one at the hospital. One nurse told her/him she could not get it to work and mentioned they were having trouble getting supplies for the vac and then they stopped using it. On 9/29/23 at 5:06 PM Witness 11 stated she did not try to place the wound vac for Resident 5. Witness 11 also stated the wet-to-dry was not appropriate for the type of wound for Resident 5. Witness 11 stated nursing staff did not want to deal with the wound vac and they did not have adequate wound vac supplies. No documentation was found in the medical record any nurses, other than Staff 9, attempted to place the wound vac. On 10/3/23 at 4:12 PM Witness 10 stated she did not attempt to place the wound vac and the main reason they did not use the wound vac was because the facility did not have the supplies to manage it. The facility frequently ran out of supplies for wound vacs. Additionally, some of the nurses did not have the skills for managing wound vacs including Staff 9 who initiated the orders being changed for Resident 5's wound care. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated they understood the concerns related to wound vacs. No additional documentation was provided. A.) On 9/18/23 at 3:00 PM a review of Resident 5's electronic health record indicated no weekly skin and wound assessments were being completed for the resident with multiple wounds. On 9/19/23 at 9:15 AM Staff 2 (DNS) acknowledged there were no weekly skin and wound assessments of Resident 5 in the electronic health record. Staff 2 stated she thought the weekly assessments were not needed because the resident had a surgical wound. Staff 2 was notified the resident's initial wound was pressure related followed by surgical intervention and required weekly assessments. On 9/19/23 at 1:17 PM Staff 6 (NP) stated the provider's expectation for assessment of Resident 5's wound would be for the wound to be assessed weekly. An initial assessment should be completed and weekly thereafter. On 9/20/23 at 2:13 PM Staff 2 (DNS) stated she checked on the assessment issue and said the resident was a Veteran's Administration (VA) recipient and only required a skilled nursing note. Staff 2 was again notified weekly assessments were still needed for the resident even if the payor source was VA. Staff 2 indicated she understood and Staff 3 provided a handwritten page dated 9/20/23 with a description of the resident's wound measurements. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated they understood the concerns related to wound vacs and assessments. No additional documentation was provided. 2. Resident 6 was admitted to the facility 7/18/2023 with diagnoses including a Stage 4 pressure ulcer of the right buttock requiring Vacuum Assisted Closure wound therapy (wound vac). A 9/20/23 at 6:62 AM Progress Note indicated the wound vac came off due to not being covered for the resident's shower. Education was provided to resident and staff to always cover the area as it was not ideal to change the vac every day. A review of Resident 6's electronic health record revealed from 9/11/23 through 9/16/23 the resident did not have the wound vac in place because the facility did not have the necessary supplies for the wound vac. A Medication Administration note dated 9/11/23 at 7:00 PM indicated a new wound care order: clean wound with wound cleanser, pat dry, use bulky gauze, wet with sterile water and pack wound with wet gauze, cover with wound vac drape. Discontinue the order when wound vac supplies came in and were in use for resident. A Medication Administration note dated 9/12/23 at 11:11 PM indicated wound care done as ordered until vac supplies arrive. A Medication Administration note dated 9/13/23 at 11:49 PM Coccyx wound: Cleansed with wound cleanser and carefully removed mostly solid mass the size of a ping pong ball. There was mostly blood, small amount of gray, white slough, and yellowish clear mucous which started to coagulate on periwound at 4 o'clock. Sterile water and bulky gauze used to pack wound with wet gauze, cover with wound vac drape. Discontinue the order when wound vac supplies came in and were in use for resident. On 9/25/23 at 10:12 AM Witness 8 stated Resident 6's wound vac care stopped because the facility did not have the wound vac care supplies to provide the care. Witness 8 said staff could not do wound vac care without the correct supplies. On 9/25/23 at 11:26 AM Staff 6 (Nurse Practitioner) stated if there was an intervention used at the hospital but not in the SNF then there was a competency issue at the facility On 10/3/23 at 4:12 PM Witness 10 stated the main reason they did not use the wound vac was because the facility did not have the supplies to manage it. The facility frequently ran out of supplies for wound vacs. Additionally, some of the nurses did not have the skills for managing wound vacs. A review of the missing documentation for Resident 6 from the Medication Administration Audit Report for 9/1//23 through 9/18/23 revealed the following physician orders were not completed by staff: -8/9/23 2:00 PM: Monitor non blanchable red area to left hip until resolved, every day and evening shift. -8/9/23 2:30 PM: non-adherent foam dressing to left hip/buttock hold in place with tape. Change as needed for soiling. two times a day for wound prevention. -8/11/23 2:00 PM: Check skin. Indicate (+) if new condition present, (-) if no new skin condition. If new condition present, document a progress note and initiate skin documentation form every evening shift, every Friday, for prevention of skin breakdown. -8/11/23 at 2:00 PM: CBC (complete blood count), CMP (comprehensive metabolic panel), Magnesium, zinc every day and evening shift for routine labs discontinue once obtained. -8/11/23 at 2:00 PM: Left hip pressure injury: Cleanse with wound cleanser, pat dry, apply calcium alginate, cover with adherent pad until resolved. every evening shifts. -8/11/23 at 2:00 PM: Monitor scab and redness to right elbow every day and evening shift. -8/11/23 at 2:00 PM: Apply skin repair to medial left foot to redness every day and evening. -8/11/23 at 2:00 PM: Apply skin repair cream to left and right lateral great toes to redness, every day and evening shift -8/11/23 at 2:30 PM: Barrier cream to left hip for redness until resolved. Two times a day. -8/11/23 2:30 PM: Clean wound with wound cleanser, pat dry, use bulky gauze, wet with sterile water and pack wound with wet gauze, cover with wound vac drape. Change twice day. Discontinue order when wound vac supplies come in and are in use for resident, two times a day related to Pressure Ulcer of right buttock Stage 4. Discontinue order when wound vac supplies arrive. -8/14/23 2:30 PM: Left hip pressure injury, cleanse with wound cleanser, pat dry, apply calcium alginate, cover with adherent pad until resolved, every evening shift. Barrier cream to left hip for redness until resolved, two times a day. -8/29/23 2:00 PM: Left hip pressure injury, cleanse with wound cleanser, pat dry, apply calcium alginate, cover with adherent pad until resolved every evening shift. -8/29/23 2:30 PM Barrier cream to left hip for redness until resolved two times a day. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated they understood the concerns related to wound vacs. No additional documentation was provided. A. A review of Resident 6's Weekly Skin Ulcer Injury Measurement & Evaluations revealed the weekly assessments were not completed weekly or timely as evidenced by: Resident 6's first weekly assessment was due on 7/25/23 but was not completed until 8/4/23 or 17 days after initial admission. The assessment was not completed for over two weeks after the resident's admission. The second weekly assessment was due on 8/1/23 but no assessment for 8/1/23 was found in the medical record. The next assessment found in the medical record was dated 8/4/23 or 10 days after the first assessment. It was not completed in the weekly timeframe. The next two (wounds now included a second wound on the hip) weekly wound assessments due 8/9/23 were not completed until 8/14/23 which was 10 days after the previous assessment or five days late. The next two weekly assessments were completed on 8/19/23 or 10 days after the last assessment. They were not completed within the weekly timeframe. The next two weekly assessments were dated 8/25/23 or 6 days after the last assessment but were not completed until 9/8/23 or 14 days from the last assessment. They were not completed within the weekly timeframe. The last reviewed weekly assessment was dated 9/1/23 but was not completed until 9/8/23 which was the same date as the two assessments for 8/25/23. The last two separate weekly assessments were completed on the same day 9/8/23. A review of two Nutrition At Risk (NAR) Reviews for Resident 6 were completed on 9/12/23 and 9/20/23 but indicated there were errors on the weekly reviews. The errors included: No date listed, IDT attendees were not listed, the Summary of Review was not completed, Relevant Medications were not listed and the 3-month review was not completed. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated they understood the concerns related to wound vacs and assessments. No additional documentation was provided.

Based on interview and record review it was determined the facility failed to ensure Staff 2 (DNS), Staff 3 (RNCM), Staff 9 (LPN), Staff 15 (CMA) and Staff 19 (LPN) adhered to standards of practice regarding medication administration for 1 of 1 sampled residents (# 4) reviewed for significant medication error. Findings include: [NAME] 851 045 0040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. [NAME] 851 045 0050 Scope of Practice Standards for Licensed Practical Nurses indicated the following: (B) Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data; (C) Selecting appropriate nursing interventions and strategies; (d) Implement the plan of care by: (A) Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration, nursing activities, nursing, medical and interdisciplinary orders; health teaching and health counseling. [NAME] 851 045 0070 Conduct Derogatory to the Standards of Nursing Defined indicated the following: (2) Conduct related to other federal or state statute/rule violations: (3) Conduct related to communication: (h) Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse co worker) in an ongoing and timely manner; and 1. Resident 4 was admitted to the facility in 9/2023 with diagnoses including STEMI (heart attack) with stent (tube inserted to promote blood flow) placement and ischemic cardiomyopathy (reduced blood flow to the heart). A Progress Alert Note dated 9/5/23 indicated the resident was on alert charting for bleeding abnormalities related to no Plavix (blood thinner) medication for three days. On Monday 9/4/23 at 4:46 PM Witness 11 indicated Resident 4's order for Plavix was transcribed incorrectly by Staff 9 (LPN). The correct dosage was confirmed with the provider but Staff 9 did not make a note about it. The pharmacy never received the order on Friday 9/1/23. Another nurse, Staff 19 (LPN), told Witness 11 not to worry about it because the medication never came in, so the resident never got it. Witness 11 verified the pharmacy did not send the medication and the medication was not pulled from the Omnicell (medication dispensing machine). Witness 11 indicated there was a problem because Staff 3 (RNCM) and Staff 15 (CMA) both documented they administered the medication and Staff 19 documented there was no supply of the Plavix. Witness 11 stated there actually was a supply in the Omnicell for the Plavix, but no one looked there, and no one pulled it. This meant Resident 4 had not received the Plavix since admission. On 9/5/23 at 4:49 PM Resident 4 had vomited and was not verbally responding to questions. Vitals were BP 92/56, Respirations 16, Pulse 56, and Temperature 97.0. 911 was called and the resident went out to the hospital. It was not documented if the hospitalization was related to the medication error. An Incident Report dated 9/11/23 for a 9/3/23 indicated Resident 4's Plavix (blood thinner) order was transcribed incorrectly as twice a day when it should have been once a day. The transcription error was found on 9/3/23. The medication was charted as given in the morning on 9/2/23 by Staff 3 (RNCM) and in the evening of 9/1/23 and the morning of 9/3/23 by Staff 15 (CMA) but none was delivered by the pharmacy and none was pulled from the Omnicell (controlled medication dispenser). For the 9/2/23 evening dose Staff 19 documented the medication was not available. On 9/11/23 the facility determined the order for Plavix twice a day was not given despite the transcription error. The report indicated Staff 3 and Staff 15 borrowed medications from other residents and gave them to Resident 4 but no documentation or evidence was provided to verify any medication was borrowed. On 9/19/23 at 1:17 PM Staff 6 (Nurse Practitioner) stated he was told the resident was likely double dosed then later told the resident was under-dosed. He was concerned the resident did not get enough medication. Staff 6 stated You cannot make that mistake, with that medication. On 9/25/23 at 11:13 AM Staff 9 indicated she transcribed the Plavix order incorrectly and the resident went three days without the Plavix. He went out to the hospital shortly after it happened but she was not sure why. On 9/27/23 at 10:03 AM Staff 15 (CMA) said she only remembered giving the medication one time. She stated emphatically she did not give the resident the medication on 9/3/23. Staff 15 said someone told her to borrow the medication from another resident. Staff 15 said she did not remember who told her to borrow medications and she did not remember which resident she took the medications from. No documentation was found in the medical record to indicate Staff 15 took medications from another resident to administer to Resident 4 and facility nursing staff were monitoring Resident 4 for not receiving the medication. On 9/27/23 at 10:06 AM Staff 19 (LPN) stated she charted no medication was available on 9/2/23. She did not give the Plavix because they did not have it. It was a wrong order. A CMA told her they did not have it, so she did not check the Omnicell. Staff 19 stated she did not tell anyone to take the medication from another resident. On 9/27/23 at 10:40 AM Staff 3 (RNCM) stated she did not go to the Omnicell to check for the Plavix, she took medication out of another resident's card to give to the resident. Staff 3 said she understood borrowing medications from another resident was not acceptable. She also said she did not replace the medication in the other resident's card. Staff 3 said she could not speak for anyone else but she had done it before (taken medications from other residents) a number of times. Staff 3 said she was aware it was not a nursing standard of practice but she was more concerned about getting medication administration done. No documentation was found in the medical record to indicate Staff 3 took medications from another resident to administer to Resident 4. A facility Medication Error Report dated 9/4/23, completed by Staff 2, failed to include Staff 3 on the list of staff involved in the medication error. The report indicated the original error was only a transcription error. The medication was not delivered over the weekend. No one pulled the medication from the Omnicell and no satellite delivery was available. The medication was charted as given by Staff 15 on 9/1/23 and 9/3/23 and by Staff 3 on 9/2/23. Staff 19 noted no supply on 9/2/23. The facility was unable to determine if any doses were given. A facility document dated 9/7/23 generated by a Regional Nurse Consultant indicated Staff 2 (DNS) insisted the medication was given to the resident although the medication was not available. Staff 2 said it could have been borrowed from another patient. Staff 2 was told written statements were needed as to where the nurse and CMA got the medication to administer but no written statements were received. The document indicated there was a lack of a thorough investigation by Staff 2 and an investigation into the medication administration in the facility was pending. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified regarding the professional standards concerns. No additional documentation was provided. 2. Based on interview and record review it was determined the facility failed to ensure Staff 2 (DNS), Staff 3 (RNCM) and Staff 9 (LPN) met professional standards for ensuring pressure ulcers were appropriately assessed and treated for 2 of 2 sampled residents (#s 5 and 6) reviewed for pressure ulcers. This placed residents at risk for further skin deterioration and delayed healing of wounds. Findings include: a. Resident 5 was admitted to the facility in 8/2023 with diagnoses including Fournier's gangrene (rare but deadly infection of the genital and perineum) and Vacuum Assisted Closure wound therapy (wound vac) for perirectal abscess wound. A hospital Wound Consult note dated 8/22/23 indicated a recommendation for wound vac therapy to encourage granulation tissue formation (development of new tissue and blood vessels), to increase the rate of healing, and to decrease the chance of complications including infection. There was enough skin between the wound edges and the anus to seal the wound vac dressing and withstand the presence of stool if loose stools occurred. There were multiple options for vac placement to avoid the dressing from being close to the anus and it would be very difficult to keep the wound clean without the vac's airtight waterproof dressing. Other therapies were ruled out related to the resident's presence of co-morbidities, high risk of infection, need for accelerated granulation tissue and history of delayed wound healing. An 8/31/23 at 2:52 PM Progress Note by Staff 9 indicated the resident's wound vac continuously came unsealed. Staff 9 called the on-call provider and told the provider multiple nurses had been unable to get the wound vac to seal, and she obtained new orders for a standard wet-to-dry dressing. No documentation was found in the medical record to indicate any nurses, except Staff 9, attempted to place the wound vac. Seven of the nine members of the licensed nursing floor staff were interviewed and indicated they had not attempted to place the wound vac as described by Staff 9. On 9/4/23 at 4:46 AM Witness 11 indicated Staff 6 (NP) was very concerned about Resident 5's wound and the treatment being provided. Staff 6 told Witness 11, unless the facility got the wound vac on quickly, he wanted the surgeon to be contacted to find out what else could be done or Resident 5 needed to discharge to a place where she/he could receive the appropriate wound care. Staff 6 also stated the wet-to-dry was not appropriate for the type of wound the resident had and was only a temporary measure while waiting for wound vac supplies. On 9/19/23 at 1:17 PM Staff 6 (NP) stated Resident 5 had Fournier's gangrene which was a rare but life-threatening infection. The resident had a long-term perineum wound which needed negative pressure (wound VAC). The wet-to-dry would not assist in wound healing because there was a massive cavity. Staff 6 said he requested a surgeon consult because the wet-to-dry was not effective for the type of wound involved. Staff 6 said he was told multiple nurses tried to obtain a seal but could not. Staff 6 was not aware Staff 9 was the only staff member who had trouble with the wound vac and multiple nurses had not attempted to place the vac. On 9/25/23 at 10:12 AM Witness 8 stated Resident 5's wound vac care stopped because the facility did not have the wound vac care supplies to provide the care. Witness 8 looked in the supply closet in the DNS's office but there were no wound vac supplies. Witness 8 said staff could not do wound vac care without the correct supplies and Staff 2 was responsible for ordering the wound vac supplies for the facility. On 9/25/23 at 11:26 AM Staff 6 (NP) was notified there was not an issue with the wound vac sealing as he had been informed by Staff 9, there was an issue of the facility not having the necessary wound vac supplies to manage the wound care and some nursing staff did not have adequate training to manage the wound vac treatments. Staff 6 stated if there was an intervention used at the hospital but not in the SNF then there was a competency issue at the facility. Staff 6 said groins and abdomens needed negative wound pressure for the greatest healing outcomes. On 9/25/23 at 1:10 PM Resident 5 indicated she/he was started on the wound vac at the hospital and it had worked great. Staff 9 told Resident 5 she could not get the wound vac to work and mentioned they had trouble getting supplies for the vac so they stopped using the wound vac. On 9/29/23 at 5:06 PM Witness 11 stated she did not try to place the wound vac for Resident 5. Witness 11 also stated the wet-to-dry was not appropriate for the wound. Witness 11 stated nursing staff just did not want to deal with the wound vac and they did not have adequate wound vac supplies. Witness 11 said she had looked for documentation in the medical record of nurses other than Staff 9 attempting to place the vac but found no documentation. On 10/3/23 at 4:12 PM Witness 10 stated she did not attempt to place the wound vac and the main reason they did not use the wound vac was because the facility did not have the supplies to manage it. The facility frequently ran out of supplies for wound vacs. Additionally, some of the nurses did not have the skills for managing wound vacs including Staff 9 who initiated the orders being changed for Resident 5's wound care. b. On 9/18/23 at 3:00 PM a review of Resident 5's electronic health record indicated no weekly skin and wound assessments were completed for the resident. On 9/19/23 at 9:15 AM Staff 2 (DNS) acknowledged there were no weekly skin and wound assessments of Resident 5 in the electronic health record. Staff 2 stated she thought the weekly assessments were not needed because the resident had a surgical wound. Staff 2 was notified the resident's initial wound was pressure related followed by surgical intervention and required weekly assessments. On 9/20/23 at 2:13 PM Staff 2 (DNS) stated she checked on the assessment issue and said the resident was a Veteran's Administration (VA) recipient so only required a skilled nursing note. Staff 2 was again notified weekly assessments were still needed for the resident even if the payor source was VA. Staff 2 indicated she understood and had Staff 3 provide a handwritten page dated 9/20/23 with a description of the resident's wound measurements. 3. Resident 6 was admitted to the facility 7/18/2023 with diagnoses including a Stage 4 pressure ulcer of the right buttock requiring Vacuum Assisted Closure wound therapy (wound vac). A review of Resident 6's electronic health record revealed from 9/11/23 through 9/16/23 the resident did not have the wound vac in place because the facility did not have the necessary supplies for the wound vac. On 9/25/23 at 11:26 AM Staff 6 (NP) 6 stated if there was an intervention used at the hospital but not in the SNF then there was a competency issue at the facility. On 10/3/23 at 4:12 PM Witness 10 stated the main reason they did not use the wound vac was because the facility did not have the supplies to manage it. The facility frequently ran out of supplies for wound vacs. Additionally, some of the nurses did not have the skills for managing wound vacs. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated they understood the concerns related to wound vacs. No additional documentation was provided. a. A review of Resident 6's Weekly Skin Ulcer Injury Measurement & Evaluations from 7/25/23 through 9/1/23 revealed the assessments were not completed weekly and the initial assessment was not completed for 17 days after the resident's admission on 7/19/23. As of 8/9/23 the resident had two weekly wound assessments the first for the original right buttock wound and a new one for a left hip wound. The assessments for both wounds were dated 8/9/23 but were not completed until 8/14/23 which was 10 days from the last assessment for the first wound. The weekly wound assessments reviewed were being completed 10-14 days apart and not the required seven days. The last three wound assessments reviewed (with two dated 8/25/23 and one 9/1/23) were all completed on the same date of 9/8/23. The review revealed the Weekly Skin Ulcer Injury Measurement & Evaluations completed by Staff 3 were not being done timely. On 10/9/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) indicated they understood the concerns related to wound vacs and assessments not being timely. No additional documentation was provided. Refer to F686 and F760

Based on interview and record review it was determined the facility failed to ensure staff provided a safe mechanical lift transfer during care for 1 of 3 sampled residents (#11) reviewed for accidents. Resident 11 sustained a pelvic fracture and bilateral leg fractures. Findings include: Resident 11 admitted to the facility in 7/2015 and readmitted on ,d+[DATE] with diagnoses including a pelvic fracture and bilateral leg fractures. An 8/9/23 Fall Incident Report revealed the following: -Resident 11 fell out of a mechanical lift during a two-person transfer. -Staff 8 (CNA) and Staff 24 (CNA) were getting Resident 11 ready for her/his smoke break, the bottom left side of the sling came off the hook. Resident 11 hit her/his head on the bottom of the bed, Staff 8 ran out of the room for help, and Staff 24 stayed with the resident. -Resident 11 was alert and talking and stated, I fell out and hit my head on the bed, but it is my legs and lower back that are hurting. Staff were unable to move Resident 11 due to her/his yelling out in pain and waited for the paramedics to arrive. -Resident 11 was sent to the hospital and it was revealed she/he sustained a pelvic fracture and bilateral hip fractures. -Staff 8 and Staff 24 were interviewed and indicated they were almost finished with the transfer when they turned Resident 11's feet in order to get her/him into the wheelchair and the bottom left sling loop came undone and the resident fell to the floor. -The care plan was followed and Staff 8 and Staff 24 were present during the time of the transfer. The sling was inspected and was not found to be faulty, and all the sling loops were intact. Staff 8 and Staff 24 were not sure how the incident happened. -It was determined the incident were isolated and abuse and neglect was ruled out. On 8/21/23 at 3:06 PM Staff 6 (LPN) stated she was present on 8/9/23 and entered Resident 11's room and she/he was flat on her/his back with her/his head pointed towards the bed and feet towards the door. Staff 6 indicated Resident 11 was not crying but stated her/his back and legs hurt. Staff 6 stated Resident 11 had severe pain when staff attempted to move her/him and tried to keep her/him comfortable until the paramedics arrived and she/he was transported to the hospital. Staff 6 indicated the left bottom strap came undone somehow during the mechanical lift transfer. On 8/21/23 at 4:41 PM Staff 8 (CNA) stated she assisted with the mechanical lift transfer on 8/9/23 when Resident 11 fell out of the mechanical lift. Staff 8 stated she and Staff 24 were getting Resident 11 up for her/his usual smoke break and once Resident 11 was in the mechanical lift they started to move her/his feet and the left sling loop came off the mechanical lift (the hook) and Resident 11 fell to the floor. Staff 8 stated Resident 11 kind of bounced onto her/his bottom and then fell down onto her/his left side on the floor. Staff 8 stated she stayed with the resident and Staff 24 went for help. Staff 8 indicated they could not move Resident 11 because she hollered ouch, ouch. Staff 8 stated they followed the care plan, were not rushed during the transfer but was not sure what happened because it happened so fast. On 8/22/23 at 9:46 AM Staff 24 stated she helped transfer Resident 11 on 8/9/23 and previously transferred Resident 11 multiple times in the mechanical lift. Staff 24 stated Staff 8 assisted with the transfer and they had Resident 11 hooked up to the mechanical lift using a sling. Staff 8 stated once they started to move Resident 11 closer to the wheelchair she/he fell out of the sling because one of the leg loops came off. Staff 24 stated Resident 11 fell on to her/his butt first and then fell on to her/his back on the floor. Staff 8 stated we were all in shock because it happened so fast. Staff 24 stated she ran out of the room for assistance and Resident 11 was transported to the hospital. On 8/22/23 at 2:23 PM Staff 3 (RNCM) stated she entered Resident 11's room and found the resident on the floor. Staff were unable to move her/him due to how painful she/he was. Staff 3 stated Resident 11 kept saying dammit get me off the floor, but when staff attempted to move her/him she/he screamed out in pain. Staff 3 stated the paramedics arrived and transported her/him to the hospital. Staff 3 stated the mechanical lift was not faulty and the sling was in good working condition but the left sling loop came off of the hook somehow. On 8/23/23 at 10:08 AM Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 2 stated Staff 8 alerted her of the incident on 8/9/23 and she entered Resident 11's room and assessed the resident. Staff 2 stated the sling was still underneath the resident but they were not able to move her/him due to the resident being uncomfortable. Staff 2 indicated Resident 11 was cool as a cucumber but was painful when and if she/he was moved. Staff 2 stated Resident 11 was transported to the hospital and fractured both of her/his legs and sustained a pelvic fracture. Staff 1 and Staff 2 stated this was an isolated incident and indicated the sling and mechanical lift were in good working condition. Staff 1 and Staff 2 stated it was determined the loop slipped off the mechanical lift during the transfer which caused the fall. Staff 1 and Staff 2 indicated Staff 8 and Staff 24 were re-educated to ensure the sling loops to the mechanical lift were all secured prior to moving any resident. Staff 1 and Staff 2 stated this was an unfortunate accident.

Based on interview and record review it was determined the facility failed to ensure residents were free from neglect of care for 1 of 1 resident (#501) reviewed for pressure ulcers. A resident was left on a bedpan for an extended time resulting in bruising of the buttocks which opened into two unstageable pressure ulcers and increased pain for the resident. Findings include: The facility's Abuse/Neglect/Misappropriation/Exploitation policies and procedures revised date of 10/2017 defined an Adverse Event as an untoward, undesirable, and usually an unanticipated event that causes death or serious injury or the risk thereof. Examples included: medication errors, injury due to falls, injuries due to abuse or neglect by caregivers or other residents, failure to identify acute change in condition, pressure ulcers due to inappropriate care and the spread of disease due to errors infection prevention and control. Resident 501 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A facility investigation dated 1/17/19 at 10:51 AM for an incident which occurred on 1/13/19 indicated Resident 501 with bruise on buttock related to extended bed pan use. The resident had requested to use a bedpan during night shift (10:00 PM to 6:00 AM) and was not removed from the bedpan until a day shift CNA (6:00 AM to 2:00 PM) removed the bedpan. Injuries observed at the time of incident included; abrasion to right buttock, bruise to left buttock and bruise to sacrum (triangular bone at the base of the spine). The incident report did not include details of who put the resident on the bedpan and at what time, who took the resident off the bedpan and at what time, additional staff involved were not identified, witness statements were not included and no risk analysis was completed. The National Pressure Ulcer Advisory Panel defined the following pressure injury stage: Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. An Initial Skin Ulcer Assessment with onset of wound dated 2/15/19 revealed Resident 501 had a facility acquired Unstageable pressure ulcer to the left buttock and pain was present. Tunneling (channels extend from a wound into and through subcutaneous tissue or muscle) and bloody drainage were present and the area around the wound was macerated (softening and breaking down of skin). The wound measured 2.25 cm (length) x 5 cm (width) x 7 cm (depth). Note: If a wound is determined to be Unstageable the depth is obscured. An Initial Skin Ulcer Assessment with onset of wound dated 2/20/19 revealed Resident 501 also had a facility acquired Unstageable pressure ulcer to the right buttock and pain was present. Tunneling, undermining (tissue under the wound edges becomes eroded resulting in a pocket beneath the skin) and bloody drainage was present. The wound measured 7 cm (length) x 7 cm (width) x 4 cm (depth). Note: if a wound is considered Unstageable the depth is obscured. A Physician order [REDACTED]. If a new condition was present document a progress note and initiate skin documentation form every evening shift, every Sunday for prevention of skin breakdown. No initial progress note was located indicating staff identified a new skin condition. On 1/13/19 at 1:17 PM a Nursing Progress Note indicated Resident 501 did not wish family to be called about the bruise as it did not hurt and would be fine. Staff would monitor the bruise until it was resolved. There was no information in the nursing progress notes to indicate what bruise staff was referring to, when or how the bruise occurred, no description of the bruising, location or measurements and no other progress notes in (MONTH) referring to the bruise or specific monitoring of the bruise. No nursing progress notes for Resident 501 were made between 1/18/19 through 1/24/19 (seven days) for the resident who was to be monitored for the significant bruising which occurred on 1/13/19. In (MONTH) on 2/15/19 at 11:23 AM a Nursing Progress Note indicated the resident was found to have opening in the left buttock were bottom of hematoma existed which is now absent. The opening is on the same side of the former pressure wound location. Opening is 2 cm x 2 cm x 3.5 cm with tunneling going towards 9 o'clock angle at length of 7 cm. Wound cleansed, packed with alginate, and dressed with resident tolerant well. Family notified. Resident continued on antibiotics. Blood saturated through prior dressing on left side. Right hematoma appears to be continuing to heal with periphery filling in and wound bed showing fresh skin on the outskirts of the existing hematoma. A 2/23/19 at 12:22 PM Nursing Progress Note indicated the resident was severely painful when attempting wound care. On 4/10/19 at 10:23 AM Staff 5 (LPN/RCM) acknowledged there was not enough information in the facility investigation to be thorough or comprehensive or to rule out neglect of care. She indicated she gave her investigation to Staff 2 (DNS) but was not aware of what Staff 2 did with it. Staff 5 said she did not report the incident and she was aware she was a mandatory reporter.

Based on interview and record review it was determined the facility failed to prevent the development of pressure ulcers for 1 of 1 resident (#501) reviewed for pressure ulcers. This resulted in Resident 501 developing two unstageable pressure ulcers and experiencing pain. Findings include: The National Pressure Ulcer Advisory Panel defined the following pressure injury stages: Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident 501 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A facility investigation dated 1/17/19 at 10:51 AM for an incident which occurred on 1/13/19 indicated Resident 501 with bruise on buttock related to extended bed pan use. The resident requested to use a bedpan during night shift (10:00 PM to 6:00 AM) staff and was not removed from the bedpan until a day shift CNA (6:00 AM to 2:00 PM) removed the bedpan. Injuries observed at the time of incident included; abrasion to right buttock, bruise to left buttock and bruise to sacrum (triangular bone at the base of the spine). The incident report did not include details of who put the resident on the bedpan and at what time, who took the resident off the bedpan and at what time, additional staff involved were not identified, witness statements were not included and no risk analysis was completed. An Initial Skin Ulcer Assessment with onset of wound dated 2/15/19 revealed Resident 501 had a facility acquired Unstageable pressure ulcer to the left buttock and pain was present. Tunneling (channels extend from a wound into and through subcutaneous tissue or muscle) and bloody drainage was present and the area around the wound was macerated (softening and breaking down of skin). The wound measured 2.25 cm (length) x 5 cm (width) x 7 cm (depth). It should be noted that if a wound is determined to be Unstageable the depth would be obscured. An Initial Skin Ulcer Assessment with onset of wound dated 2/20/19 revealed Resident 501 also had a facility acquired Unstageable pressure ulcer to the right buttock and pain was present. Tunneling, undermining (tissue under the wound edges becomes eroded resulting in a pocket beneath the skin) and bloody drainage was present. The wound measured 7 cm (length) x 7 cm (width) x 4 cm (depth). Note: if a wound is considered Unstageable the depth is obscured. On 4/10/19 at 11:24 AM Staff 4 (RNCM) indicated she was notified by a CNA the resident was left on the bedpan. The CNA reported she did not receive report (CNA to CNA communication) from the outgoing CNA on night shift regarding the resident being on a bedpan. Staff 4 saw the edges of the bedpan were imprinted on the resident's buttocks and there was some small initial bruising which at first had a small area involved but about a week later it changed and got worse. A Physician order [REDACTED]. If a new condition was present document a progress note and initiate skin documentation form every evening shift, every Sunday for prevention of skin breakdown. No initial progress note was located indicating staff identified a new skin condition. On 1/13/19 at 1:17 PM a Nursing Progress Note indicated Resident 501 did not wish family to be called about the bruise as it did not hurt and would be fine. Staff would monitor the bruise until it is resolved. There was no information in nursing progress notes to indicate what bruise staff was referring to, when or how the bruise occurred, no description of the bruising, location or measurements and no other progress notes in (MONTH) referring to the bruise or specific monitoring of the bruise. No nursing progress notes for Resident 501 were made between 1/18/19 through 1/24/19 (seven days) for the resident who was to be monitored for the significant bruising which occurred on 1/13/19. A 2/15/19 at 11:23 AM a Nursing Progress Note indicated the resident was found to have opening in the left buttock were bottom of hematoma existed which is now absent. The opening is on the same side of the former pressure wound location. Opening is 2 cm x 2 cm x 3.5 cm with tunneling going towards 9 o'clock angle at length of 7 cm. Wound cleansed, packed with alginate, and dressed with resident tolerant well. Family notified. Resident continued on antibiotics. Blood saturated through prior dressing on left side. Right hematoma appears to be continuing to heal with periphery filling in and wound bed showing fresh skin on the outskirts of the existing hematoma. A 2/23/19 at 12:22 PM Nursing Progress Note indicated the resident was severely painful when attempting wound care. On 4/9/19 at 1:23 PM Witness 3 (family) stated in mid-January the resident was left on a bedpan for over three hours. Facility staff did not tell Witness 3 about it until mid-February. The resident's bottom had a bruised ring around it. Witness 3 reported she/he took pictures of the resulting pressure ulcers (provided to surveyor). Staff told me the old wound had opened again, not that there were new wounds. By the end of (MONTH) the DNS called and indicated the resident was not thriving and Resident 501 was admitted to Hospice. On 4/10/19 at 10:16 AM Staff 8 (CNA) indicated Staff 9 (CNA) found the resident who was on the bedpan for over 3 hours. Staff 8 stated she stayed with residents when they were on bedpans until they were done but she knew some CNA's did not. On 4/10/19 at 10:45 AM Staff 9 (CNA) indicated she found the resident on the bedpan around 7:30 AM. Staff 9 came to work at 6:00 AM and stated she did not get information during report (CNA to CNA communication) to indicate the resident was on the bed pan. Staff 9 also stated, the resident did not know she/he was already on a bedpan. Staff 9 took the resident off the bedpan and observed the resident's skin was indented with an outline of the bedpan. She saw the resident had light bruising in the shape of the bed pan and later Staff 9 indicated she saw the resident's wounds and they were shaped like the bed pan. On 4/10/19 at 11:24 AM Staff 4 (RNCM) indicated she was notified by the CNA the resident was left on the bedpan. Staff 4 saw the edges of the bedpan imprinted on the resident's buttocks and at first there was just a small area involved but about a week later it changed and got worse. On 4/17/19 at 1:05 PM Staff 11 (RN) stated she was not there for the initial incident but when she first saw the wounds there were two darkened thin markings which appeared to be the outline of a bedpan. On 4/10/19 at 10:00 AM Staff 3 (RNCM) indicated the resident was found on the bedpan during day shift morning cares and was placed on the bedpan on night shift. Staff 3 indicated it was likely the hematomas resulted in the pressure ulcer development. On 4/10/19 at 10:23 AM Staff 5 (LPN/RCM) acknowledged it was possible the pressure ulcers were related to the resident being left on the bedpan.

Based on observation, interview and record reviewed it was determined the facility failed to consistently implement interventions for the prevention of pressure ulcers for 1 of 2 sampled residents (#44) reviewed for pressure ulcers. This resulted in the development of an unstageable (the depth of the wound cannot be determined) pressure ulcer. Findings include: Resident 44 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A care plan dated 8/3/18 addressed alteration in skin related to a surgical wound on the left hip and was revised on 9/17/18 to include an unstageable pressure ulcer to the coccyx (tailbone). Care plan interventions included to encourage repositioning every 2 to 3 hrs., provide incontinent care, weekly skin checks, pressure reduction mattress, PT eval and treat for pressure relief, refer to nutrition care plan. A revision to the care plan on 9/17/18 included an alternating air mattress and a goal of no new skin breakdown. A Significant Change of Condition MDS dated [DATE] indicated Resident 44 did not currently have pressure ulcers. The corresponding Pressure Ulcer CAA indicated Resident 44 was end of life, precautions were in place to help prevent breakdown, noted incontinence and included a care plan would be developed but did not include a goal for the problem. On 9/13/18 at 4:56 AM a new skin issue report documented an open area on Resident 44's coccyx. There were no predisposing physiological factors identified. An investigation note dated 9/14/18 concluded Resident 44 complained of pain, staff reported she/he did not like to be moved around, the care plan was in place and followed with an additional plan to add a protein supplement. On 9/14/18 at 11:23 AM an Initial Skin Ulcer Assessment documented a facility acquired unstageable pressure ulcer to the coccyx measuring 1 cm by 1 cm. The assessment further noted the wound bed could not be visualized due to being covered with 100% slough (dead tissue, soft and pale in color). On 9/21/18 at 1:57 PM a Weekly Skin Ulcer Measurement Wound Evaluation described the same information from the 9/14/18 Initial Skin Ulcer Assessment document and noted no change to the wound. On 9/25/18 at 8:09 AM Resident 44 was observed lying on her/his back with the head of the bed slightly elevated. Resident 44 acknowledged having a pressure ulcer developed about a month ago and believed it was from lying in bed and denied pain. Observations of Resident 44 on 9/25/18 at 10:57 AM, 9/26/18 at 11:50 AM, 9/26/18 at 3:28 PM and 9/27/18 at 8:53 AM revealed Resident 44 lying on her/his back with the head of the bed elevated at various levels dependent on whether Resident 44 was watching TV or eating. On 9/26/18 at 3:21 PM Staff 14 (CNA) stated she was not aware of Resident 44 refusing care or having any skin problems. On 9/26/18 at 3:30 PM Staff 15 (CNA) stated Resident 44 preferred to lie on her/his back but would allow staff to move her/him. Staff 15 further indicated she was aware the resident would develop a rash frequently. On 9/27/18 at 1:51 PM Staff 16 (CMA) stated she was not aware of any refusals of care from Resident 44 or if Resident 44 had any skin issues. On 9/27/18 at 2:57 PM Staff 17 (CMA) stated he was not aware of Resident 44 having any skin issues. On 9/27/18 at 4:18 PM Staff 18 (RN) stated Resident 44 had a wound on the coccyx, she/he was fearful to turn but had not experienced Resident 44 refusing care. On 9/28/18 at 8:58 AM during a wound care observation Resident 44 was lying on her/his back and no positioning pillows or devices were in place. Resident 44 appeared fearful and the CNA encouraged and explained the need to turn her/him. The wound appeared to be approximately 0.2 cm by 0.5 cm in size. The center appeared dry and pale. The surrounding tissue was pale and without open areas, redness or signs or symptoms of infection. Record review for Resident 44 indicated she/he did not refuse turning or repositioning to get her/him off the pressure ulcer. On 9/28/18 at 11:20 AM Staff 1 (DNS) stated there was an area in the medical record for staff to document refusals of care but there was no documentation found indicating Resident 44 refused care.

Based on interview and record review it was determined the facility failed to comprehensively assess, provide estimated fluid needs and monitor all fluid intake and output to maintain hydration status for 2 of 3 sampled residents (#s 1 and 3) reviewed for a change of condition. Residents 1 and 3 experienced a change of condition which required hospitalization and were diagnosed with [REDACTED]. 1. Resident 1 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of a ADL CAA dated 9/23/14 revealed the resident was admitted to the facility after a fall at home with weakness, decrease mobility, indwelling catheter and the need for extensive assistance with ADLs. The CAA indicated the resident was at risk for a nutritional imbalance. Review of a Dehydration/Fluid Maintenance CAA dated 9/23/14 revealed the resident had experienced constipation since admission to the facility and was at risk for a fluid imbalance. The CAA indicated a care plan would be developed related to the risk for constipation. The CAA did not include an analysis of the resident's risk and contributing factors for potential dehydration. Review of a nutritional assessment dated [DATE] revealed the resident was at high risk for a nutritional imbalance and had an estimated fluid need of 1700 cc's per day. The assessment indicated the facility would monitor wieght and intake. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of a comprehensive care plan dated 12/19/14 revealed the resident was at risk for potential alteration in nutrition and hydration. The facility's goals were for the resident to show no signs or symptoms of a fluid imbalance and receive adequate nutrition/hydration. Staff interventions included offer fluids between meals, monitoring food and fluid intake each meal and monitor for signs and symptoms of dehydration i.e. concentrated urine, decreased urine output, vital signs changes and an altered level of consciousness. There was no documentation in the resident's clinical record fluids were offered to the resident between meals. Review of a daily fluid intake and output record for February and March 2015 which includes meals, supplements and 120 cc's of fluid with medications: [REDACTED] 2/24/15 input was 1520 cc's and output was 1700 cc's 2/25/15 input was 1270 cc's and output was 775 cc's 2/26/15 input was 955 cc's and output was 800 cc's 2/27/15 input was 1370 cc's and output was 925 cc's 2/28/15 input was 1040 cc's and output was 675 cc's 3/1/15 input was 1060 cc's and output was 480 cc's 3/2/15 input was 300 cc's and output was 200 cc's There was no documentation the facility identified the resident's fluid input of less than 1700 cc's and decreased fluid intake and output from 2/27/15 through 3/2/15. Review of a Meal Monitor Flow Sheet for 3/1/15 the resident ate 100% of breakfast, 25% of lunch and 10% of dinner. The resident drank a total of 580 cc's of fluids. Review of a Meal Monitor Flow Sheet for 3/2/15 revealed the resident refused breakfast and lunch and was out of the facility for dinner. The sheet indicated the resident drank no fluids for breakfast or lunch. Review of the resident's clinical record revealed no nursing notes from 2/12/15 through 3/1/15. Review of a Meal Monitor Flow Sheet for February and March 2015 revealed the resident was offered a nighttime snack or supplement and documented as not accepted by the resident every day from 2/1/15 through 3/2/15. Review of a Vital Signs & Weight Flow Sheet revealed no daily documentation of blood pressure, temperature, pulse, respiration's or blood oxygen saturation after 1/2/15. Review of an ADL Flow Record for 3/2/15 revealed the resident had slept all shift. Ref (refused) all meals. The flow sheet did not indicate the resident's urine was dark colored. Review of a nursing note dated 3/2/15 at 4:00 pm revealed the resident was unresponsive with lung congestion and a cough. The resident's temperature was 101.5 degrees and received Tylenol. The note indicated a resident family member was at the resident's bedside and wanted to send the resident to the emergency room . The note indicated 911 was called and the resident was transported to a local hospital. Review of a hospital note dated 3/2/15 revealed the resident was seen for a fever and altered level of consciousness. The note indicated the resident was barely responsive and the resident's catheter bag was filled with a brownish colored concentrated urine. The resident's creatinine (test for kidney function and a indicator of potential dehydration) was 5.16 (resident's baseline level was 0.83). The note also indicated the resident was diagnosed with [REDACTED]. In an interview on 6/2/15 at 9:35 am Staff 1 (Resident Care Manager Assistant) said the resident was alert and able to make needs known. Staff 1 said the resident was able to eat and drink independently. Staff 1 said the resident received additional fluids when administered medications of 120 cc's. Staff 1 acknowledged the lack of nursing notes from 2/12/15 to 3/1/15 and said the facility did not chart daily unless the resident was on alert charting or receiving skilled care. In an interview on 6/2/15 at 10:35 am Witness 1 (Family Member) said she/he visited the resident on 3/2/15 and found the resident non-responsive. Witness 1 informed the charge nurse and the charge nurse was not able to wake the resident up. Witness 1 said the resident had a fever, was sweating and the resident's bed was wet. Witness 1 said the resident had not eaten breakfast or lunch and the resident's catheter bag contained dark brown urine. Witness 1 said the resident was dehydrated and requested the facility send the resident to a local hospital for evaluation. In an interview on 6/2/15 at 1:00 pm Staff 2 (RN) said he did not remember the resident. Staff 2 said if a resident's urine was dark colored it would be documented in the nursing notes and the CNAs were responsible for reporting any changes of condition to the charge nurse. In an interview on 6/2/15 at 1:15 pm Staff 6 (CNA) said if the resident urine had been dark it would have been noted on the back of the ADL sheet. Staff 6 said the CNAs document fluid intake for meals on the Meal monitor and report the totals on each shift to nursing. Staff 6 said the total fluid input for the day is documented by nursing on the Intake and Output Record sheet. In an interview on 6/3/15 at 9:34 am Staff 3 (CNA) said the resident was able to make needs known and remembered the resident was sleeping a lot more prior to going to the hospital. In an interview on 6/3/15 at 2:00 pm Staff 4 (CNA) said on 3/1/15 the resident ate all of breakfast and did not eat much for lunch. Staff 4 said the resident kept telling her she/he was not fell ing well and seemed confused. Staff 4 said if the resident refused a meal she would report to the charge nurse who would document in the nursing notes. Staff 4 said if there was a change in color of the resident's urine she would report to the charge nurse. Staff 4 did not notice a change in the resident's urine color. Staff 4 said nursing was responsible for charting on the input and output sheets and reviewing any changes in input or output. In an interview on 6/2/15 at 2:15 pm Staff 5 (DNS) acknowledged there was no documentation of the resident's daily vital signs for February and March 2015. In an interview on 6/3/15 at 1:19 pm Staff 5 said input and output is only documented to ensure the resident's catheter was functioning properly. Staff 5 said the facility was not documenting strict input and output which would include all fluids received by the resident. Staff 5 said the resident was not on strict input and output monitoring. In an interview on 7/13/15 Staff 5 indicated there was no documentation the resident was offered fluids between meals. 2. Resident 3 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of a nutritional assessment dated [DATE] revealed the resident was at high risk for a nutritional imbalance and had an estimated fluid need of 2600 cc's per day. The assessment indicated the facility would monitor weight and intake. The assessment did not include an analysis of the resident's increased risk for dehydration due to [MEDICATION NAME] administration. Review of a Dehydration/Fluid Maintenance CAA dated 3/27/15 revealed the resident was admitted to the facility for therapy and IV antibiotics. The CAA indicated the resident was at risk due to weakness, decreased mobility, dehydration and the need for ADL support. The CAA did not include an analysis of the resident's increased risk of dehydration due to [MEDICATION NAME] administration. Review of a comprehensive care plan dated 4/9/15 revealed the resident had the potential for alteration in nutrition and hydrations due to [MEDICAL CONDITION] and the need for a specialized diet. Contributing factors included bacteremia, diabetes and hypertension. The facility goals for the resident included no signs or symptoms of a fluid imbalance and receiving adequate hydration. Staff interventions included offering fluids between meals, monitoring food and fluid intake at each meal and monitoring for signs and symptoms of dehydration (i.e. concentrated urine, decrease urine output, altered level of consciousness and vital sign changes). Review of a Intake and Output record revealed daily fluid intake and output was documented from 3/20/15 through 3/24/15. There was no documentation of the daily fluid input or output for the resident from 3/24/15 through 5/3/15. Review of a Meal Monitor Flow Sheet for April and May 2015 revealed the fluid intake for: 4/26/15 was 1720 cc's 4/27/15 was 1040 cc's 4/28/15 was 720 cc's 4/29/15 was 1200 cc's 4/30/15 was 1200 cc's 5/1/15 was 1880 cc's 5/2/15 was 480 cc's 5/3/15 was 480 cc's The flow sheet also indicated the resident refused lunch and dinner on 5/2/15 and breakfast and dinner on 5/3/15. Review of the resident clinical record revealed no documentation the facility identified the resident's fluid intake of less than 2600 cc's from 4/26/15 through 5/3/15. Review of a nurse's note dated 5/2/15 at 9:10 pm revealed the resident continued to have vomiting and staff would monitor. Review of a lab report dated 5/2/15 at 10:32 pm revealed a creatinine (lab value indicating kidney function and potential dehydration) level of 4.14 (normal 0.6 to 1.2). Review of a nurse's note dated 5/3/15 at 4:30 am revealed the resident was restless and complained of nausea. Water sips helpful for nausea and staff would continue to monitor. Review of a nurse's note dated 5/3/15 at 1:10 pm revealed the resident was in bed sleeping with some nausea in the morning. Review of a nurse's note dated 5/3/15 at 5:12 pm revealed a telephone call from the resident's physician who requested the facility send the resident to the emergency room for acute kidney failure. At 6:45 pm the resident left via ambulance to a local hospital and the resident's family was informed. Review of a emergency department note dated 5/3/15 revealed the resident was seen for generalized weakness and abnormal lab results. The note indicated the resident had nausea, vomiting and palpitations. Review of a hospital history and physical note dated 5/3/15 revealed the resident was seen at a local hospital due to abnormal lab results. The note indicated the resident creatinine was 4.32 (normal 0.6 to 1.2). The resident was diagnosed with [REDACTED]. In an interview on 6/3/15 at 1:00 pm Staff 1 (Resident care Manager Assistant) said the resident was only monitored for urine output for the first three days of admission. Staff 1 the CNAs would notify the charge nurse if the resident had not voided at all and there was no way to tell if the resident had decreased urine output. Staff 1 acknowledged the resident had decreased fluid intake prior the resident being sent to the hospital and the decreased intake could have contributed to the resident being dehydrated. In an interview on 7/13/15 Staff 5 indicated there was no documentation the resident was offered fluids between meals.

Based on interview and record review it was determined the facility failed to monitor the effects of insulin, ensure orders for potassium were clarified or implement bowel care protocol to treat constipation for 2 of 11 sampled residents (#s 65 and 44) for whom medications were reviewed. This resulted in Resident 65 requiring hospitalization . Finding include: 1. Resident 65 was admitted to the Memory Care Community (MCC) in the facility in 2011 with [DIAGNOSES REDACTED]. Resident 65's Comprehensive Care Plan dated 1/25/12 for diabetes had interventions that included monitoring meal intake, encouraging healthy snacks between meals, checking CBGs and giving insulin as ordered with a goal to keep the resident's CBGs between 70 and 250. The Sliding Scale Insulin Coverage Data Collection form indicated on 2/8/12 Resident 65 was given 5 units of [MEDICATION NAME] (rapid acting insulin) for a CBG of 176 prior to lunch, as ordered. The resident's February 2012 Meal Monitoring Flow Sheet indicated on 2/8/12 Resident 65 refused to eat any lunch. There was no documented evidence that staff were monitoring the resident's CBGs or that Resident 65 was given a meal replacement or snack after being given insulin and refusing to eat. Facility NN dated 2/8/12 revealed Resident 65 was found to be unresponsive at 4:05 pm. The CBG was 42. Staff administered [MEDICATION NAME] (injectable rescue medication for [DIAGNOSES REDACTED]-low blood sugar) per the facility protocol. The resident continued to be unresponsive. Staff called the physician who ordered another dose of [MEDICATION NAME] and to send Resident 65 to the hospital. On 6/14/12 at 1:17 pm Staff 3 (RNCM) stated Resident 65 would refuse to eat a meal when served but would often eat a snack between meals. She said it was rare for the resident to go without something to eat. On 6/15/12 at 10:13 am Witness 9 (Medical Director) said if insulin was given and the resident did not eat he would expect staff would monitor the resident's CBGs. 2. Resident 65 was readmitted to the Memory Care Community (MCC) in the facility on 1/24/12 after being hospitalized for [REDACTED]. Other [DIAGNOSES REDACTED]. The physician's progress notes dated 1/27/12 indicated Resident 65 returned from the hospital following treatment for [REDACTED]. On 2/3/12 the physician ordered Resident 65's daily [MEDICATION NAME] dose to be increased to 80 mg tid and the KCl 40 mEq to also be given tid for [MEDICAL CONDITION]. On 3/9/12 Resident 65's physician lowered the [MEDICATION NAME] 80 mg from tid back to once daily and requested labs be drawn in one week on 3/21/12. On 3/15/12, after the physician received the lab results, He notified the facility and ordered Resident 65 to be sent to the hospital related to having critical labs including high levels of potassium ([MEDICAL CONDITION]). The Emergency Department report dated 3/15/12 indicated the resident's labs, "demonstrated worsening [MEDICAL CONDITION] and [MEDICAL CONDITION]." The "potassium level likely related to dehydration. Given his chronic mental status it was suspected he was not eating and drinking well." Resident 65 was treated with an IV [MEDICATION NAME] of two liters normal saline and D50 ([MEDICATION NAME]). Resident 65 was then admitted to the hospital for monitoring. On 6/13/12 at 2:30 pm this information was discussed with Staff 3 (RNCM). Staff 3 stated she would expect [MEDICATION NAME] and KCl to be increased or decreased together. There was no evidence that the facility questioned the order regarding leaving the high dose of KCl in place after reducing the [MEDICATION NAME] dose. On 6/15/12 at 10:13 am Witness 9 (Medical Director) said typically both [MEDICATION NAME] and KCl were reduced or increased together. He said if the potassium levels were low the KCl may not be decreased with the [MEDICATION NAME]. 2. Resident 44 was admitted to the facility in April 2011 with a [DIAGNOSES REDACTED]. In an interview on 6/13/12 at 8:53 pm Witness 7 (family member) stated Resident 44 recently had an episode of constipation [MEDICATION NAME] at least five days. According to Resident 44's ADL Flow Sheet for May and June, 2012, there was no documentation of a bowel movement (BM) between 5/25/12 and 6/5/12. Review of NN for Resident 44 revealed no documentation between 5/19/12 and 6/5/12. Nurses' Notes dated 6/5/12 at 7:30 pm indicated Resident 44 had two episodes of emesis and refused dinner and HS medications. According to NN dated 6/5/12 at 8:30 pm, Resident 44 denied nausea or pain. Nurses' Notes dated 6/6/12 documented the resident had a "very large" BM and a new order for [MEDICATION NAME] (a laxative) to be given daily. In an interview at 9:30 am on 6/14/12, Staff 13 (LPN) stated the night shift nurse was to review bowel records and give the day shift a list of residents who had not had a documented BM in three days. As a day shift nurse, Staff 13 indicated he would then assess the resident and attempt to determine if there had been an undocumented BM. The day shift was to give an oral laxative to start the bowel care protocol. On 6/14/12 at 11:10 am Staff 13 (LPN) stated night shift did not use a specific form to inform the day shift regarding bowel care needs. It was written on "scrap paper." Staff 13 indicated each licensed nurse was responsible for reviewing bowel records to see who might need intervention on their shift, however, it did not always get done. He did not give any PRN bowel medication to Resident 44 on 6/1 or 6/2/12, when according to the ADL record it would have been indicated. In an interview on 6/14/12 at 3:29 pm Staff 20 (LPN, Assistant to the RNCM) stated the night shift nurse reviewed ADL records, filled out the Bowel Protocol form and left a note for the CMA or Licensed Nurse on day shift to give PRN bowel medications. Results of the bowel interventions were to be documented on the ADL record, TAR or MAR. Night shift nurses reviewed those records and decided if the next step in the bowel protocol was necessary. The Bowel Protocol forms were kept in a binder at the nurses' station. Review of the information contained in the binder revealed the Bowel Protocol forms had not been completed between 5/28 and 6/6/12. At 3:30 pm on 6/14/12, Staff 20 stated the regular night shift nurse was on vacation and the nurse who was filling in apparently had not completed the forms. On 6/14/12 at 4:48 pm, Staff 22 (RN) stated she was the nurse assigned to the Memory Care Community and the long term care hall on 6/5/12. She recalled Resident 44's episode of emesis on 6/5/12. Staff 22 did not recall performing a bowel assessment and did not review records to see when the resident last had a BM. On 6/15/12 at 8:38 am these findings were discussed with Staff 3 (RNCM) who confirmed the bowel care protocol was not followed.

Based on interviews and records review it was determined the facility failed to follow physician's orders and care plan fall interventions for 1 of 3 sampled residents (#1). Resident 1 fell , was injured and required hospitalization . Findings include: Resident 1 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Review of a fall assessment dated [DATE] revealed the resident was at risk for falls due to mental status, history of falls, poor safety awareness and an unstable gait. Review of the care plan dated 3/18/11 revealed the resident was at risk for fall and interventions included a low bed and a pressure alarm while the resident was in bed. Review of a physician's order dated 3/28/11 revealed the resident was to have a pressure alarm on while in bed or a wheelchair. Review of a NN dated 4/1/11 at 1:30 am revealed Staff 1 (LPN) had responded to a noise in the resident's room and found the resident face down on the floor. The resident had attempted to get out of bed to use the bathroom. Staff 1 assessed the resident for injuries and found a laceration with blood and a bruise on the resident's forehead. The resident complained of head and shoulder pain and was sent to the emergency room for evaluation. Review of a written statement by Staff 2 (CNA) dated 4/1/11 revealed "I forgot to turn bed alarm back on." Review of an emergency room note dated 4/1/11 revealed the resident suffered a fall resulting in a contusion of the left forehead. The resident was treated and sent back to the facility the same day. Review of an Incident & Unusual Occurrence Report dated 4/2/11 revealed the resident was found face down on the floor between the resident's bed and the room window. The report indicated the resident's room lights were on, no bed alarm was heard and the resident's call light had not been activated. The resident fell after an attempt to get out of bed to use the bathroom and suffered a laceration and bruise to the left forehead and a knee abrasion. The report concluded the resident's bed was not in the low position and the resident's pressure alarm had not been activated per the resident's care plan. In an interview on 4/12/11 at 10:05 am the resident did not remember falling on 4/1/11. In an interview on 4/12/11 at 10:10 am Staff 1 (LPN) stated she was called down by Staff 3 (CNA) to the resident's room on 4/1/11 and the resident was found face down on the floor next to the resident's bed. Staff 1 said there was blood coming from the resident's forehead and the resident had a right knee skin tear. Staff 1 asked the resident what had happened and the resident indicated he/she attempted to use the bathroom and fell . Staff 1 said the resident was care planned for a pressure alarm in bed which had not been activated prior to the resident's fall. Staff 1 assessed the resident and the resident was sent to the emergency room for evaluation. In an interview on 4/21/11 at 8:20 am Staff 2 (CNA) said the resident had been toileted prior to the fall and was put back to bed around midnight. Staff 2 said, while putting the resident back to bed, Staff 2 had spilled some of the resident's candy on the floor. After the resident was in bed Staff 2 picked up the candy and had forgot to turn the resident's pressure alarm on. Staff 2 said she was alerted about an hour later by Staff 1 and Staff 3 (CNA) the resident had fallen. Staff 2 said the resident's bed was in the low position when she had left the resident's room. In an interview on 4/21/11 at 9:30 am Staff 3 (CNA) was passing the resident's room and noticed the resident was sitting on the edge of the resident's bed leaning forward. Staff 3 said, before she could assist the resident, the resident fell forward and landed face first on the floor. Staff 3 said the resident's pressure alarm did not sound. Staff 3 said Staff 1 and Staff 2 were called to the resident's room, the resident was assessed for injuries and the resident's physician was notified. Staff 3 said the resident had a bruise on the knee and forehead and was sent to the emergency room for evaluation.

Based on observations, interviews and record reviews, it was determined the facility failed to prevent the development of Stage 4 pressure ulcers (Stage 4 pressure ulcers are defined as full thickness skin loss with extensive destruction to muscle, bone, undermining and sinus tracts) for 2 of 4 sampled residents (#s 11 and 13) who had skin breakdown. Residents 11 and 13 had facility acquired pressure ulcers that worsened to Stage 4. Findings include: 1. Resident 11 was admitted to the facility on [DATE] including [DIAGNOSES REDACTED]. The 1/8/08 local hospital Patient Transfer Form indicated the resident was hospitalized from [DATE] through 1/8/08 and the resident's coccyx was intact without redness. The facility's 1/8/08 Admission Nursing Assessment form indicated the resident's skin was warm, dry and intact. The resident's 1/22/08 MDS assessed the resident as not having a current pressure ulcer or a history of resolved ulcers. The MDS indicated the skin treatments utilized were pressure relieving device in chair, bed and turning/repositioning program. The corresponding 1/22/08 RAPS indicated the Pressure Ulcer RAP was triggered due to impaired bed mobility, incontinence and unknown history of pressure ulcers. The resident's skin was to be monitored daily with personal care and a weekly skin audit was to be done by the licensed nurses. The resident's physician was to be notified when skin issues were identified. The resident's January 2008 MAR indicated [REDACTED]. The 1/26/08 Wound Documentation Form, completed by an LPN, indicated the resident had a Stage 2 pressure ulcer (A Stage 2 pressure ulcer is defined as a partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) on the bony prominence of the coccyx. The ulcer measured 1.5 cm and the surrounding skin was intact, there was no odor and the resident was not experiencing pain. The 1/26/08 physician's telephone order was obtained for treatment of [REDACTED]. The 1/29/08 Wound Documentation Form, written by an LPN, indicated the resident's pressure ulcer had "minimal purulent (containing pus) drainage and the ulcer was dark in color." The Weekly RN Pressure Ulcer Report for 1/26/08 through 2/2/08 indicated the resident had a facility acquired Stage 2 pressure ulcer on the coccyx area that was first identified on 1/26/08. The measurement was 1.5 cm and was described as being open and dark in color. The 2/19/08 Wound Documentation Form, written by an LPN, indicated the resident's ulcer was 1 cm long and .5 cm in width. The ulcer was described as being open, painful with dressing changes. CNAs were encouraged to keep resident off of her "bottom." There was no evidence the resident's care plan was updated after 2/19/08 to include the encouragement of the resident to be off of her "bottom." The Weekly RN Pressure Ulcer Report for 2/14/08 through 2/21/08 indicated the ulcer improved and measured 1 cm by .5 cm, was intact and had no drainage. The resident's February 2008 MAR/TAR indicated the resident's dressing was changed on 2/25/08 though there was no documentation regarding the condition of the resident's ulcer on the MAR/TAR, NN, Wound Documentation Form or Weekly RN Pressure Ulcer Report. The 2/28/08 Wound Documentation Form, written by an LPN, assessed the resident's pressure ulcer as a Stage 4 with measurements of 3 cm in length, 1 cm wide and 1 cm in depth. The ulcer was described with "moderate serosanguineous (bloody) drainage and there was an odor. The description indicated the area much worse, larger, more painful. Black-grey deep..." The LPN indicated the CNAs would be instructed to keep the resident off of her buttocks except for meals. There was no evidence the resident's care plan was updated until 3/1/08 to include approaches to assist the resident into bed after each meal and for the resident to be only turned from side to side. There was a note written on 3/1/08 by Staff 8 (LPN) on the back of the resident's Wound Documentation Form describing the resident's ulcer as "3 cm across 2.5 cm deep, dark, foul smelling with purulent drainage...." The 3/2/08 Wound Documentation Form completed by Staff 8 (LPN) described the resident's ulcer as "very foul smelling purulent drainage, dark in color increased in size and depth...." There was no evidence the resident's physician was notified of the change in the resident's pressure ulcer from 2/28/08 when it was described as a Stage 4 pressure ulcer until 3/3/08, a period of four days. On 12/17/09 at 8:38 am, Staff 2 (DNS) was unable to provide evidence the resident's physician was notified. The 3/3/08 NN, written by the former Assistant Director of Nursing (LPN) indicated the charge nurse noted the resident's coccyx ulcer increased in size and had slough (dead matter). The 3/4/08 Wound Documentation Form, written by an LPN, described the resident's ulcer as "dark black, red peri wound edges very foul smelling and continued in past 5 days to grow quickly from 1.5 to 4.5 cm wide dressing changes daily with increased pain when washing the wound...." There was no evidence the resident's pressure ulcer was assessed by an RN from 2/21/08 until the resident was seen at the wound clinic on 3/4/08. On 12/17/09 at 9:00 am, Staff 2 (DNS) was unable to provide evidence the RN assessed the resident's pressure ulcer. The 3/4/08 Wound Clinic visit documentation indicated the progression of the resident's coccyx ulcer was from a small, clean abrasion/shearing ulcer (Stage 2) that was resolving without difficulty. The documentation indicated, "Prior to checking the wound I was able to smell a foul odor-thinking patient had had a bowel movement. Patient had an Allevyn dressing across wound that was saturated with purulent drainage and foul odor. Coccyx wound measured 3 cm by 4 cm with unknown depth. Wound shaped like a crater and wound bed is covered with soft black, thick fibrous eschar (black necrotic tissue) in center with tight adhered yellow eschar along edges. Edges closed by virtue of eschar. Wound oozing black mucoid drainage with foul odor. Periwound with bright [DIAGNOSES REDACTED] (redness) that extends out approximately 3 cm in all directions...." The 3/4/08 fax written by the Assistant DNS ( LPN) to the resident's physician indicated Resident 11 "has a Stage IV (4) wound on her coccyx area which was a Stage II (2) slow resolving shearing wound prior. In follow up with nurses on duty the wound required daily checks for wound dressing changes and on 3/2/08 the wound remained a Stage II. On 3/3/08 when nurse went to change dressing she noted the significant decline in wound status and we obtained an order for [REDACTED]. An interview on 12/17/09 at 9:00 am with Staff 2 (DNS) revealed there was no evidence to support the statement in the 3/4/08 fax to the physician indicating the resident's pressure ulcer was a Stage 2 on 3/2/08. The 4/11/08 NN written at 2:00 pm indicated the pressure ulcer had perforated the resident's bowel. The resident's physician was planning on discussing surgical options with the resident's family. The 5/19/08 NN (no time) indicated the resident's test results indicated the resident was a poor surgical candidate and the resident's family declined to proceed with surgery. The resident's family was made aware that the resident's ulcer may never heal. A review of the resident's record from 5/19/08 through 12/17/09 revealed the resident's pressure ulcer was being treated according to the physician's orders [REDACTED]. 2. Resident 13 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Review of the resident's Admission Nursing assessment dated [DATE] revealed the resident's skin was intact. Review of the MDS and RAPs dated 8/8/09 revealed the resident had no pressure ulcers and was "currently without any skin breakdown, he is at risk for pressure sores...." Review of the resident's care plan dated 8/8/09 revealed the resident was at risk for pressure ulcers and the resident was to have pressure relieving devices in the bed and wheelchair. An addition dated 8/24/09 revealed the resident had a stage 1 pressure ulcer (persistent area of skin redness without a break in the skin) that was to be treated three times daily. Review of the NN of 8/24/09 (am) revealed the resident had a stage 1 pressure ulcer on the coccyx that measured 4 cm by 3 cm, without skin breakdown and therapy orders were in place. Review of the weekly skin checks revealed the resident's skin was documented as intact on 8/30/09, 9/6/09, 9/13/09 and 9/20/09. Review of the NN of 9/22/09 at 1:00 pm revealed the resident had open areas on the coccyx. Review of a Wound Documentation Form revealed an entry dated 9/22/09 that the resident had two stage 2 areas (partial thickness loss of skin layers that present as an abrasion, blister or shallow crater) on the coccyx. An entry dated 9/25/09 revealed the resident had three stage 2 areas measuring 1 by 0.5 cm, 0.25 by 0.25 cm and 3 by 1 cm. An entry on 10/9/09 revealed the resident's wounds were 80 percent covered by eschar (black necrotic tissue) and on 10/15/09 the wounds were 100 percent covered with slough (layer of dead tissue). All the noted entries were signed by LPNs. Review of two Wound Documentation Forms with first entry dates of 10/20/09 revealed the resident had two pressure ulcers, one on the coccyx and one on the right side of the coccyx. The forms documented the resident's pressure ulcers were not present on admission. Review of the Wound Documentation Form for the coccyx wound revealed on 10/20/09 the wound was unstageable (a wound covered by eschar or slough), measured 3 by 4 cm and with tunneling between 3 and 4 o'clock. The next entry, dated 10/29/09, revealed the wound was a stage 4 (full thickness loss of skin and subcutaneous tissue exposing muscle or bone), measured 2.4 by 2.8 cm and 1.6 cm deep with tunneling between 11 and 1 o'clock. An entry dated 11/5/09 revealed the wound was a stage 4, measured 2.4 by 2.5 cm and was 1.5 cm deep with tunneling between 11 and 1 o'clock. All the noted entries were signed by LPNs. Review of the Wound Documentation Form for the wound on the right side of the coccyx revealed on 10/20/09 the wound was a stage 3 (full thickness loss of skin, exposing subcutaneous tissue, could appear as a crater) and measured 3 by 2 cm. An entry dated 10/29/09 revealed the wound measured 0.5 by 0.5 cm. All the noted entries were signed by LPNs. Review of the resident's physician's orders [REDACTED]. In an interview on 12/16/09 at 10:22 am Staff 2 (DNS) and Staff 8 (LPN) agreed that each wound noted on 9/22/09 and 9/25/09 should have had a separate Wound Documentation Form. Staff 2 acknowledged a RN had not assessed the resident's wounds, documented on the wound sheets or reviewed the wound sheets.