Every finding on record at Ridge Crest at Meadow Ridge

Based on review of the clinical record, facility documentation, facility policy, and interviews for two of three residents (Resident #2 and #3) reviewed for quality of care, the facility failed to maintain the confidentiality and privacy of Resident #2 and #3, when their medication blister packs containing resident-identifying information was improperly included with Resident #1's discharge medications. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included falls, diabetes mellitus, and prostate cancer. Physician order dated 3/6/26 directed Abiraterone (used to treat prevent the production of Testosterone in the treatment of prostate cancer) 250 milligrams (mg), four tablets (1000 mg total), to be administered daily for the treatment of prostate cancer. Resident #3 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, diabetes mellitus, atrial fibrillation, and anemia. Physician order dated 3/4/26 directed Potassium Chloride Extended Release 10 mEq (milliequivalents) tablets, to be administered daily for the treatment of congestive heart failure. Record review identified Resident #1 was discharged from the facility on 3/11/26. Review of photographs of medication blister packs sent with Resident #1 upon discharge from the facility, identified the medications included a blister pack labeled for Resident #2's Abiraterone (10 tablets), and a blister pack labeled for Resident #3's Potassium Chloride (30 tablets). Interview with Resident #1 on 5/7/26 at 10:10 AM identified following discharge from the facility on 3/11/26, Resident #1 reviewed the medications he/she was sent home with, and discovered medications prescribed for Resident #2 and Resident #3, including Abiraterone and Potassium Chloride, were improperly included with his/her discharge medication bag. Resident #1 subsequently notified the facility of the medication error. Interview with RN #1 on 5/7/26 at 12:15 PM identified she was unaware medications belonging to Resident #2 and Resident #3 had been improperly included in Resident #1's discharge medication bag at the time of discharge. Interview with the DON on 5/7/26 at 10:40 AM identified the facility became aware Resident #1 was discharged with medications belonging to Resident #2 and Resident #3 after notification from Resident #1. The DON stated the facility did not have a licensed staff member available to pick up the medications sent with Resident #1 in error, and Resident #1's family returned Resident #2 and Resident #3's medications to the facility on 3/12/26. The DON stated Resident #2 and Resident #3's medications should not have been sent home with Resident #1, and was unable to explain how they were included in Resident #1's medications upon discharge. The facility Transfer or Discharge, Resident-Initiated Policy directed in part, the information conveyed will include (resident) medications, including when last received. The facility did not provide a policy regarding resident confidentiality for surveyor review during the survey.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for discharge process, the facility failed to ensure the resident was discharged with all prescribed narcotic medications as ordered. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery and neuropathy. The Resident Care Plan (RCP) dated 3/8/26 identified Resident #1 at risk for pain, and a plan to be short-term stay (planned discharge to the community). Interventions directed pain evaluations as indicated, administer pain medication as ordered, and monitor pain every shift, and planned discharge to the community/home with potential services. Physician order dated 3/8/26 directed to administer Oxycodone 5 milligrams (mg) one (1) tablet every four (4) hours as needed for pain scale 4 to 7, and administer two (2) tables every four (4) hours as needed for pain scale 8 to 10. The 5-Day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact, and received opioids within the last seven (7) days. Record review identified Resident #1 was discharged from the facility on 3/11/26. Nursing note dated 3/11/26 at 20:29 (8:29 PM) written by RN #1, identified Resident #1 was discharged home with medications and belongings, with teaching of medications. Narcotics were not given at the time of discharge. The note continued with a late entry addendum that indicated Resident #1 called the facility t 9:15 PM about how he/she needed Oxycodone, and he/she was in agony. RN #1 explained protocol of signing out the narcotics out and he/she hung up phone when given the option to have someone pick up medication the tomorrow morning. Review of the Post-Discharge Plan of Care/Resident Medication Profile (discharge paperwork), dated 3/11/26 at 4:04 PM identified Oxycodone was listed on the form as a medication directed for use upon discharge. The form directed Oxycodone 5 mg twice daily for seven days and Oxycodone 5 mg every four hours as needed for pain management upon discharge. Interview with Resident #1 on 5/7/26 at 10:10 AM identified Resident #1 was discharged from the facility on 3/11/26 with medications. When Resident #1 was going to self-administer his/her narcotic medication and reviewed his/her medications the facility supplied upon discharge (with the medication), he/she noted the pain medication (Oxycodone) was missing. Resident #1 called the facility and spoke with RN #1 who informed him/her that the narcotic medication needed to be signed out (when discharged ). Resident #1 stated RN #1 had not advised Resident #1 of the requirement when he/she was discharged , and the Oxycodone was not sent home with Resident #1. Interview with RN #1 on 5/7/26 at 12:15 PM identified Resident #1 was discharged from the facility on 3/11/26 and RN #1 was responsible for completing the discharge process, including discharge education and medication reconciliation. RN #1 stated facility process required residents to receive education and sign for both routine and narcotic medications upon discharge. RN #1 stated she failed to properly educate Resident #1 regarding the narcotic medication and the need to sign-out the Oxycodone; RN #1 failed to ensure Resident #1 signed for and received the prescribed narcotic medication prior to discharge. RN #1 stated Resident #1 later contacted the facility reporting the narcotic medication had not been received and she gave instruction that the medication could be picked up at the facility. Interview with the DON on 5/7/26 at 10:40 AM identified Resident #1 abruptly self-discharged from the facility on 3/11/26, and nursing staff failed to ensure the prescribed narcotic medication (Oxycodone) was provided to Resident #1 at the time of discharge. The DON stated Resident #1's family subsequently returned to the facility on 3/12/26 to retrieve the Oxycodone. The DON further stated the facility practice required residents to receive prescribed narcotic medications upon discharge, unless refused by the resident. The facility Transfer or Discharge, Resident-Initiated Policy directed in part, the information conveyed will include (resident) medications, including when last received. Review of the undated facility Transfer or Discharge, Facility-Initiated Policy directed in part, documentation of transfer or discharge was to include disposition of medications.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1), reviewed for a change in condition, the facility left unlicensed staff with a resident who was identified with a significant change in condition, and failed to ensure a resident's active do not resuscitate (DNR) order was honored when he/she was identified to have no pulse, no respirations, and had fixed and dilated pupils, and failed to ensure Emergency Medical Services (EMS) was notified prior to a pronouncement of death. The findings include: Resident #1 had a diagnosis of heart failure, hypertension (high blood pressure), atrial fibrillation (irregular heart rhythm), aneurysm of the heart (bulging area in the heart muscle), and rheumatic tricuspid insufficiency (heart not pumping blood effectively). The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition, and required maximal assistance ADLs and transfers. The Resident Care Plan (RCP) dated [DATE] identified a risk for decreased cardiac output, and code status was DNR (Do Not Resuscitate). Interventions directed to monitor for chest pain and shortness of breath, and do not administer cardio-pulmonary resuscitation (CPR). Physician order dated [DATE] directed DNR and RN May Pronounce (RNP) death. Nursing note dated [DATE] at 8:05 AM identified resident was last observed by staff at 2:30 AM in recliner. Resident prefers to sleep in recliner due to shortness of breath while laying down, related to CHF diagnosis. Resident's legs were noted to be edematous, and Resident #1 keeps legs elevated while in the recliner. Resident #1 walked unassisted to the opposite side of his/her bed to use the commode and had a fall after commode use. The call bell was noted on the armrest of recliner and was not on at the time of discovery. Nonskid socks were in place. Reportable event dated [DATE] at 2:58 AM identified NA #1 reported Resident #1 was on the floor at 2:45 AM. RN #1 responded to the room and observed Resident #1 lying on his/her left side on the floor with his/her head towards the foot of the bed and had minimal verbal responses. RN assessment was completed and RN #1 was in the process of getting paperwork together while the NAs obtained vital signs and the LPN #1 obtained oxygen. LPN #1 then notified RN #1 that Resident #1 had become unresponsive and was without a pulse. The RN #1 observed pupils were fixed and dilated, Resident #1 had no response to noxious stimuli, pulse was absent and respirations were absent for one (1) minute. Resident #1 was a DNR and RNP, and RN #1 pronounced death at 2:58 AM. The DNS was notified at approximately 3 AM (approximately 15 minutes after Resident #1 was found on the floor), the local police were notified at 3:04 AM, and EMS was contacted at 3:23 AM (approximately 38 minutes after Resident #1 was found on the floor). EMS contacted the local hospital emergency room doctor regarding Resident #1's DNR orders, and received clearance to accept the facility's DNR order and to not carry out any resuscitation efforts. Resident #1 was pronounced by the paramedic at 3:43 AM (45 minutes after RN #1 had pronounced death). The medical examiner declined the case and stated that the resident had a terminal collapse. Facility statement from RN #1 dated [DATE] identified after Resident #1 was found on the floor, she performed an assessment and identified Resident #1 had minimal verbal responses and was only moaning, and she made the decision to transfer to Resident #1 to the hospital. The statement indicated that during RN #1's preparation to call emergency services RN #1, was notified by the charge nurse (LPN #1) that Resident #1 became unresponsive and was without a pulse. RN #1 noted Resident #1 had DNR and RNP orders in place and she pronounced death at 2:58 AM. Review of EMS Fire District dispatch run sheet identified they were notified at 3:09 AM of a possible untimely and arrived at Resident #1 at 3:20 AM. Resident #1 was on the floor in her/his room, was warm to touch and had no pulses present. Nursing home staff informed EMS that Resident #1 had a hematoma to the left side of his/her head and was on a blood thinner. Staff reported Resident #1 was a DNR and had been on the floor for about 30 minutes before the ambulance arrived. Med control was called to see if the DNR was valid and informed the physician of the situation and the doctor directed to follow the DNR. The staff then informed EMS that Resident #1 was seen at 2:30 AM and then 15 minutes later staff heard moaning from the room and Resident #1 was found on the floor with agonal respirations (slow, gasping, or snoring-like breaths that occurs during severe medical emergencies). EMS rolled Resident #1 onto his/her back and observed a wound on the left side of his/her head with blood around the area. No lung or heart sounds were heard, and EMS noted the beginning of rigor (temporary muscle stiffness that occurs after death) in the jaw. Medic arrived on scene and was informed of the incident, and the [NAME] gave the time of death as 3:43 AM. Review of local police Medic (paramedic) identified they were dispatched at 3:12 AM and arrived at Resident #1 at 3:38 AM. Resident #1 was found to be pulseless and apneic (without respirations) by EMS, and had an active DNR order. Resident #1 was observed unresponsive, had no respirations, no pulses at the carotid (neck), femoral (groin) and radial (wrist) and no heart signs. Medic was presented with an active DNR order and Resident #1 was wearing a DNR bracelet on the left writs. Resident #1 had a hematoma noted on the right forehead, with no additional obvious trauma noted. Although attempted, RN #1 was unavailable for interview during the survey. Interview and record review with NA #1 on [DATE] at 12:41 PM identified she last saw Resident #1 at 2:30 AM and then about 2:45 AM or 2:50 AM she observed Resident #1 on the floor. NA #1 asked Resident #1 if he/she was okay, and Resident #1 did not respond and she then left the room to notify the nurse. Interview and record review with LPN #1 on [DATE] at 12:10 PM identified he was entering Resident #1's room as RN #1 left the room to call 911. LPN #1 proceeded into Resident #1's room and observed two (2) NAs were in the room and Resident #1 was on the floor unresponsive with no pulse or respirations. LPN #1 then left the room to obtain the crash cart and notify RN #1 that Resident #1 no longer had a pulse or respirations, leaving Resident #1, unresponsive, with two (2) NA's (unlicensed staff) in the room. LPN #1 stated when he returned to the room with the crash cart, he started providing rescue breaths to Resident #1 because it was non-invasive and Resident #1 had a signed DNR, and CPR could not be performed. LPN #1 stated he gave rescue breaths for approximately two (2) minutes, and then RN #1 pronounced Resident #1's death. RN #1 called 911 after she pronounced the death. Interview failed to identify why LPN #1 left the room to obtain the crash cart and did not send one (1) of the NAs for the cart. Interview and record review with the DNS on [DATE] at 1:05 PM identified she was notified about 3 AM that Resident #1 had a fall and had expired. Resident #1 was last seen about 2:30 AM, and NA #1 responded to the room when she heard a noise, and found Resident #1 on the floor. NA #1 notified RN #1/supervisor and when RN #1 assessed Resident #1, he/she was moaning and crying and RN #1 called EMS. LPN #1 entered the room as RN #1 was exiting the room. LPN #1 observed Resident #1 had no pulse or respirations, and LPN #1 left the room to notify RN #1 and to get the crash cart. When LPN #1 left the room, he left two (2) NAs in the room with Resident #1, who was unresponsive with no pulse or respirations. LPN #1 returned to the room and started rescue breaths, and then RN #1 pronounced the death at 2:58 AM. RN #1 called the DNS after Resident #1 was pronounced, and the DNS directed RN #1 to call EMS because it was an unanticipated death. The DNS stated LPN #1 should have stayed in the room with Resident #1 and should have delegated a NA to obtain the crash cart and notify the RN of the change in condition. Further, the DNS stated LPN #1 should not have performed rescue breaths because Resident #1 was a DNR. Although requested, the of facility did not provide a CPR Policy or Do Not Resuscitate Policy, for surveyor review. Review of the CT Public Health Code: 19a-580d-1 (5) directed in part, a Do Not Resuscitate order or DNR order means an order written by a Connecticut licensed physician to withhold cardiopulmonary resuscitation, including chest compressions, defibrillation, or breathing or ventilation by any assistive or mechanical means including, but not limited to, mouth-to-mouth, mouth-to-mask, bag-valve mask, endotracheal tube, or ventilator for a particular patient. Review of facility Post-Mortem Care, RN Pronouncement Policy dated March of 2023 directed staff in the event of an unanticipated death and if emergency medical services or hospice had not taken over procedures for the determination of death then staff are to call 911.

Based on review of staff interviews, review of the clinical record and facility documentation for 1 of 1 sampled residents reviewed for hospice services (Resident #29) and for 1 of 2 sampled residents (Resident #46) reviewed for death, the facility failed to ensure the Resident Care Plan (RCP) was comprehensive to include hospice care. The findings include: 1. Resident #29's diagnoses included dementia and Alzheimer's disease. A Resident Care Plan dated 9/18/24 identified Resident #29 had impaired cognition related to advanced dementia. Interventions included repeating instructions as necessary, maintaining as consistent a routine as possible, and keeping environmental stimuli to a minimum. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #29 had a short/long term memory problem and was dependent on staff for eating, oral hygiene, dressing and personal hygiene. A physician's order dated 12/6/24 directed to admit Resident #29 to hospice care. Interview and clinical record review on 3/19/25 at 7:55 AM with the MDS Coordinators (RN #3 and RN #4) identified that a care plan was not developed in regards to Resident #29 receiving hospice services and that it was the responsibility of the MDS department to implement a care plan once notified that a resident was receiving hospice. Additionally, the interview identified that social services would notify the interdisciplinary team when a resident was admitted to hospice and that when they receive notification, they would develop a care plan. Additionally, RN #3 and RN #4 indicated they did not receive notification that Resident #29 was admitted to hospice services. An interview and clinical record review on 3/19/25 at 9:15 AM with the Director of Social Services identified Resident #29's family member requested a consultation for hospice on 12/4/24 and that the resident was admitted to hospice on 12/6/24. Additionally, the interview identified that when a referral was made for hospice, social services would send out an email notification to the inter-disciplinary team. Once the referral was accepted and the resident was admitted to hospice, the social worker would send another notification to the interdisciplinary team. Additionally, the Director of Social Services stated email notification was sent to the interdisciplinary team on 12/4/24. An interview and clinical record review on 3/20/25 at 11:02 AM with the DNS identified that a hospice care plan for Resident #29 had not been implemented after admission to hospice on 12/6/24 and that it should have been developed per facility policy. Additionally, it identified that social services would send email notification to the interdisciplinary team when a resident was referred to hospice and then a follow-up notification when the resident was accepted. That would serve as notification for the MDS department to implement a care plan. It was identified that an email notification was sent from social services to the MDS department on 12/4/24 stating that a referral had been made to hospice for Resident #29, but there was not a follow-up email sent when the resident was accepted and admitted to hospice on 12/6/24. Subsequent to surveyor inquiry, a care plan for hospice was developed. The care planning-interdisciplinary team policy dated 3/2022 identified that the interdisciplinary team was responsible for the development of resident care plans. Review of the hospice program policy dated 7/2017 that it is the responsibility of the facility to administer prescribed therapies delineated in the hospice plan of care. 2. Resident #46 was admitted to the facility in April 2024 with diagnoses that included Parkinson disease, dementia, and anxiety. A Resident Care Plan dated 11/13/24 identified Resident #46 had a functional decline with interventions to evaluate range of motion, assess current functional level and complete the activities of daily living section on the Minimum Data Set (MDS) assessment. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 was cognitively intact and required partial/moderate assistance for eating and oral hygiene. Additionally, the MDS identified Resident #46 required substantial assistance for personal hygiene and was dependent for dressing, transfers, and toileting. A nursing notes dated 11/20/24 at 9:28 PM identified Resident #46 was admitted to hospice services. The Resident Care Plan (RCP) dated 11/20/25 failed to identify the RCP was comprehensive to include Resident #46 receiving hospice services. A nursing note dated 11/20/24 at 10:05 PM identified Resident #46 was sent to the hospital for agitation, being difficult to re-direct, swinging laptop and hitting staff. A nursing note dated 12/5/24 at 8:58 PM identified that Resident #46 returned to the facility from the hospital. The RCP dated 12/5/24 also failed to identify the RCP was comprehensive to include Resident #46 receiving hospice services. An interview and review of the RCP on 3/24/25 at 11:10 AM with the MDS Coordinator (RN #4) failed to identify that a care plan had been developed by the facility regarding hospice services. RN #4 further noted that the Director of Social Services was responsible for developing hospice plan of care. An interview on 3/24/25 at 11:24 AM with the Director of Social Services identified that either the social worker or the MDS Coordinator was responsible for developing a care plan regarding hospice. Additionally, the MDS Coordinator noted that the RCP did not include Resident #46 receiving hospice services, was not sure of the reason a hospice care plan was not developed, but the facility policy was for one to be completed upon admission to hospice services. An interview with the DNS on 3/24/25 at 11:55 AM identified that a care plan for hospice services was not developed when hospice services were initiated on 11/20/24, and one should have been implemented. The care planning-interdisciplinary team policy dated 3/2022 identified that the interdisciplinary team was responsible for the development of resident care plans. 51101

48950 Based on the facility policy, record review, and interviews for 1 of 3 sampled residents (Resident #36) reviewed for accidents, the facility failed to ensure the Resident Care Plan was reviewed and revised after a fall with a major injury. Resident #36 was admitted to the facility in January 2025 with diagnosis that included heart failure, hypotension, and falls. A Fall Risk assessment dated [DATE] identified Resident #36 was a fall risk, and a fall prevention care plan was initiated or updated. The admission Minimum Data Set assessment (MDS) dated [DATE] identified was cognitively intact and was independent for eating, and oral hygiene. The MDS also, identified Resident #36 required partially moderate assistance for transfers, dressing, and was dependent for showering. The MDS further identified Resident #36 required touch supervision when ambulating. The Resident Care Plan (RCP) dated 1/3/25 identified Resident #36 was at risk for falls with interventions that included to complete a fall risk score, place call system and most frequently used items with in reach and provide orientation to room. Physician orders dated 1/21/25 directed that Resident #36 was able to ambulate in his/her room independently as well as toileting and transfer. A Reportable Event form dated 1/31/25 at 3:15 AM identified that Resident #36 was ambulating in his/her room independently when his/her walker hit the door. Further identifying that Resident #36 was independent with ambulation. Additionally, Resident #36 was found on the floor, bleeding from his/her head and sent to the hospital for evaluation. Nursing notes dated 1/31/25 at 3:47 AM identified that Resident #36 fell while trying to get to the bathroom, hitting his/her right side of head which was bleeding, and was sent to the emergency room . Nursing notes dated 2/11/25 at 8:40 PM identified that Resident #36 returned to the facility on [DATE] with a diagnosis of a left femur fracture, odontoid fracture, closed head injury, and a scalp laceration. An interview and review of the RCP on 3/19/25 at 12:15 PM with the DNS failed to identify the care plan had been reviewed/revised after Resident #36's fall with injury on 1/31/25. She further identified that the policy was for the Resident Care Plan to be updated after each fall, and that the Minimum Data Set Nurse and DNS were responsible for updating after the fall on 1/31/25. Further, the DNS identified that Resident #36 was out of the building for so long that it was an oversight that the Resident Care Plan was not updated to reflect the fall, and updating the Resident Care Plan was important because it could help to prevent further falls. Subsequent to surveyor interview, the care plan was revised on 3/19/25 by Registered Nurse #4 but the date of 3/5/25 was electronically entered as the created date (despite the care plan being updated on 3/19/25), and effective date listed as 2/12/25. The revised care plan identified Resident #36 was a risk for falls with interventions directed to place call system and most frequently used items within resident's reach, evaluate Resident #36's ability to understand the instructions provided, identify resident specific interventions to aid in the prevention of falls, communicate interventions via the resident summary and nursing assistant assignment sheet. Review of the Fall and Fall Risk Management policy identified that the interdisciplinary team, with input from the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. Also, identified if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 4 residents (Resident #45) reviewed for pressure ulcers, the facility failed to ensure physician orders related to an air mattress included type of setting and ensure the air mattress was set correctly. The findings include: Resident #45 was admitted to the facility in February of 2025 and had diagnoses that included sepsis, pressure injury, encephalitis and chronic kidney disease. A Nursing Admission assessment dated [DATE] identified Resident #45 was admitted from the hospital to the facility, had a short-term and long term memory problem, had limited range of motion to both arms and both legs, was dependent for eating, required assistance of 2 staff members for toileting, had edema to both arms/legs, and had pressure injuries to the coccyx and buttock. The Resident Care Plan (RCP) dated 2/25/25 identified Resident #45 was at risk for alteration in skin integrity related to a State 3 pressure ulcer to the coccyx, a Stage 2 pressure ulcer to the left buttock, a low back surgical area, and perifungal rash. Interventions included to complete weekly wound evaluations, encourage side to side positioning, and a pressure reduction mattress on the bed. A physician order dated 2/25/25 directed to complete a weekly skin check under the evaluation tab in the electronic record every week starting on 2/25/25 and to obtain evaluation and treatment by a wound physician. Additionally, a physician order dated 2/25/25 directed to place an alternating air pressure relief mattress to the bed and adjust by Resident #45's weight or preferences. The physician order failed to identify instructions to ensure the mattress was set on alternate pressure mode and not static pressure mode. A Wound Assessment document dated 2/25/25 identified Resident #45 was admitted with pressure injuries to the coccyx and left buttock. The coccyx wound presented as a Stage 3, had a moderate amount of serosanguinous (SS) drainage, and measured 2 centimeters (cm) in height by 1.5 cm in width by 0.3 cm in depth. Additionally, the left buttock pressure ulcer presented as a Stage 2, had 100% non-granulated tissue, a small amount of SS drainage, and measured 3 cm in height by 3 cm in width by 0.2 cm in depth. The assessment further identified the pressure ulcer treatment to both areas was to cleanse with Normal Saline and pat dry, apply Medihoney (a topical wound treatment) followed by Calcium Alginate (a topical wound treatment), cover with a Silicone adhesive foam dressing, change the dressing 2 times a day, and ensure an air mattress was in place (but failed to identify the type of setting, alternating air or static). A physician order dated 2/27/25 directed to cleanse the coccyx and left buttock with normal saline and pat dry, apply Medihoney followed by calcium alginate, cover with a Silicone adhesive foam dressing, change the dressing 2 times a day, and ensure air mattress was in place (but failed to identify the type of setting, alternating air or static). A Wound progress note dated 3/3/25 and written by MD #1 identified she was requested to provide a wound consultation for Resident #45. Resident #45 had a Stage 3 coccyx pressure injury to the coccyx and noted the wound base was 75 to 99% granulations, had no odor, moderate amount of SS drainage and measured 1 cm by 1 cm by 0.2 cm. Additionally, Resident #45 had a pressure injury to the left buttock which now presented as unstageable, had a 100% brown crusty wound bed, moderate amount of SS drainage, and measured 3.5 cm by 3.5 cm by 0 1 cm. The assessment further identified the treatment was to cleanse the left buttock with normal saline and pat dry, apply Santyl (topical debriding wound treatment) followed by calcium alginate, cover with a silicone adhesive foam dressing, change the dressing 2 times a day, and ensure air mattress was in place. The note further identified treatment recommendations to both areas was to cleanse the wounds, apply Santyl (wound debriding ointment) followed by Calcium Alginate to the base of the wound, secure with a dry clean dressing, and change the dressing 2 times a day. A wound progress note written by MD #1 on 3/17/25 identified she saw Resident #45 for evaluation and management of his/her pressure injuries to the left buttock and coccyx. The note identified the coccyx and left buttock pressure injuries had bridged (merged) into a single wound and documentation going forward would be as a single wound under location of left buttock. The note further identified the bridged left buttock pressure injury was unstageable, the wound base contained 75-99% slough and 1-24% granulation, had no odor, had a moderate amount of serous drainage, and measured 3 cm by 4 cm by 0.1 cm. A physician order dated 3/17/25 directed to cleanse the left buttock unstageable pressure injury with Normal Saline and pat dry, apply Santyl (wound debriding ointment) followed by Calcium Alginate, cover with a Silicone adhesive foam dressing, change the dressing 2 times a day, and ensure air mattress was in place (but failed to identify the type of setting, alternating air or static). Observation on 3/18/25 at 9:15 AM and on 3/18/25 at 10:22 AM identified Resident #45 lying supine in bed on an air mattress with both arms elevated on pillows. The air mattress' pressure adjustment knob was set between 180 and 210 and static mode engaged (Resident #45 weighed 192.0 pounds). Observation on 3/18/25 at 10:48 AM identified 2 Nurse Aides (NA) entered Resident #45's room to provide care. Resident # 45 was provided morning care with an incontinent brief change and Resident #45 was dressed. Resident #45 was then positioned supine in bed with both arms elevated on pillows. An air mattress was in place on the bed with the pressure adjustment knob set between 180 and 210 and static mode engaged. An interview with the Assistant Director of Nursing Services (ADNS) on 3/19/2025 at 10:06 AM identified alternating pressure air mattress settings were set by the resident weight and that she does not touch the static/alternate button on the mattress pump. Observation on 3/19/25 at 11:19 AM identified Resident #45 lying supine in bed with the head of bed (HOB) at 30 degrees and both arms elevated on pillows. There was an air mattress in place on the bed with the pressure adjustment knob set between 180 and 210 and static mode engaged. An interview with Registered Nurse (RN) #1 on 3/20/25 at 10:04 AM identified there were physician orders to check the alternating pressure air mattresses every shift for function and weight setting. RN #1 identified she verified the setting using the resident's most recent weight in the computer and that she did not touch the static/alternate button as that wasn't part of the order. Observation on 3/24/25 at 9:42 AM, on 3/24/25 at 10:21 AM and at 12:15 PM identified Resident #45 was lying supine in bed on an air mattress with the HOB at 90 degrees. The air mattress' pressure adjustment knob was set between 180 and 210 and static mode engaged. An interview with Occupational Therapist (OT) #1 on 3/24/25 at 10:50 AM identified Resident #45 did not get out of bed for long periods of time at the request of the nursing department due to the presence of pressure wounds. She identified that Resident #45 would get out of bed for therapy before lunch and then Resident #45 would go back to bed shortly after lunch. An interview with MD #1 on 3/24/25 at 10:58 AM identified air mattresses were put in place for residents at high risk for skin breakdown especially for residents with limited mobility putting them at high risk for skin breakdown to the heels and buttocks. MD #1 identified she deferred to the facility for their protocol for the settings for the air mattresses used within the facility, but that usually the settings were set by the facility based on the resident's weight. MD #1 identified that use of the alternating pressure mode versus static pressure mode settings on the facility air mattresses depended on the mattress type and the manufacturer recommendations. The Treatment Administration Record dated 3/1/25 through 3/31/25 identified the physician order for an alternating pressure relief mattress adjusted by Resident #45's weight or preferences was signed off every shift by the nurses (but failed to identify the type of setting, alternating air or static). Interview with the DNS on 3/24/25 at 1:48 PM identified the air mattresses used by the facility were set based on resident weight and preferences. The DNS identified that all the facility air mattresses were alternating pressure air mattresses and she was not aware that several of the facility air mattresses, including Resident #45's were set to the static mode, and not alternating pressure mode. The DNS further identified the alternating pressure function should be in place at all times (and not the static function) to provide wound prevention and healing by limiting the pressure in one area on the resident's skin for extended periods. An interview with the Direct Home Medical Provider of equipment Clinical [NAME] President (the company of the air mattress used for Resident #45) on 3/27/25 at 1:27 PM identified that it was not correct practice to keep the air mattress set at the static pressure mode for long periods of time. Additionally, the Direct Home Medical Provider of equipment [NAME] President identified that air mattresses were dual therapy and provide both low air loss and alternating pressure to prevent and manage wounds. She indicated that when a resident required the use of a brief for incontinence and had a draw sheet or pad on top of the mattress those extra layers negated the benefits of the mattresses low air loss and the alternating pressure function of the mattress would then take over as the main feature to prevent and manage wounds. Additionally, the Medical Provider [NAME] President identified that use of the static pressure mode was intended for only short periods such as while providing care or during meals to provide extra support while the resident was sitting upright to eat, but that the mattress should then be returned to the alternating pressure mode when those activities were completed. Also the interview identified keeping the air mattress setting on the static pressure mode consistently for long periods of time would contribute to wound deterioration or the development of a wound for a resident at risk for skin breakdown. Also, the Direct Home Medical Provider of equipment [NAME] President further identified that the suppliers providing the air mattresses to the facility were responsible for providing education to the facility on the proper use of all functions of the air mattresses. Review of the Air Element Mattress Owner's Manual identified on page 9 of the manual that the alternate/static switch selects between alternate pressure mode and static pressure mode. The manual identified with alternate pressure mode, alternating air cells are partially deflated and inflated, avoiding prolonged pressure on any single point beneath the resident to help prevent pressure ulcers. The manual further identified with the static pressure mode, all of the air cells are equally inflated.

Based on observations, review of facility policy/procedures and interviews regarding medication storage, the facility failed to ensure expired medication was disposed of and failed to ensure a medication cart was locked when not in use. The findings include: a. Observation on [DATE] at 10:16 AM with Licensed Practical Nurse (LPN) #2 of the Cedar East medication room identified 2 central line dressing change kits expired [DATE] intravenous (IV) start kits with Chloraprep (these were not patient specific) expired [DATE] and 3 IV start kits for residents who were no longer at the facility expired [DATE]. Interview on [DATE] at 10:18 AM with LPN#2 identified the nursing supervisor was responsible for rotating the stock in the medication rooms. LPN #2 indicated that staff should check the expiration dates prior to using the items and that there were no residents on her unit that required or had an IV that required a dressing change. Interview on [DATE] at 2:04 PM with Registered Nurse (RN) #2 who was the RN nursing supervisor identified all staff were responsible for discarding expired items from the medication room and that the supervisors oversee the medication rooms. Interview on [DATE] at 1:00 PM with the DNS identified all staff were responsible for discarding expired items. Additionally, the DNS noted that facility staff did not start IV's but were responsible to complete dressing changes. Furthermore, the DNS indicated there was only 1 resident who had a Peripherally Inserted Central Catheter (PICC) line and would currently require a dressing change but did not reside on the unit with the expired items. b. Observation on [DATE] at 1:27 PM identified LPN #3 walk away from the Elm unit medication cart, left the cart unlocked with the keys dangling in the lock mechanism. The medication cart was located at the nurses' station as LPN #3 walked 40 feet down the hallway and entered a resident room out of view of the medication cart. During this time, 2 residents and 3 staff members passed by the unsecured cart. Interview on [DATE] at 1:34 PM with LPN #3 identified the facility policy was to lock the cart and take the key if you were leaving the cart. Additionally, LPN #3 indicated that she sometimes leaves the keys in the lock if she was not going to be away from the medication cart for a long time. Interview on [DATE] at 2:04 PM with Registered Nurse (RN) #2 who was the RN nursing supervisor identified the expectation was that the medication carts remained secured when not in use and when out of sight of the nurses. Interview on [DATE] at 1:00 PM with the DNS identified that nurses should maintain possession of the medication cart keys and the carts should not be left unattended unsecured. The facility policy for Administering and storage of medications identified compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use.

Based on observation, review of facility documentation, review of facility policy/procedures and interviews for medication storage and narcotic reconciliation, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medication and failed to ensure that an account of all controlled drugs was maintained and periodically reconciled. The findings include: On 3/19/25 at 11:03 AM, review of the narcotic reconciliation and audit procedure with the DNS identified she was responsible for narcotic monitoring to include reconciliation and facility audits. The DNS described the facility audits the same as shift to shift counts on the unit medication carts. The DNS indicated she didn't have a regular process for reconciliation and that the last audit was completed in May 2024. Additionally, the DNS indicated an audit was only completed on the Omnicell (a secured machine that contains medication) and not the medication carts on the units or controlled medication in the emergency box. The DNS identified that when the nurses receive a delivery of medication from the pharmacy, they sign for the narcotics and place the yellow copy of the Controlled Substance Disposition Record (CSDR) into the DNS inbox and the white copy goes on the unit medication cart with the medication. If the medication was finished, discontinued, or needed to be destroyed, the white copy was given to the DNS and matched up with the yellow sheet, reconciled and if needed, the medication destroyed. The DNS identified that neither the yellow copies of the CSDRs nor the inventory slips were used in confirming reconciliation of narcotics. Additionally, delivery slips from the pharmacy were sometimes kept on the unit and discarded after a while and not reviewed/reconciled with the yellow copy. The DNS indicated that medications were obtained from other pharmacies or brought in as personal medications and were kept on the unit medication carts with a facility created medication count sheet that was kept with the medication. There were no corresponding yellow copies for accountability. The DNS indicated that if a narcotic was thought to be missing, she would be able to ask the pharmacy for a receipt of delivery but couldn't answer about personal medication brought from home. Although requested, narcotic audit or reconciliation documentation was not provided by the facility. The facility policy for Inventory control of controlled substances (5.4) identified a facility representative should regularly check the inventory records to reconcile inventory to include current and discontinued inventory of controlled substances to the log used in the facility's controlled medication inventory system, current inventory to the controlled medication declining inventory record and to the resident's MAR, and unused controlled substances held in storage awaiting destruction with the declining inventory record. The facility policy for Routine Reconciliation of Controlled Substances (5.5) identified the facility should routinely reconcile controlled substances stored in medication carts and emergency supplies and should reconcile controlled substances waiting to be destroyed. The policy indicated that the reconciliation should be performed by two licensed nurses or a licensed nurse and authorized and licensed healthcare professional, or per applicable law and the frequency of the reconciliation is determined by the Director of Nursing. The policy identified that a routine reconciliation of controlled substances should compare the total number of doses originally dispensed by the pharmacy to the number of doses remaining to the number of doses recorded as remaining on the medication-specific declining inventory sheet to the number of doses administered according to the resident's medication administration record.

Based on record review, facility documentation, and staff interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include a refusal of care. The findings include: Resident #2 had a diagnosis of cerebral infarction (stroke). The admission Minimum Data Set, dated [DATE] identified Resident #2 had a Brief Interview for Metal Status (BIMS) score of 3 indicating severe cognitive impairment, rejects care at times, and is occasionally incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 8/20/2023 identified bladder and bowel incontinence with interventions that directed to incontinence every shift. Facility reportable event dated 8/28/2023 at 8:23 AM identified at 7:40 AM Resident #2 was found in bed on an air mattress with two (2) incontinent pads underneath and was soaked in urine with bed linens also soaked with urine. Review of NA #2's written statement dated 8/28/2023 identified she reported the refusal of care to RN #2. Review of RN #2's written statement dated 8/28/2023 identified NA #2 reported the refusal of care. The statement further indicated RN #2 did not document the refusal of incontinent care and did not notify the on-coming shift of the refusal. The investigation Summary dated 8/30/2023 identified Resident #2 required two (2) staff for care, and was incontinent of bowel and bladder. The Summary indicated on 8/28/2023 at 7:40 AM, when NA #2 attempted to provide incontinent care, Resident #2 refused the care and NA #2 notified RN #2/charge nurse. Record review failed to identify any documentation of Resident #2's refusal of care. Interview and record review with the DNS on 11/26/2024 at 3:20 PM identified NA #2 and RN #2 did not document the resident's refusal of care. The DNS stated she did not know why it was not documented, but that it would be her expectation that Resident #2's refusal of care should have been documented. Review of facility Perineal Care policy dated February of 2018 directed staff to document if the residents refuses care, the reason why and the intervention taken.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for quality of care, the facility failed to notify the health care representative prior to the initiation of an antidepressant. The findings include: Resident #2 had diagnoses that included dementia. Record review identified Person #1 was the responsible party for Resident #2. The Resident Care Plan (RCP) dated 8/2/2019 identified Resident #2 at risk for weight loss related to dementia. Interventions directed to provide diet and supplementation per physician orders, monitor weights, and assist as needed with meals. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicative of severe cognitive impairment as resident was unable to complete the interview and was extensive assistance with assist of one (1) with all ADLs (activities of daily living). APRN note dated 8/20/2019 (written by APRN #1) identified Resident #2 had a poor appetite, a had a labile mood, hits often, and fights physically with staff. APRN #1 recommended Mirtazapine (Remeron - Antidepressant) 7.5 milligrams (mg) mg at night, for mood and appetite, and if physical aggression persisted, will consider Seroquel. The note failed to indicate if APRN #1 notified Person #1 of the medication initiation. Physician order dated 8/20/2019 directed to administer Mirtazapine 7.5 mg at night, for fourteen (14) days. Review of the August 2019 medication administration record (MAR) identified Resident #2 received one dose of Mirtazapine 7.5 mg on 8/21/2019. Review of the nursing and social services progress notes failed to identify a note indicating Person #1 was notified regarding Resident #2's new order for Mirtazapine. Interview with Person #1 on 10/16/2024 at 10:35 AM identified he/she was Resident #2's power of attorney for financial and healthcare matters. Person #1 identified he/she received an email from the facility on 8/23/2019, requesting Person #1 to sign a consent form for the initiation of Mirtazapine 7.5 mg. At the time the email was received, Person #1 and Resident #2 were on a LOA (leave of absence) from the facility for a medical appointment. Person #1 reviewed the paperwork sent to the medical appointment and Person #1 identified Mirtazapine was already added on Resident #2's medication list. Interview and review of the Psychopharmacological Medication Informed Consent form with DON on 10/16/2024 at 2:45 PM identified this was the documentation the facility used in 2019, to ensure consent was obtained and documented from a resident's responsible party/representative. The DON indicated it was the nursing team and physician's responsibility to ensure the responsible party was notified prior to the initiation of a new medication. The DON identified after reviewing Resident #2's clinical records, she was unable to verify if Person #1 was notified of the new medication orders prior to administration, but verified Person #1 should have been notified. Although requested, the facility was unable to provide a Psychopharmacological Medication Informed Consent form signed by Person #1. Although requested, interview with the DON identified the facility did not have a policy pertaining to notification to a responsible party/representative of the initiation of a new medication.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff notified the RN timely after a resident had an unwitnessed fall. The findings include: Resident #1 had diagnoses that included chronic obstructive pulmonary disease, hypertension, and osteopenia. The Resident Care Plan (RCP) dated 9/11/2024 identified Resident #1 was at risk for falls. Interventions directed to provide orientation to the room and call system, and call bell and items within resident's reach. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four out of fifteen (4/15), indicative of severe cognitive impairment and required substantial assistance with all ADLs (activities of daily living). A facility incident report and investigation dated 9/18/2024 at 10:20 AM identified the resident's assigned NA entered Resident #1's room to provide AM care and Companion #1 (Resident #1's companion) showed the NA the resident's right hand pinky finger was bruised and misaligned. The charge nurse was notified, and physician orders obtained for an x-ray. X-ray results identified a fracture involving fifth proximal phalanx (finger bone) with minimal displacement. There is associated soft tissue swelling. MD #1 was notified and directed to transfer Resident #1 to the hospital for evaluation. The facility investigation dated 9/23/2024 identified Companion #1 reported he/she left the room on 9/17/2024 about 8:30 PM, and when arrived at the facility on the morning of 9/18/2024, he/she observed the misaligned finger. Staff interviews were conducted and identified on 9/18/2024 between 2 and 3 AM NA #1 observed Resident #1 on the floor. NA #1indicated the resident was attempting to go to the bathroom, and NA #1 did not report the fall to the nurse. Subsequent to the incident, NA #1's employment was terminated. Review of the Hospital Diagnostic Studies dated 9/18/2024 identified Resident #1's X-Ray of the right hand indicated a nondisplaced fracture of the base of the fifth proximal phalanx. Interview with NA #1 on 10/16/2024 at 11:45 AM identified on 9/18/2024 in the early morning, Resident #1's roommate came into the hallway to notify staff that Resident #1 had fallen. Upon entering the room, NA #1 observed Resident #1 on the floor and asked NA #2 for assistance. NA #1 and NA #2 assisted Resident #1 into the wheelchair and with his/her care, and then into bed. NA #1 indicated Resident #1 did not express any pain, but just wanted to go back to bed. NA #1 identified she did not report the fall to the nurse and was unable to explain why, but stated she should have notified the nurse. Interview with NA #2 on 10/16/2024 at 3:30 PM identified on 9/18/2024 NA #1 asked him to assist Resident #1 after he/she had fallen on the floor. The NAs assisted Resident #1 off the floor and with care, and then back into bed. NA #2 stated that Resident #1 was adamant that he/she was fine and just wanted to go back to bed. NA #2 indicated NA #1 assured him that she would report the fall to the nurse, and NA #2 continued with his shift. NA #2 stated he did not report the fall to the nurse, because he thought NA #1 would have done it. Further, NA #2 stated that although NA #1 verbalized she was going to report the incident, he also should have reported the incident. NA #2 stated he knew all falls are to be reported, but trusted NA #1 to report it because she was an experienced aide who trained him when he was hired. Interview with the DON on 10/16/2024 at 1:15 PM identified during the investigation process, NA #2 stated he had assisted NA #1 after Resident #1 had fallen to the floor and NA #1 told him that she would report the fall to the nurse. The DON further stated during the initial interview with NA #1, NA #1 originally stated that nothing happened during the shift, but when presented with NA #2's statement, NA #1 stated Resident #1 had fallen and the NAs assisted Resident #1 off the floor without notifying the nurse. NA #1 stated she did not notify the nurse because she was nervous. Subsequent to the incident, NA #1's employment was terminated, and NA #2 received education regarding reporting all incidents to the nurse. Review of the Acute Condition Changes Policy dated 3/2018 identified direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse.

Based on a review of the facility Infection Control Program, review of facility documentation and staff interviews, the facility failed to ensure that licensed nursing staff completed the facility's annual education and competencies training for Intravenous Therapy IV. The findings include: The Facility assessment dated [DATE] indicated in part that services and care offered include intravenous medication and IV nutrition. The Facility Assessment further indicated that competencies for nurses included in part, IV Line maintenance. The Facility Assessment did not include IV therapy under 1.11 Staff Training/Education and Competencies; General Requirements for All Health Center Staff that is completed upon hire and annually. Interview and review of facility documentation with RN #2 on 10/25/2022 at 1:20 PM identified although, the annual IV in-servicing for licensed nurses are completed annually on-line, RN # 2 was unable to access evidence of the training for the surveyor. RN #2 further indicated the last IV therapy competency training was completed back in 2020. She also indicated she did not follow up or conduct an interview with the nurses to see if they completed the IV therapy on-line from 2/14/2020 to present. Interview and review of facility documentation with the DNS and RN #2 on 10/25/22 at 1:25 PM indicated that they would check the Human Resource files for any in-servicing-education. The facility failed to provide evidence that licensed staff received IV therapy training after 2/14/2020 to present to ensure staff was qualified , trained and competent in accordance to professional standards of practice.

Based on a review of the facility Infection Control Program, review of facility documentation, facility policy review, and staff interviews, the facility failed to ensure that unlicensed nursing staff completed the facility's annual education and competencies training for Intravenous Therapy IV. The findings include: The Facility assessment dated [DATE] indicated in part that services and care offered include intravenous medication and IV nutrition. The Facility Assessment did not include IV therapy under 1.11 Staff Training/Education and Competencies; General Requirements for All Health Center Staff that is completed upon hire and annually. An interview on 10/25/2022 at 10:30 AM with Director of Nursing Services (DNS) and Registered Nurse (RN #2) identified the nurse aides in the facility did not receive any training or competencies regarding how to care for a resident who has an IV and indicated the nurse aides were told to see the charge nurse if they had any questions regarding IV therapy. Interview and review of facility documentation with RN #2 on 10/25/2022 at 1:20 PM identified she was unable to provide evidence of IV therapy training and competency completed by nurse aides after 2/14/2020 to present. RN #2 also indicated she did not follow up or conduct an interview with the nurse aides to see if they completed the IV therapy on-line from 2/14/2020 to present. Interview and review of facility documentation with the DNS and RN #2 on 10/25/22 at 1:25 PM indicated that they would check the Human Resource files for any in-servicing-education. The facility failed to provide evidence that unlicensed staff received IV therapy training and competency after 2/14/2020 to present.

Based on clinical record reviews, review of facility policy and interviews for 2 of 2 residents (Resident # 145 and #146) reviewed for grievances, the facility failed to act on the resident reported concern related to missing personal items in a timely manner and within accordance to facility policy. The findings included: 1. Resident #145 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 10/21/22 identified Resident #145 had functional Activities of Daily Living (ADL) decline and at risk for cognitive decline. Interventions directed physical, occupational and speech therapy to evaluate and treat per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing admission note dated 10/23/22 at 2:25 PM identified Resident #145 is alert and orient time four, required the assistance of one person with transfer only with hemi walker and assistance of one person with dressing, bathing, and toileting. An interview on 10/24/22 at 11:25AM with Resident #145 identified s/he had left a pair of expensive tweezers on the dietary meal tray. Staff took the tray away but did not remove the tweezers. Resident #145 stated s/he reported the concern to staff but could not recall the name of the staff member at this time. The dietary staff later verbalized they noticed the tweezers but did not know what happened to them. A review of the nursing progress notes, social worker notes and grievance log dated 10/23/22 through 10/24/22 failed to identify the resident reported concern of missing tweezers was followed up by facility staff. An interview on 10/25/22 at 1:22 PM with the Dietary Director identified dietary staff who find missing items on dietary meal trays either return the items to the resident if they know who the resident is or bring them to the nurse's station and report the missing items to the nursing staff. The Dietary Director further indicated she was informed by the nursing staff on 10/22/22 of Resident # 145's missing tweezers. However, the dietary staff were unable to locate the missing item. The facility Resident Rights policy revised 2/2021 notes residents have the right to voice grievances to the facility, or other agencies that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal and to have the facility respond to his or her grievances. The facility failed to follow up and provide an outcome or resolution to Resident # 145's concern regarding missing a pair of extensive tweezers. 2. Resident #146 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 10/22/22 identified Resident #146 was a new admission and adjusting to the facility. An intervention directed that all staff answer questions as they arise. The admission note dated 10/22/22 at 5:42 PM identified the resident was cognitively intact and had no memory impairment. The assessment also noted the resident was independent with ADL. An interview on 10/24/22 with Resident # 146 at 1:27 PM identified a bag of the resident's belongings that came from the hospital went missing. Resident #146 reported the missing items to Occupational Therapist (OT #2) on 10/23/22 because the bag contained shoes needed for walking. OT #2 was unable to locate the missing items at the time it was reported. Resident # 146 further indicated no update has been provided to him/her regarding the missing belongings from the hospital. An interview on 10/25/22 at 2:11 PM with OT #2 identified Resident #146 did report missing shoes to her. OT #2 indicated that although she could not recall the staff names, she reported the missing item to the assigned nurse aide. An attempt to interview (NA #2) on 10/25/22 was unsuccessful. An interview on 10/26/22 at 10:34 AM with Social Worker (SW #1) indicated when a list is generated for reported missing item a grievance form is also generated. The grievance form is sent to all departments to conduct an in-house search. If the missing item was not found, it would be replaced by the facility. SW #1 further indicated she was made aware of the missing items from the Administrator (subsequent to surveyor inquiry) and indicated she was going to follow up with the residents who had missing items. The policy for Grievances /Complaints Filing dated 4/2017 given to surveyor during the survey directed that residents and representatives have the right to file grievances orally or in writing and may be filed anonymously. The Administrator and staff will make prompt efforts to resolve grievances to the resident's satisfaction. Upon receipt of a grievance, the grievance officer, Administrator, and staff will take immediate action to prevent further violations of resident rights while the grievance is being investigated. The facility failed to provide evidence that they conducted an in-house search to located Resident # 146's missing hospital bag with the resident's shoes needed for walking per facility policy.

Based on clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 1 sampled resident (Resident # 346) reviewed for allegations of neglect, the facility failed to conduct a thorough investigation regarding an allegation of being left on the toilet for several hours. The findings include: Resident #346's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 1/28/22 identified a risk for falling and intervention directed to remind the resident to call for assistance for any mobility needs. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #346 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicating no cognitive impairment and no memory problems. The assessment also noted the resident required extensive assistance of two staff members for transfers out of bed and for toilet use. The nurse's note dated 2/6/22 at 11:02 AM identified Resident #346 required the assistance of two staff members for transfers with the utilization of a sliding board. The nurse's note also noted Resident # 346 was non-weight bearing on the right leg and required extensive assistance of two staff members for toileting. A review of the grievance file dated 2/7/22 identified the resident alleged that s/he was left on the toilet for several hours and no one answered her/his call bell during the previous night. Interview and review of the facility's Maintenance Time- Response Monitoring Report with the Administrator on 10/27/22 at 12:00 PM identified the following for resident call bell answer time: On 2/5/22 on the 11-7 AM, 7-3 PM and 3-11 PM shift the resident's call bell was answered within 2- 5 minutes. On 2/6/22 11-7 AM through 3:00 PM and 2/7/22 11-7 AM, 7-3 PM and 3-11 PM the resident's call bell was answered within 2- 5 minutes. A review of the facility's electronic documentation of Resident # 346's ADL care identified the following: On 2/5/22 on the 11-7 AM, 7-3 PM and 3-11 PM shift the resident received care from the assigned Nurse Aide (NA). On 2/6/22 11-7 AM through 3:00 PM and 2/7/22 11-7 AM, 7-3 PM and 3-11 PM the resident received care from the assigned NA. However, the facility electronic documentation of Resident # 346's ADL care on 2/6/22 on the 3-11 PM failed to reflect that staff had documented that care had been provided to the resident on the evening shift. Interview with the Administrator on 10/27/22 at 12:00 PM to 12:05 PM identified s/he could not provide evidence that care was provided to Resident # 346 on the 3-11 PM shift on 2/6/22 secondary to agency nurse aide staff failed to document the care provided. The Administrator was also unable to provide evidence that the facility conducted a thorough investigation of the resident's allegation of being left on the toilet and what type of care the agency nurse aide staff provided to the resident on 2/6/22 on the 3- 11 PM shift. The facility policy for Abuse and Neglect - Clinical Protocol 3/2018 defines neglect as failure of the facility, its employees or service provider to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility failed to thoroughly investigate the resident's allegation of being left on the toilet for several hours to ensure the resident was free from neglect.

Based on clinical record review, review of facility policy and staff interviews for 1 of 1 resident (Resident #3) reviewed for advance directive, the facility failed to transcribe the Do Not Resuscitate (DNR) and Registered Nurse may Pronounce (RNP) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The admission MDS assessment dated [DATE] identified Resident #3 had intact cognition and required extensive assistance of 2 person with transfer, dressing and toileting and hygiene. The assessment also noted the resident was non-ambulatory. The care plan dated 10/19/22 for Resident # 3's advanced directive directed staff to honor the resident wishes. Interventions included to allow opportunity for expression of feelings or concern, informed resident, or responsible party of any change in status and to provide emotional support to the resident or responsible party. A review of Resident # 3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Assistant Director of Nursing (ADON) on 10/25/22 at 10:20 AM identified that the licensed nurse on the unit was responsible for transcribing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Licensed Practical Nurse (LPN #4) on 10/25/22 at 1:50 PM identified the licensed staff was responsible for transcribing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent to inquiry, LPN # 4 transcribed Resident # 3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy for transcribing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to transcribe Resident # 3's DNR and RNP physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of the clinical record, facility documentation, facility policy, and staff interviews for 1 resident (Resident # 145) reviewed for rehabilitation, the facility failed to implement specialized rehabilitative services related to the use of a motorized chair for mobility to attain the resident's highest level of physical, mental, functional, and psycho-social well-being in a timely manner. The findings include: Resident #145 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 10/21/22 identified Resident #145 had functional ADL decline and at risk for cognitive decline. Interventions included physical, occupational and speech therapy to evaluate and treat per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident Summary (care card) dated 10/21/22 noted Resident #145 was limited assist with bed mobility, Extensive assist with toileting, transfer, dressing and personal hygiene and, non-ambulatory. The Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Initial assessment identified Resident #145 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #145 was noted to live alone at home, independent with ADL's, moderate independence with transfers and ambulated using a 3-wheel walker or cane. Resident #145 was also able to drive. The assessment identified Resident # #145 had poor functional endurance requiring moderate assist with transfers, weak upper extremity use and poor safety awareness. A plan was in place that included neurological re-education, self-care/ ADL, therapeutic activities, ultrasound, and wheelchair management five time weekly for 60 days. The admission note dated 10/22/22 at 5:42 PM identified the resident was cognitively intact and had no memory impairment. The assessment also noted the resident was independent with ADL. The Occupational therapy (OT)progress note dated progress note dated 10/24/22 noted Resident #145 was seen for balance and transfer training, supervision while toileting and wheelchair management. Resident #145 was able to bring him/herself to the restroom to perform toilet transfer. A subsequent OT progress note dated 10/24/22 noted Resident #145 was seen for safety of use for a newly acquired power scooter. Resident #145 required cues to pivot towards the scooter rather than away for increase efficiency with transfers. Resident #145 required cue to use fine motor control of the joystick device to obtain maximum level of control. Resident #145 required multiple cues to maintain grasp, and cues to maintain low speed to negotiate objects with ease and increased safety as well as to be able to stop from objects with ease and increased safety so as not to hit them. Resident #145 required supervision level at this time until able to consistently use device at the safest level of function. An observation on 10/24/22 at 1: 30 PM identified Resident #145 stating to Admissions Person #1 You are taking away my favorite toy. An interview on 10/25/22 at 9:15 AM with Resident #145 identified s/he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #145 reported renting a motorized chair for use in the facility the previous day. Resident #145 reported s/he was self-propelling in the hall just after receiving the motorized chair for approximately 20 minutes before being stopped by staff (Admissions Person #1) who inquired how the wheelchair was obtained. According to Resident #145, Admissions Person #1 explained it was not the way we do things here and informed Resident #145 that s/he needed to be assessed for safety and would be required to return the chair. Admission Persons#1 indicated an alternate wheelchair would instead be provided that would allow Resident #145 to self-propel manually using his/her functioning arm. Resident 145 waited all day for someone to come with the alternate wheelchair and no one did. Rehabilitation Director #2 did come later that evening but did not mention anything about an alternate chair. Resident #145 indicated the current wheelchair s/he was using did not allow him/her to self-propel effectively and felt depressed as now s/he as s/he was cooped up with the inability to self-mobilize. Resident #145 stated she would have preferred to keep the motorized chair. An interview on 10/25/22 at 9:45AM with Rehabilitation Director #1 identified, any resident wishing to use a motorized chair would first require an assessment to determine if they are cognitively intact to maneuver the chair, assess speed and adjust as needed, and make sure they can safely maneuver around corners, furniture, and elevator use. A treatment plan would then be put be put in place to for the use of the motorized chair. Rehabilitation Director #1 indicated she was not in the facility the day prior but had been made aware Resident #145 had just been admitted on [DATE]. The facility had been looking for a one-armed wheelchair from the community. Alternately, Resident #145 had acquired a motorized chair from the community without anyone's knowledge. Resident #145 was assessed and determined not to be safe with the use of the motorized wheelchair. Therefore, the motorized wheelchair was returned. Rehabilitation Director #1 did not know the status of availability for the one-armed wheelchair. An interview on 10/25/22 at 10:00 AM with OT #1 identified she had worked with Resident #145 on 10/23/22. Resident #145 had asked OT #1 what her opinion was for the use of a motorized chair. OT #1 indicated she was unsure at that time as she had not been working with Resident #145. Later that afternoon, the motorized wheelchair was delivered to Resident #145's room. OT #1 indicated she assessed Resident #145's use of the motorized chair for ability to manage the control stick, negotiate obstacles and overall safety with use. OT #1 determined Resident #145 would require supervision level with the use of the chair until the required skills were mastered. OT #1 did not know why the chair was returned. An interview on 10/25/22 at 10:21 AM with Admissions Person #1 identified she was notified by Rehabilitation services Resident #145 had acquired a motorized chair from the community and was determined to be unsafe. Admissions Person #1 told Resident #145 s/he would have to return the motorized chair and explained a one-armed wheelchair would be provided by therapy for the resident's use. Admissions Person #1 indicated Resident #145 stated s/he was sad to see the chair go but saved money in the rental of the equipment. Admissions Person #1 did not know the status of the acquisition of the one-armed wheelchair for Resident #145. An interview on 10 /25/22 at 10:37AM with Rehabilitation Director #2 indicated he did inquire about a one-armed wheelchair in the community from two places but had not yet acquired one for use. An interview on 10/27/22 11:53 AM with DNS identified there was a miscommunication between staff in this case. The DNS indicated she would expect staff to provide services that allow any resident to function at the highest practicable level. Although a policy for the provision of services that allow the highest practicable level of well being was requested, none was provided.

Based on observations, clinical record review, facility policy and procedures, review of facility documentation and interviews for one of two units (Elm) reviewed for infection control for (Residents # 32 and #101), the facility failed to consistently implement standard precautions to prevent the spread of infection. The findings include: During a review of the facility's infection control surveillance on the Elm unit on 2/11/20 outside of Resident #32 and Resident #101 room (who was identified with transmission based precautions) for a suspected infection identified Housekeeper (HK#1) coming outside of the room fully donned in his/her protective equipment (i.e. mask, gown and gloves), without the benefit of discarding his/her protective equipment prior to leaving the residents' room. HK#1 was observed standing outside of the residents room wearing his/her protective equipment, tossing small items of trash in the trash bin of his/her cleaning cart located outside of the room in the corridor near the entrance of the room. Upon continued infection control surveillance observation on 2/11/20, HK#1 was observed reaching under his/her protective gown with his/her gloved hand, patting down his/her scrub top and then reaching inside his/her scrub pocket for keys. HK#1 removed his/her gloved hand from the scrub pocket in an attempt to begin to sort through cleaning items on the cart with his/her gloved hands until surveyor intervened. HK#1 re-entered the room, removed and disposed of his/her protective equipment and placed it in a trash receptacle inside the residents' room near the exit. HK#1 was further observed entering the residents' bathroom and could be heard washing his/her hand prior to exiting the room. HK #1 then attempted to clean the keys in his/her pocket with hand sanitizer as opposed to the sanitizing cloths until surveyor intervened. An interview with HK#1 at the time of the observation indicated he/she was wearing protective equipment because Resident #32 and Resident#101 may have an infection. HK #1 also indicated and he/she should not have been standing outside of the residents' room at his/her cleaning cart wearing the protective equipment. On 2/11/20 12:40 P.M. interview with the DNS regarding observations of HK#1 standing outside Resident # 32 and Resident # 101's room while wearing his/her protective equipment at the housekeeping cart. The DNS further indicated HK #1 should not have been standing outside the room with protective equipment on after leaving the residents room.

Based on observations, clinical record reviews, review of facility documentation, review of facility policy, and interviews for two of two sampled residents (Resident 24 and #36) reviewed for physical restraints, the facility failed to ensure the residents were free from physical restraints. The findings included: 1. Resident #24's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #24 was moderately cognitively impaired and required extensive assistance with bed mobility and transfers and the resident was not restrained. The Resident Care Plan (RCP) dated 10/9/18 identified at risk for falls and at risk for elopement. Interventions directed secondary to the resident's impulsive and restless behavior, standing up without assistance to provide assistance as needed with ADL transfers and mobility and to keep the bed in low position. Additionally, directed to allow the resident to travel freely on the unit as restrictions generally serve to agitate and increase the person's desire for the unobtainable. A physician's orders [REDACTED]. The fall risk assessment dated [DATE] identified the resident scored 90. The risk of falling scale indicated a score of greater than or equal to 51 was a high risk. Observation on 12/17/18 at 9:16 A.M. identified Resident #24's was asleep in bed with the bed in the low position, against the wall on the door side with one quarter rail up on the window side. Interview with LPN #1 on 12/17/18 at 7:58 A.M. identified the bed has always been against the wall as a fall measure. An interview with the DNS on 12/18/18 at 1:10 P.M. identified the bed should not have been placed against the wall. If a bed is placed against the wall, a waiver needs to be submitted to the Department of Health (DPH) requesting that the bed be placed against the wall and then the waiver need to be approved by the DPH. Additionally, the DNS indicated he/she conducted an investigation of the incident and discovered a NA had placed the bed against the wall. Interview with NA #1 on 12/19/18 at 12:41 P.M. identified Resident # 24 has attempted to get out of bed in the past and can while in bed throw his/her legs over the side of the bed. Subsequent to surveyor inquiry, the resident's bed was moved away from the wall and the DNS in-serviced staff on restraints, fall prevention and approved interventions. 2. Resident #36's [DIAGNOSES REDACTED]. The significant change in status MDS assessment dated [DATE] identified Resident #36 was moderately cognitively impaired and required extensive assistance with bed mobility and transfers, had a history of [REDACTED]. The assessment also noted the resident was not restrained. The care plan dated 10/29/18 identified at risk for falls related to history, repeated falls and fracture of right hip and impaired vision related to [MEDICATION NAME] degeneration. Interventions directed to check on the resident every hour when in bed and to provide visual cue in the bathroom and at bedside, to remind resident to ask for assistance with standing and directed to keep the floor in room/corridors clean, dry and free of clutter/obstacles that may impede safety. The fall risk assessment dated [DATE] identified a score of 55 where a score of greater than or equal to 51 identified a high risk for falls. A physician's orders [REDACTED]. Observation on 12/17/18 at 7:42 A.M. identified Resident #36 in bed asleep. On the left side of the bed on the window side of the room, the 1/4 side rail was noted up. At the end of the side rail were two dining room type chairs with the seats touching the mattress extending almost all the way to the foot board. On the right side of the bed on the door side of the room, the 1/4 side rail was up. At the end of the side rail was a wing chair with the foot rest partially open sitting parallel to the bed so that the arm of the wing chair was touching the mattress and the foot rest extended almost to the foot board. Interview with the DNS on 12/17/18 7:56 A.M. identified the chairs should not be position like that and indicated he/she would call the supervisor to find out why the resident was left in that way. A re-interview with the DNS on 12/18/18 at 1:00 P.M. identified the chairs should not have been placed around the resident's bed and indicated he/she had conducted an in-service with staff to make them aware that placing chairs around the bed was a form of restraining the resident. Although, the DNS could not identify the staff member who had placed the chairs around the resident's bed, he/she was able to identify that staff had provided care to the resident and then replaced the chairs around the bed. Interview with NA #2 on 12/19/18 at 12:36 P.M. identified he/she has not personally observed Resident # 36 getting out of bed, but knew the resident was a fall risk. Subsequent to surveyor inquiry, the chairs were removed away from the resident's bed and the DNS in-serviced staff on restraints, fall prevention and approved interventions. Review of facility restraint policy identified, in part, restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls.

Based on observations, clinical record review and interviews for one sampled resident (Resident #36) reviewed for accidents, the facility failed to ensure a safe environment. The finding include: Resident #36's [DIAGNOSES REDACTED]. The significant change in status MDS assessment dated [DATE] identified Resident #36 was moderately cognitively impaired and required extensive assistance with bed mobility and transfers, had a history of [REDACTED]. The assessment also noted the resident was not restrained. The care plan dated 10/29/18 identified at risk for falls related to history, repeated falls and fracture of right hip and impaired vision related to [MEDICATION NAME] degeneration. Interventions directed to check on the resident every hour when in bed and to provide visual cue in the bathroom and at bedside, to remind resident to ask for assistance with standing and directed to keep the floor in room/corridors clean, dry and free of clutter/obstacles that may impede safety. The fall risk assessment dated [DATE] identified a score of 55 where a score of greater than or equal to 51 identified a high risk for falls. A physician's orders [REDACTED]. Observation on 12/17/18 at 7:42 A.M. identified Resident #36 in bed asleep. On the left side of the bed on the window side of the room, the 1/4 side rail was noted up. At the end of the side rail were two dining room type chairs with the seats touching the mattress extending almost all the way to the foot board. On the right side of the bed on the door side of the room, the 1/4 side rail was up. At the end of the side rail was a wing chair with the foot rest partially open sitting parallel to the bed so that the arm of the wing chair was touching the mattress and the foot rest extended almost to the foot board. Interview with the DNS on 12/17/18 7:56 A.M. identified the chairs should not be position like that and indicated he/she would call the supervisor to find out why the resident was left in that way. A re-interview with the DNS on 12/18/18 at 1:00 P.M. identified the chairs should not have been placed around the resident's bed and indicated he/she had conducted an in-service with staff to make them aware that placing chairs around the bed was a form of restraining the resident. Although, the DNS could not identify the staff member who had placed the chairs around the resident's bed, he/she was able to identify that staff had provided care to the resident and then replaced the chairs around the bed. Interview with NA #2 on 12/19/18 at 12:36 P.M. identified he/she has not personally observed Resident # 36 getting out of bed, but knew the resident was a fall risk. Subsequent to surveyor inquiry, the chairs were removed away from the resident's bed.

Based on review of the clinical record, staff interviews, and a review of the facility policy for one sampled resident (Resident #47) who presented with peripheral vascular ulcers, the facility failed to notify the physician of a change in condition to ensure timely treatment that resulted in immediate jeopardy. The finding included: Review of the clinical record identified Resident #47 was admitted to the facility on [DATE] with a right lower extremity venous ulcer. The resident was treated by a plastic surgeon commencing in (MONTH) of (YEAR). Resident #47 was previously treated by a vascular surgeon from 2014 through (YEAR) with failed attempts to heal the wound both with conservative management and non-human allografts. Resident #47 underwent an angioplasty of the right femoral popliteal system in (MONTH) of (YEAR). Resident #47 was admitted from an acute care setting in (MONTH) of (YEAR) after an operative procedure that included a wound debridement and skin graft. The skin graft was obtained from the resident's left medial thigh. Resident #47 was treated with antibiotics as the right lower extremity wound was infected with pseudomonas. Resident #47's [DIAGNOSES REDACTED]. The Norton pressure scale dated 6/13/17 identified the resident was at high risk for skin breakdown, however, review of the clinical record failed to identify an admission assessment of the left leg graft site or the right leg vascular ulcer. Review of the nurse's notes dated 6/13/17 identified Resident #47 refused to have the wound site dressings changed. The facility notified the plastic surgeon on 6/13/17, however, failed to obtain an order until 6/18/17 that directed to not disturb the dressing. The physician's order for wound care dated 6/21/17 directed to cleanse the right lower extremity and left medial thigh with normal saline, apply [MEDICATION NAME] cream, followed by a [MEDICATION NAME] dressing. An ace wrap was to be placed from the right foot to the knee over the venous ulcer and paper tape to be placed on the donor site. The order further directed to change the dressings daily and as needed. The nursing care plan dated 6/14/17 identified skin integrity as a problem related to limited mobility and chronic leg ulcers with interventions that included weekly skin assessments, compromised skin areas would be monitored and managed by the physician orders, utilize a pressure relieving mattress and skin cushion for chair use. The care plan further directed to turn and reposition the resident every two hours, update the physician with any changes in compromised areas and with any signs of wound complications, signs of infections or failure to make progress. The Minimum (MDS) data set [DATE] identified intact cognition, extensive assistance for bed mobility, transfers, ambulation and toilet use, no repositioning program, and no pressure ulcers. Review of Resident #47's clinical record from 6/13/17 through 9/4/17 failed to identify that weekly wound measurements and assessments had been completed. On 9/5/17 the visual skin assessment identified the right lower leg wound measured 24 centimeters (cm) by 22 cm by 0.2 cm with a pink/yellow wound bed that had a pungent odor and a large amount of clear drainage with granulation and slough. The graft site was identified on the left medial thigh that measured 3 cm by 12 cm. The site was noted to be red in color, with a small amount of serosanguinous drainage, and the wound bed was mostly granulated with scattered spots of slough. On 9/13/17 and 9/20/17 the right lower leg measured 23 cm by 22 cm by 0.2 cm. Although review of the clinical record identified skin/wound assessments were conducted on 9/5/17, 9/13/17, and 9/20/17, the facility failed to identify weekly wound bed assessments of either wound and/or failed to measure or track the graft site wound from 6/13/17 through 9/4/17. The nursing care plan dated 6/14/18 identified a potential for decreased cardiac output as a problem with interventions that included monitor and document for complaints of headache, decreased urinary output, and bilateral lower extremity [MEDICAL CONDITION]. Additional interventions included to monitor and document the presence of bluish color of nailbeds, lips, oral mucosa and extremities, mental status changes and report to the physician. The plan further directed to assess for therapeutic effectiveness of the residents medications and monitor for adverse effects, elevate the head of the bed, administer oxygen as needed and monitor intake and output per physician order. Review of the nurse's notes from 6/13/17 through 9/26/17 failed to identify that circulation assessments were conducted on multiple occasions throughout the course of the residents three and a half month admission. Further review of the nurse's notes dated 9/26/17 identified Resident #47 was transferred to an acute care setting to evaluate the wound and the condition of the right lower leg extremity. Review of the hospital record dated 9/26/17 identified Resident #47 presented to the emergency room in extreme pain with swelling and foul smelling purulent discharge from the right leg. The resident was noted to be dysarthric and confused. The right lower extremity appeared non- healing with complete destruction of the skin and soft tissue with the exposure of a long tendon. The toe was mottled blue and cyanotic. A pedal pulse could not be obtained in the right foot.[MEDICAL CONDITION] and gangrene of the lower extremity was diagnosed . On 9/28/17 a right above knee amputation was completed. Interview and review of the nurse's note date 9/24/17 at 11:00 AM with RN #1 on 12/20/17 at 12:30 PM identified the right lower extremity wound had moderate amounts of yellow, bloody drainage and had a foul odor. RN #1 indicated she notified the physician of the wound assessment however, she did not speak to him/her for further directions and did not document the notification. Interview and review of the nurse's note dated 9/25/17 at 4:01 PM with LPN #1 on 12/19/17 at 11:30 AM identified the right lower extremity wound bed contained white slough with a dark colored drainage in a moderate amount with a foul odor and poor circulation was noted on the right lower extremity with toes that had turned blue LPN #1 indicated s/he notified RN #4, who was the nursing supervisor, and also called MD #4. LPN #1 indicated MD #4 informed the facility to notify MD #2, who was the plastic surgeon. LPN #1 identified a call was placed to MD #2 and documented that the physician would follow up with the resident on the following day. Interview and review of the nurse's notes with RN #4 on 12/19/17 at 11:45 AM indicated s/he cared for Resident #47 on 9/25/17 from 3:00 PM until 11:30 PM and identified s/he was aware of the poor circulation to the right lower extremity and elevated the residents legs. RN #4 indicated s/he did not conduct a circulation assessment nor speak with the physician as felt this issue could wait until the next day. Interview with RN #3 on 12/20/17 at 11:55 AM identified s/he cared for Resident #47 on 9/25/17 from 11:00 PM until 7:00 AM the following morning. RN #3 indicated s/he did not conduct a circulation assessment of the resident's extremity. RN #3 identified s/he did not notify the physician as she was not aware of a change in condition. Interview and review of the clinical record with the Director of Nursing (DON) on 12/20/17 at 10:00 AM identified the facility practice is to have the nursing supervisor conduct a comprehensive circulatory and wound assessment, and to immediately communicate the change in condition with the physician to ensure prompt treatment for [REDACTED]. Interview with MD #4 who was the attending physician and the Medical Director on 12/21/17 and on 12/22/17 respectively, identified they do not recall being notified on 9/5/17, 9/24/17 or on 9/25/17 regarding the wound change and/or decreased circulation to the right lower extremity. The Medical Director indicated they would expected to be notified of a deteriorating change in the wound and a decrease in peripheral circulation. The Medical Director identified with either condition s/he would have transferred the resident immediately to an acute care setting. Interview with MD #2, who was the plastic surgeon, on 12/20/17 at 10:30 AM indicated that the office received a call on 9/25/17 however, s/he was only notified regarding increase drainage to the wound. MD #2 identified had s/he known about the residents poor circulation direction would have been given to transfer the resident to the hospital immediately as this was a medical condition that required urgent treatment. Although the facility policy entitled Change in a Resident's Condition directed in part, that the nurse would notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition or the need to transfer the resident to a hospital, review of the clinical record and interview with facility staff failed to identify timely notification to the physician when a decline in the peripheral vascular was noted on 9/24/17. Further, the policy indicated a significant change of condition was defined as a major decline in the resident's status that would not resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The nurse would make detailed observations and gather relevant and pertinent information for the provider. The facility failed to recognize that notification to the physician was not done when the vascular ulcer was noted to decline as evidenced by decreased circulation to the right lower extremity and increased drainage with a foul odor, therefore, the Department requested an action plan to include interventions to mitigate any further risks to other residents. The action plan included skin assessments on all patients, circulatory, motor, and sensory checks on residents in need, ongoing education to staff regarding circulatory checks, timely physician notification, wound measurements, and audits of visual skin assessments.

Based on a review of the clinical record, staff interviews, and a review of the facility policy for one of three sampled residents reviewed for wounds (Resident #47), the facility failed to provide the necessary care and services to ensure the resident was free from neglect that resulted in immediate jeopardy. The findings included: Review of the clinical record identified Resident #47 was admitted to the facility on [DATE] with a right lower extremity venous ulcer. The resident was treated by a plastic surgeon commencing in (MONTH) of (YEAR). Resident #47 was previously treated by a vascular surgeon from 2014 through (YEAR) with failed attempts to heal the wound both with conservative management and non-human allografts. Resident #47 underwent an angioplasty of the right femoral popliteal system in (MONTH) of (YEAR). Resident #47 was admitted from an acute care setting in (MONTH) of (YEAR) after an operative procedure that included a wound debridement and skin graft. The skin graft was obtained from the resident's left medial thigh. Resident #47 was treated with antibiotics as the right lower extremity wound was infected with pseudomonas. Resident #47's [DIAGNOSES REDACTED]. a. The Norton pressure scale dated 6/13/17 identified the resident was at high risk for skin breakdown, however, review of the clinical record failed to identify an admission assessment of the left leg graft site or the right leg vascular ulcer. Review of the nurse's notes dated 6/13/17 identified Resident #47 refused to have the wound site dressings changed. The facility notified the plastic surgeon on 6/13/17, however, failed to obtain an order until 6/18/17 that directed to not disturb the dressing. The following physician's order for wound care dated 6/21/17 directed to cleanse the right lower extremity and left medial thigh with normal saline, apply [MEDICATION NAME] cream, followed by a [MEDICATION NAME] dressing. An ace wrap was to be placed from the right foot to the knee over the venous ulcer and paper tape to be placed on the donor site. The order further directed to change the dressings daily and as needed. The nursing care plan dated 6/14/17 identified skin integrity as a problem related to limited mobility and chronic leg ulcers with interventions that included weekly skin assessments, compromised skin areas would be monitored and managed by the physician orders, utilize a pressure relieving mattress and skin cushion for chair use. The care plan further directed to turn and reposition the resident every two hours, update the physician with any changes in compromised areas and with any signs of wound complications, signs of infections or failure to make progress. The Minimum (MDS) data set [DATE] identified intact cognition, extensive assistance for bed mobility, transfers, ambulation and toilet use, no repositioning program, and no pressure ulcers. Review of Resident #47's clinical record from 6/13/17 through 9/4/17 failed to identify that weekly wound measurements and assessments had been completed. On 9/5/17 the visual skin assessment identified the right lower leg wound measured 24 centimeters (cm) by 22 cm by 0.2 cm with a pink/yellow wound bed that had a pungent odor and a large amount of clear drainage with granulation and slough. The graft site was identified on the left medial thigh that measured 3 cm by 12 cm. The site was noted to be red in color, with a small amount of serosanguinous drainage, and the wound bed was mostly granulated with scattered spots of slough. On 9/13/17 and 9/20/17 the right lower leg measured 23 cm by 22 cm by 0.2 cm. Although review of the clinical record identified skin/wound assessments were conducted on 9/5/17, 9/13/17, and 9/20/17, the facility failed to identify weekly wound bed assessments of either wound and/or failed to measure or track the graft site wound from 6/13/17 through 9/4/17. Interview and review of the nurse's note date 9/24/17 at 11:00 AM with RN #1 on 12/20/17 at 12:30 PM identified the right lower extremity wound had moderate amounts of yellow, bloody drainage and had a foul odor. RN #1 indicated she notified the physician of the wound assessment however, she did not speak to him/her for further directions and did not document the notification. Interview and review of the nurse's note dated 9/25/17 at 4:01 PM with LPN #1 on 12/19/17 at 11:30 AM identified the right lower extremity wound bed contained white slough with a dark colored drainage in a moderate amount with a foul odor. LPN #1 indicated s/he notified RN #4, who was the nursing supervisor, and also called MD #4. LPN #1 indicated MD #4 informed the facility to notify MD #2, who was the plastic surgeon. LPN #1 identified a call was placed to MD #2. LPN #1 documented that the physician would follow up with the resident on the following day. Interview and review of the nurse's notes with RN #4 on 12/19/17 at 11:45 AM indicated she cared for Resident #47 on 9/25/17 from 3:00 PM until 11:30 PM and identified she did not speak with the physician as she felt this issue could wait until the next day. Further review of the nurses notes dated 9/26/17 identified Resident #47 was transferred to an acute care setting to evaluate the wound and a possible need for intravenous antibiotics. Review of the hospital record dated 9/26/17 identified Resident #47 presented to the emergency room in extreme pain with swelling and foul smelling purulent discharge from the right leg. The resident was noted to be dysarthric and confused. The right lower extremity appeared non- healing with complete destruction of the skin and soft tissue with the exposure of a long tendon.[MEDICAL CONDITION] and gangrene of the lower extremity was diagnosed . On 9/28/17 a right above knee amputation was completed. Interview and review of the clinical record with the Director of Nursing (DON) on 12/20/17 at 10:00 AM identified from (MONTH) through (MONTH) of (YEAR) weekly wound assessments had not been completed by the facility for Resident #47. The DON indicated the nurse in charge of each unit had been assigned to conduct weekly wound assessments however, the charge nurse failed to monitor non-pressure wounds and the facility failed to ensure the measurements and/or assessments of the wound beds were completed. Interview with MD #4 who was the attending physician and the Medical Director on 12/21/17 and on 12/22/17 respectively, identified they do not recall being notified on 9/5/17, 9/24/17 or on 9/25/17 regarding the wound change. The Medical Director was also not aware that weekly wound assessments were not completed for several months. The Medical Director indicated s/he would have expected the facility to ensure that comprehensive weekly wound assessments were conducted and to be notified of a deteriorating change in the wound. The facility policy entitled wound care, directed in part, that the facility would verify a physician's order for the procedure and review the resident's care plan to assess for any special needs of the resident including pain medication prior to the treatment. The policy further directed that the type of wound, the date and time of the wound care, any change in the resident's condition, the wound bed color, size and drainage would be assessed when inspecting the wound and documented to the medical record. The supervisor would be notified if the resident refused the wound care. b. Review of the nurse's notes from 6/13/17 through 9/26/17 failed to identify that circulation assessments were conducted on multiple occasions throughout the course of the residents three and a half month admission. The nursing care plan dated 6/14/17 identified a potential for decreased cardiac output as a problem with interventions that included monitor and document for complaints of headache, decreased urinary output, bilateral lower extremity [MEDICAL CONDITION]. Additional interventions included to monitor and document the presence of bluish color of nailbeds, lips, oral mucosa and extremities, mental status changes and report to the physician. The plan further directed to assess for therapeutic effectiveness of the residents medications and monitor for adverse effects, elevate the head of the bed, administer oxygen as needed and monitor intake and output per physician order. Interview and review of the nurse's note dated 9/25/17 at 4:01 PM with LPN #1 on 12/19/17 at 11:30 AM identified poor circulation to the right lower extremity with toes that had turned blue. LPN #1 indicated s/he notified RN #4, who was the nursing supervisor regarding the change in circulation and also called MD #4. LPN #1 indicated MD #4 informed the facility to notify MD #2, who was the plastic surgeon. LPN #1 stated a call was placed to MD #2. LPN #1 documented that the physician would follow up with the resident on the following day. During an interview and review of the nurse's notes with RN #4 on 12/19/17 at 11:45 AM, s/he indicated she cared for Resident #47 on 9/25/17 from 3:00 PM until 11:30 PM and identified she was aware of the poor circulation to the right lower extremity and elevated the residents legs. RN #4 indicated s/he did not conduct a circulation assessment and s/he did not speak with the physician as s/he felt this issue could wait until the next day. Interview with RN #3 on 12/20/17 at 11:55 AM identified s/he cared for Resident #47 on 9/25/17 from 11:00 PM until 7:00 AM the following morning. RN #3 indicated s/he did not conduct a circulation assessment of the resident's extremity. RN #3 identified s/he typically completed a visual observation of the residents foot and looks for swelling, pressure areas and an eyeball assessment for circulation. Further review of the nurses notes dated 9/26/17 identified Resident #47 was transferred to an acute care setting to evaluate the wound and the condition of the right lower leg extremity. Review of the hospital record dated 9/26/17 identified upon admission to the emergency room the residents toes were mottled blue and cyanotic. A pedal pulse could not be obtained in the right foot. Interview with the DON on 12/19/17 at 3:00 PM indicated although the facility did not have a policy that directed circulatory assessments the expectation would be to conduct a circulation, motion and sensation (CMS) assessment once a shift on any resident that required this assessment in accordance with the plan of care. Interview with MD #4 who was the attending physician and the Medical Director on 12/21/17 and on 12/22/17 identified they do not recall being notified on 9/25/17 regarding the change in circulation to the residents right lower leg. MD #4 and the Medical Director indicated they would have expected to be notified when the change in condition occurred and would have transferred the resident immediately to an acute care setting. Interview with MD #2, who was the plastic surgeon, on 12/20/17 at 10:30 AM indicated that the office received a call on 9/25/17 however, s/he was only notified regarding increase drainage to the wound. MD #2 identified had s/he known about the residents poor circulation they would have directed to transfer the resident to the hospital immediately as this was a medical condition that required urgent treatment. c. Interview with the DON on 12/20/17 at 2:45 PM identified the physician should have been notified of the wound assessment on 9/5/17 and on 9/24/17 when a foul odor was present. The physician should also have been notified on 9/25/17 of both the wound assessment and the poor circulation to the right lower extremity. Further interview with the DON indicated on 9/25/17 the facility practice is to have the nursing supervisor conducted a comprehensive wound and circulation assessment, notified the physician, and transferred the resident to the hospital. Interview with the Medical Director on 12/21/17 at 1:15 PM identified s/he would have expected to be notified regarding the change in condition on 9/24/17 and on 9/25/17 to ensure prompt treatment. The facility policy entitled Change in a Resident's Condition directed in part, the nurse would notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition or the need to transfer the resident to a hospital. A significant change of condition was defined as a major decline in the resident's status that would not resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The nurse would make detailed observations and gather relevant and pertinent information for the provider. Review of the clinical record and interview with the facility staff failed to identify that the facility assessed Resident #47's peripheral vascular ulcer from 6/13/17-9/4/17, failed to notify the physician when the peripheral vascular wound was noted to have a signifcant decline on 9/24/17 and failed to maintain the resident's optimum physical wellbeing which led to neglect. The facility failed to recognize that the necessary care and services in accordance with the resident treatment plan and facility policy and procedures was provided to ensure the resident was free from neglect, therefore, the Department requested an action plan to include interventions to mitigate any further risks to other residents. The action plan included skin assessments on all patients, circulatory, motor, and sensory checks on residents in need, ongoing education to staff regarding circulatory checks, wound measurements, timely physician notification and audits of visual skin assessments.

Based on a review of the clinical record, staff interviews, and a review of the facility policy for one of three sampled residents reviewed for wounds (Resident #47), the facility failed to provide prompt treatment to promote the resident's highest level of physical well-being that resulted in immediate jeopardy. The finding included: Review of the clinical record identified Resident #47 was admitted to the facility on [DATE] with a right lower extremity venous ulcer. The resident was treated by a plastic surgeon commencing in (MONTH) of (YEAR). Resident #47 was previously treated by a vascular surgeon from 2014 through (YEAR) with failed attempts to heal the wound both with conservative management and non-human allografts. Resident #47 underwent an angioplasty of the right femoral popliteal system in (MONTH) of (YEAR). Resident #47 was admitted from an acute care setting in (MONTH) of (YEAR) after an operative procedure that included a wound debridement and skin graft. The skin graft was obtained from the resident's left medial thigh. Resident #47 was treated with antibiotics as the right lower extremity wound was infected with pseudomonas. Resident #47's [DIAGNOSES REDACTED]. The Norton pressure scale dated 6/13/17 identified the resident was at high risk for skin breakdown, however, review of the clinical record failed to identify an admission assessment of the left leg graft site or the right leg vascular ulcer. Review of the nurse's notes dated 6/13/17 identified Resident #47 refused to have the wound site dressings changed. The facility notified the plastic surgeon on 6/13/17, however, failed to obtain an order until 6/18/17 that directed to not disturb the dressing. The following physician's order for wound care dated 6/21/17 directed to cleanse the right lower extremity and left medial thigh with normal saline, apply [MEDICATION NAME] cream, followed by a [MEDICATION NAME] dressing. An ace wrap was to be placed from the right foot to the knee over the venous ulcer and paper tape to be placed on the donor site. The order further directed to change the dressings daily and as needed. The nursing care plan dated 6/14/17 identified skin integrity as a problem related to limited mobility and chronic leg ulcers with interventions that included weekly skin assessments, compromised skin areas would be monitored and managed by the physician orders, utilize a pressure relieving mattress and skin cushion for chair use. The care plan further directed to turn and reposition the resident every two hours, update the physician with any changes in compromised areas and with any signs of wound complications, signs of infections or failure to make progress. The Minimum (MDS) data set [DATE] identified intact cognition, extensive assistance for bed mobility, transfers, ambulation and toilet use, no repositioning program, and no pressure ulcers. Review of Resident #47's clinical record from 6/13/17 through 9/4/17 failed to identify that weekly wound measurements and assessments had been completed. On 9/5/17 the visual skin assessment identified the right lower leg wound measured 24 centimeters (cm) by 22 cm by 0.2 cm with a pink/yellow wound bed that had a pungent odor and a large amount of clear drainage with granulation and slough. The graft site was identified on the left medial thigh that measured 3 cm by 12 cm. The site was noted to be red in color, with a small amount of serosanguinous drainage, and the wound bed was mostly granulated with scattered spots of slough. On 9/13/17 and 9/20/17 the right lower leg measured 23 cm by 22 cm by 0.2 cm. Although review of the clinical record identified skin/wound assessments were conducted on 9/5/17, 9/13/17, and 9/20/17, the facility failed to identify weekly wound bed assessments of either wound and/or failed to measure or track the graft site wound from 6/13/17 through 9/4/17. The nursing care plan dated 6/14/17 identified a potential for decreased cardiac output as a problem with interventions that included monitor and document for complaints of headache, decreased urinary output, bilateral lower extremity [MEDICAL CONDITION]. Additional interventions inclided to monitor and document the presence of bluish color of nailbeds, lips, oral mucosa and extremities, mental status changes and report to the physician. The plan further directed to assess for therapeutic effectiveness of the residents medications and monitor for adverse effects, elevate the head of the bed, administer oxygen as needed and monitor intake and output per physician order. Review of the nurse's notes from 6/13/17 through 9/26/17 failed to identify that circulation assessments were conducted on multiple occasions throughout the course of the residents three and a half month admission. The Minimum (MDS) data set [DATE] identified intact cognition, extensive assistance for bed mobility, transfers, ambulation and toilet use, no repositioning program, and no pressure ulcers. Further review of the nurses notes dated 9/26/17 identified Resident #47 was transferred to an acute care setting to evaluate the wound and the condition of the right lower leg extremity. Review of the hospital record dated 9/26/17 identified Resident #47 presented to the emergency room in extreme pain with swelling and foul smelling purulent discharge from the right leg. The resident was noted to be dysarthric and confused. The right lower extremity appeared non- healing with complete destruction of the skin and soft tissue with the exposure of a long tendon. The toe was mottled blue and cyanotic. A pedal pulse could not be obtained in the right foot.[MEDICAL CONDITION] and gangrene of the lower extremity was diagnosed . On 9/28/17 a right above knee amputation was completed. Interview and review of the nurse's note date 9/24/17 at 11:00 AM with RN #1 on 12/20/17 at 12:30 PM identified the right lower extremity wound had moderate amounts of yellow, bloody drainage and had a foul odor. RN #1 indicated she notified the physician of the wound assessment, however, she did not speak to him/her for further directions and did not document the notification. Interview and review of the nurse's note dated 9/25/17 at 4:01 PM with LPN #1 on 12/19/17 at 11:30 AM identified the right lower extremity wound bed contained white slough with a dark colored drainage in a moderate amount with a foul odor and poor circulation was noted on the right lower extremity with toes that had turned blue. LPN #1 indicated s/he notified RN #4, who was the nursing supervisor, and also called MD #4. LPN #1 indicated MD #4 informed the facility to notify MD #2, who was the plastic surgeon. LPN #1 identified a call was placed to MD #2. LPN #1 documented that the physician would follow up with the resident on the following day. Interview and review of the nurse's notes with RN #4 on 12/19/17 at 11:45 AM indicated s/he cared for Resident #47 on 9/25/17 from 3:00 PM until 11:30 PM and identified s/he was aware of the poor circulation to the right lower extremity and elevated the residents legs. RN #4 indicated s/he did not conduct a circulation assessment and did not speak with the physician as felt this issue could wait until the next day. Interview with RN #3 on 12/20/17 at 11:55 AM identified s/he cared for Resident #47 on 9/25/17 from 11:00 PM until 7:00 AM the following morning. RN #3 indicated s/he did not conduct a circulation assessment of the resident's extremity. RN #3 identified s/he typically completes a visual observation of the resident's foot and looks for swelling, pressure areas and an eyeball assessment for circulation. Interview and review of the clinical record with the Director of Nursing (DON) on 12/20/17 at 10:00 AM identified from (MONTH) through (MONTH) of (YEAR) weekly wound assessments had not been completed by the facility for Resident #47. The DON indicated the nurse in charge of each unit had been assigned to conduct weekly wound assessments, however, the charge nurse failed to monitor non-pressure wounds and the facility failed to ensure the measurements and/or assessments of the wound beds were completed. Further interview with the DON indicated although the facility did not have a policy that directed circulatory assessments the expectation would be to conduct a circulation, motion and sensation (CMS) assessment once a shift on any resident that required this assessment in accordance with the plan of care. Interview with MD #4 who was the attending physician and the Medical Director on 12/21/17 and on 12/22/17 respectively, identified they do not recall being notified on 9/5/17, 9/24/17 or on 9/25/17 regarding the wound change and/or decreased circulation to the right lower extremity. The Medical Director was not aware that weekly wound assessments were not completed and indicated he would have expected the facility to ensure that comprehensive weekly wound assessments were conducted, to be notified of a deteriorating change in the wound and a decrease in peripheral circulation. The Medical Director identified with either condition he would have transferred the resident immediately to an acute care setting. Interview with MD #2, who was the plastic surgeon, on 12/20/17 at 10:30 AM indicated that the office received a call on 9/25/17 however, s/he was only notified of the increased drainage to the wound. MD #2 identified had s/he known about the residents poor circulation they would have directed to transfer the resident to the hospital immediately as this was a medical condition that required urgent treatment. The facility policy entitled wound care directed in part that the facility would verify a physician's order for the procedure and review the resident's care plan to assess for any special needs of the resident including pain medication prior to the treatment. The policy further directed that the type of wound, the date and time of the wound care, any change in the resident's condition, the wound bed color, size and drainage would be assessed when inspecting the wound and documented to the medical record. The supervisor would be notified if the resident refused the wound care. The facility policy entitled Change in a Resident's Condition directed in part that the nurse would notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition or the need to transfer the resident to a hospital. A significant change of condition was defined as a major decline in the resident's status that would not resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The nurse would make detailed observations and gather relevant and pertinent information for the provider. Review of the clinical record and interview with the facility staff failed to identify that the facility assessed Resident #47's peripheral vascular ulcer from 6/13/17-9/4/17 and failed to maintain the resident's optimum physical wellbeing. The facility failed to recognize that the necessary care and services in accordance with the resident treatment plan to address the vascular ulcer was not provided, to promote the resident's highest level of physical well-being, therefore, the Department requested an action plan to include interventions to mitigate any further risks to other residents. The Department requested an action plan to include interventions to mitigate any further risks to other residents. The action plan included skin assessments on all patients, circulatory, motor, and sensory checks on residents in need, ongoing education to staff regarding circulatory checks, wound measurements, timely physician notification and audits of visual skin assessments.

Based on clinical record reviews, observations and interviews for two of six sampled residents reviewed with pressure sores (R#40, 97), the facility utilized a prescription wound treatment on intact skin resulting in a pressure sore developing and/or failed to monitor and/or assess skin for changes, and/or failed to provide appropriate treatments and protection to an open wound. The findings include: 1. Resident #40's [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] noted an old pressure ulcer that was healed to the coccyx. Admission physician orders [REDACTED]. Physician orders [REDACTED]. There was no nursing note or skin assessment to indicate why the topical medication was ordered for scar tissue. The admission MDS dated [DATE] identified that the resident was cognitively impaired, required assistance from staff for bed mobility and transfers, was continent of bowel and bladder, was not at risk for pressure sore development and did not have a pressure sore. Nurse's notes dated 2/23/16 documented a skin breakdown to the coccyx reported by the day shift nurse. Upon exam at 21:30, the resident was found with an unstageable pressure ulcer to the coccyx /right medial buttock. Granulation and slough were seen in the wound bed. Physician orders [REDACTED]. A wound assessment dated [DATE] noted the presence of an unstageable wound measuring 0.5 by 0.5 by 0.25 cm deep. The wound bed appearance was documented as healing and the origin date erroneously documented as present on admission on 2/11/16 (resident had no wound on admission). Interview and review of the clinical record on 03/15/2016 at 10:54:41 AM with RN#2 noted that he/she was unable to explain how the wound was not found until it had become an unstageable pressure sore when licensed nurses were signing off that they had applied a prescription ointment three times a day. On 03/15/2016 at 1:14:02 PM, review of the manufacturer's package insert with RN#2 noted that Venelex is used to provide wound healing and the treatment of [REDACTED]. RN#2 noted that the prior wound nurse, initiated the protocol to use the drug Venelex for skin protection although the manufacturer's recommendations did not indicate that as a use. Review of the clinical record and interview with the ADNS on 03/16/2016 at 12:49:11 PM failed to provide documentation to address why Venelex was ordered on [DATE]. RN#2 was unable to provide documentation of skin assessments from 2/14 through 2/24/16 when the resident was first noted with an unstageable pressure ulcer. 2. Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified a yellow, non-blanchable pressure ulcer to the buttock measuring 1.00 cm x 0.5 cm x 0.50 with no odor and/or drainage present. Physician orders [REDACTED]. Nurse's notes dated 1/12/16 identified a stage three pressure ulcer to the gluteal cleft measuring 1.8 cm x 0.6 cm x 0.6 cm, wound bed with 100% moist yellow slough, no surrounding redness or drainage identified. An admission MDS assessment dated [DATE] identified the resident had severely impaired cognition, no mood or behaviors were exhibited, required limited assistance with bed mobility and transfers, extensive assistance with personal hygiene, was frequently incontinent of bowel and bladder, at risk for pressure ulcer development, had one stage three pressure ulcer, pressure reducing devices were on the bed and chair, and the resident was not on a turning and repositioning program. The RCP dated 1/28/16 identified a stage three pressure ulcer was present on admission. Interventions included treatment per physician orders, encourage side to side positioning in bed, air mattress and air cushion to chair. Physician orders [REDACTED]. Weekly wound review dated 2/24/16 identified an unstageable pressure ulcer on the gluteal cleft measuring 1.8 cm x 0.8 cm with 100% moist, pale yellow slough present, no areas of depth identified, now an unstageable wound. Physician orders [REDACTED]. A revision to the plan of care was noted on 3/1/16 identifying a new intervention to leave the wound open to air, assess for changes every evening, and continue with weekly wound measurements. An observation and interview with RN #2 on 3/16/16 at 10:30 AM identified R # 97 lying in bed on his/her back with two (2) incontinent briefs on. R #97 was unable to reposition him/herself and required both RN #2 and NA #1 to assist in repositioning R #97 to his/her right side. The pressure ulcer was noted to be open to air with no dressing in place. The pressure ulcer measured 1.8 cm x 0.8 cm with 100% yellow slough and no drainage. RN #2 identified at that time that R #97 should not have had two briefs on, and will follow up with the APRN to complete an assessment. Interview and review of the clinical record with APRN #1 on 3/16/16 at 11:00 AM identified R #97 had this pressure ulcer prior to admission and the resident's responsible party did not want the area treated. Additionally APRN #1 identified the pressure ulcer should not have been left open to air and should have had dressing covering the area. Subsequent to surveyor inquiry APRN #1 assessed the pressure ulcer and identified the wound with 100% of yellow waxy slough - nonfluctutuating, no drainage, periwound within normal limits. APRN directed to apply Santyl to the wound bed, skin prep to the peri-wound, and cover with an Allevyn dressing. A facility policy and procedure for pressure ulcer prevention and management identified pressure ulcers are assessed to location, stage, size, surrounding tissue, drainage, wound bed, and related pain. A wound noted as an unstageable pressure ulcer is identified as a full thickness tissue loss in which the base of the ulcer is covered with slough, until enough slough is removed to expose the base of the wound , the true depth , and therefore stage can not be determined. The facility wound management protocols identified the facility adheres to standards of practice regarding all wound care.

Based on interview and clinical record review for one of three residents in survey sample reviewed for accidents (R#2), facility failed to re-evaluate the resident for use of a transfer device after a decline mobility status. The findings include: Resident #2 was admitted to facility on 02/14/2012 with [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified that the resident required the extensive of two (2) staff for transfers between surfaces including bed, chair, and wheel-chair and was totally dependent on staff for toileting with assistance of two (2) staff. The Resident Care Plan dated 12/03/13 identified that the resident was at risk for falls due to MS and foot drop and was non-ambulatory on the unit. Interventions included all transfers with Sarita (mechanical sit to stand device) with assistance from two (2) staff. Physician orders [REDACTED].#2 be transferred via Sarita/ standing lift with the assistance of two (2) staff, resident non-ambulatory at wheel chair level- may remain on bed rest for comfort. Nurse's notes dated 02/23/13 identified that the resident complained of pain in his/her right leg. The area was noted to be yellowish in color. A subsequent x-ray was obtained and identified an acute (new) fracture of the right lower leg. The hospital discharge summary/radiologic (x-ray) exam dated 02/24/13 identified a non-displaced fracture of the proximal tibia with a partial avulsion fracture of the tibial tuberosity located in the right lower extremity. An additional fracture was identified located in the left lower extremity that was noted as a partially avulsed fracture of the tibial tuberosity. Facility accident/incident investigation documentation (addendum) dated 02/26/13 identified that the injury R#2 sustained was potentially consistent with the use of the Sarita lift due to the required slight flexed position of both knees and probable contraction of the bilateral (both legs) quadriceps muscles during transfers. Interview and review of R # 2's clinical record and/or therapy notes with the Director of Therapy (PT #1) on 04/08/14 at 2:10 PM identified that although there was an initial Physical Therapy (PT) evaluation completed on 02/17/2012 and a subsequent PT evaluation on 02/28/2012 (identified for private pay), there was no further evaluation for the utilization of a mechanical standing transfer assistive device conducted prior to R #2 sustaining lower extremity fractures/injuries. Interview with PT#2 on 04/09/14 at 9:20 AM indicated that she/he had worked with R # 2 daily (to stand in the parallel bars at the resident and family's request) and in the eight (8) months prior to R # 2 sustaining the lower extremity fractures, R # 2 had a decline in function and no longer ambulated. PT #2 further identified that R #2 could stand at the parallel bars without her/his assistance for five (5) seconds and indicated that transfers by facility staff were sometimes longer than needed, up to five (5) minutes (which required the resident to stand in the lift) while toileting the resident. She was unable to provide documentation that the resident had been re-assessed for the appropriateness of the Sarita/standing lift transfers subsequent to the resident's inability to ambulate and/or bear weight for more than 5 seconds.