Every finding on record at Rochester Restorative Care Center

Based on observation, interview and document review, the facility failed to maintain a safe environment to ensure resident care equipment was in safe repair when a call light with exposed wires was found in use for 1 of 1 resident (R2), reviewed for call lights. Findings includeR7's care plan, dated [DATE], identified R2 had a focus of self-care deficit related to diabetes, suspected deep tissue injury to buttock, heart failure, depression, osteoarthritis of knees, pain and weakness. Interventions revised on [DATE], identified R2 required the physical assistance of two staff members with toileting and transfers.R2's admission minimum data set (MDS) assessment, dated [DATE], identified R2's cognition was intact and able to make needs known.During an observation and interview on [DATE] at 4:08 p.m., R2 was seated in her wheelchair in her room and stated the call light on the other side of the room she uses when she has to use the commode, does not always work and there are blue wires hanging out of it. R2 stated that does not seem safe to me, further adding that it has been like this since she first got here over a month ago, and she had told several staff, and no one did anything about it. An observation of the call light cord referenced by R2 confirmed the plastic protective casing was split open, leaving bare blue wires exposed and accessible while the device remained plugged into the wall and in active use.During an interview on [DATE] at 4:50 p.m., nursing assistant (NA)-A verified a blue wire was hanging out of R2's attached call light cord. NA-A stated it was not safe, would be a fire hazard, and immediately removed the hazardous equipment from the room. NA-A then obtained a different cord from an empty room to replace the broken device and stated she would notify maintenance of the problem. Furthermore, NA-A stated the standard facility policy to follow would be to log into the Tells electronic work-order system to notify maintenance, so they are aware of the broken equipment.During an interview on [DATE] at 4:56 p.m., the director of nursing (DON) stated a call light cord that has wire poking through would not be safe for use and the policy to follow would be to notify maintenance and have it replaced right away. The DON further stated that all staff should know how to notify maintenance through the Tells system.During an interview on [DATE] at 4:06 p.m., maintenance (M)-A stated if there were wires hanging out of a call light it would not be safe for use. The maintenance assistant confirmed that staff should utilize the Tells electronic system to immediately report broken equipment directly to maintenance devices, and verified they had to replace R2's call light cord the previous night because it was bad and the wire was hanging out.Facility policy, Call Lights: Accessibility and Timely Response, reviewed 1/2026, identified that staff will report problems with a call light or the call system immediately to the supervisor and or maintenance director and will provide immediate or alternative solutions until the problem can be remedied.

Based on observation, interview, and document review, the facility failed to assess, identify, and utilize appropriate full body mechanical lift sling sizes to ensure safe transfer techniques according to manufacturer instructions to prevent and/or reduce the risk of accidents for 2 of 2 residents (R4 and R2) reviewed for mechanical lift transfers.Findings include:R4's care plan dated 1/6/26, identified a focus of activities of daily living (ADL) self-care performance deficit related to left and right below the knee amputation, diabetes, and insomnia. Intervention revised 8/13/26, directed staff to use 2 staff with Hoyer mechanical lift (a full-body mechanical lift used to safely hoist and move non-weight-bearing residents) for all transfers; however, R2's care plan failed to identify the specific size of the sling R2 required for safe transfers.R4's Therapy Communication to Nursing dated 4/20/26, identified R4 required Hoyer lift for functional transfers and assist of 2 due to non-weight bearing on lower extremity.R4's admission minimum data set (MDS) dated [DATE], identified R4's cognition was intact, noted an impairment in range of motion in bilateral lower extremities, and identified R4 required a wheelchair for mobility. The assessment further documented that R4 was completely dependent on staff for transfers (meaning a helper does all of the effort and the resident does none of the effort to complete the activity, or the physical assistance of two or more helpers is required for the resident to complete the activity).R4's Kardex printed 8/18/26, directed staff to provide assist of 2 staff with Hoyer mechanical lift for all transfers. R2's Kardex did not identify the size of sling R4 required for transfers.R4's weight dated 8/18/26 identified R4 weighed 110.4 pounds. During an observation and interview on 8/18/26 at 10:30 a.m., R4 (a bilateral below-the-knee amputee) was lying in bed and stated she utilized a Hoyer mechanical lift for all transfers. R4 stated she felt the mechanical lift sling currently used by staff was too large for her based on how she hung in the device during transfers and noted that facility nurses also told her the sling was too large. R4 stated she weighed approximately 109 pounds. A physical observation of the mechanical lift sling located in R4's room revealed a blue lift sling with green tubing, which indicated a size large.During an interview on 8/18/26 at 10:50 a.m., nursing assistant (NA)-B verified that both R4 and R2 required full body mechanical lifts for transfers and confirmed that neither resident's Kardex designated a specific sling size. NA-B stated that while sizing should be determined by height and weight, facility Kardex's did not typically identify sling sizes, leaving staff to guess or eyeball it by looking at the resident.During an interview on 8/18/26 at 11:00 a.m., nursing assistant (NA)-C stated that when transferring a resident with a mechanical lift, staff simply look at the size of the sling and use their best guess to determine what size to use. NA-C further stated she had no clue where the height and weight measurement chart was located to determine the correct mechanical lift sling size.During an observation of a mechanical lift transfer on 8/18/26 at 11:24 a.m., NA-B and NA-C completed a full-body mechanical lift transfer for R4 from the bed to her wheelchair. NA-C stated staff had no documentation to look at to determine the correct sling size, sizes are never listed on the Kardex, and staff must guess based on the resident's size. NA-B stated she thought R4's last weight was 109 pounds. Following the transfer, NA-C inspected the sling and verified it was a size large by the green piping, further stating she did not think the facility had any medium sizes in the building because all she could find were large-sized slings and based on R4's weight should probably use a medium sized sling.During an interview on 8/18/26 at 11:09 a.m., a licensed practical nurse (LPN)-A stated that when residents who require a full body mechanical lift are admitted , the nurse manager is supposed to use a measuring tool to determine the correct sling size, update the care plan, and document the appropriate size sling on the Kardex. The LPN reviewed multiple resident records and verified that while some records identified a sling size, R4 and R2's Kardex directed staff to use a two-person physical assistance with a full body mechanical lift but completely lacked any designated sling size.R2R2's hospital discharge orders, dated 6/20/26, identified R2 required extensive support for the completion of all transfers and recommended that nursing staff continue the use of a Hoyer lift for transfers. However, the discharge documentation did not identify the specific size of the mechanical lift sling required to safely perform these transfers.R2's care plan dated 6/30/26, identified a focus of activities of daily living (ADL) self-care performance deficit related to diabetes, suspected deep tissue injury to buttock, heart failure, depression, osteoarthritis of knees and weakness. Intervention revised 7/8/26, directed to use 2 staff with Hoyer mechanical lift for all transfers; however, R2's care plan failed to identify the specific size of the sling R2 required for safe transfers.R2's admission Minimum Data Set (MDS) assessment, dated 7/5/26, identified R2's cognition was intact, noted an impairment in range of motion in R2's bilateral lower extremities, and identified R2 required a wheelchair for mobility. The assessment further documented that R2 was completely dependent on staff for transfers.R2's kardex printed 8/18/26, directed staff that R2 required assist of 2 with Hoyer mechanical lift for all transfers. R2's Kardex did not identify the size of sling R2 required for transfers.R2's weight dated 8/19/26 identified R2 weighed 238.2 pounds.R2's record was reviewed and lacked a Mechanical Lift Sling Assessment to determine the safe and proper sling size.During an interview on 8/19/26 at 4:08 p.m., R2 stated she did not feel safe in the mechanical lift sling staff were using during transfers. R2 felt like she was going to fall out of the device and noted that there were rips in the specific sling staff were using on her, further adding that the lift experience did not feel safe.During a telephone interview on 8/19/26 at 1:36 p.m., the case manager stated she assisted R2 with contacting an on-site social worker to file a formal grievance on 7/29/26 regarding an unsafe Hoyer transfer. The case manager verified that in July, staff utilized the wrong lift pad (mechanical lift sling) when transferring R2, which caused R2 to not feel safe. The case manager further noted that R2 was very adamant about the incident and felt her safety concerns were being avoided by facility staff.During an interview on 8/18/26 at 10:56 a.m., NA-B assumed a nurse manager completed assessments to determine sizing. Furthermore, a physical inspection of R2's room with NA-B revealed an extra-large sling resting on a chair with a visible rip on the left side of the material; NA-B verified this ripped sling was the exact equipment staff had been using to transfer R2 and stated it was unsafe and should be thrown away.During an interview on 8/18/26 at 11:47 a.m., the RN nurse manager (NM)-A stated that when a new resident requiring a mechanical lift was admitted , the sling sizing was determined based solely on the resident's weight. NM-A provided specific weight brackets for medium, large, and petite slings, but admitted she was unsure of other required measurements and was unaware of which specific slings staff were currently using with the mechanical lift. NM-A reviewed R2 and R4's records and verified that both the comprehensive care plan and the Kardex had not been updated to identify the specific size of the mechanical lift sling required for safe transfers.During an interview on 8/18/26 at 1:45 p.m., the director of nursing (DON) stated that whenever a resident was identified to use a mechanical lift or stand assist lift, the resident should be appropriately assessed for the accurate sling size, should be updated to the care plan and kardex. The DON verified that an assessment for an appropriately sized sling had not been completed for R2 and R4 and acknowledged that the facility utilizes both an older lift model and a newer lift model. DON identified they will be immediately assessing all residents who utilize mechanical lifts for appropriate sling size.The manufacturer's Invacare Patient Sling Reference Guide revised 11/10, identified a warning that staff must inspect the sling before each use for wear, tears, and loose stitching. The guide explicitly identified that bleached, torn, cut, frayed, or broken slings are unsafe, could result in injury, and must be discarded immediately. Additionally, the guide identified a color and weight chart for sling sizing, noting that a petite sling has navy binding, a medium sling has purple binding, a large sling has green binding, and an extra-large sling has blue binding, while adding a specific note that sling size and fit can vary significantly depending on patient weight and girth.The manufacturer's Invacare User Manual, dated 2011, identified for the portable patient lift identified under General Guidelines and Safety Information that for the comfort and safety of the individual being lifted, staff must use an Invacare approved sling that is recommended by the individual's doctor, nurse, or medical assistant. The manual explicitly identified a warning that bleached, torn, cut, frayed, or broken slings are unsafe, could result in injury, and must be discarded immediately. Furthermore, the manual identified under Maintenance guidelines that it is important to inspect all stressed parts, such as slings, for signs of cracking, fraying, deformation, or deterioration, and replace any defective parts immediately to ensure the lift is not used until repairs are made.[NAME] to ensure the lift is not used until repairs are made.

Based on observation, interview, and document review, the facility failed to assess and monitor non-pressure-related skin injuries for changes until resolved, failed to provide ordered care, failed to timely transcribe physician treatment orders, and failed to address ongoing resident treatment refusals for 2 of 3 residents (R4 and R8). In addition, the facility failed to ensure physician-ordered daily weights were obtained and failed to notify the primary care provider of notification thresholds and the omitted weights for 2 of 3 residents (R4 and R7).Findings include:R8 skinR8's Face sheet printed 8/19/26, identified diagnoses of 2 diabetes mellitus (a long-term medical condition that affects blood sugar levels which severely slows down wound healing and decreases blood circulation) and morbid obesity due to excess calories (severe overweight that threatens health and increases skin-to-skin friction risks).R8's weekly skin assessment dated [DATE], identified no skin issues noted.R8's progress note dated 7/12/26 at 4:50 p.m., identified R8 sustained a fall in the shower room resulting in a cut to her left great toe. The note identified the area was cleansed and a dressing was applied; however, the entry failed to document any wound measurements or a description of the injury.R8's progress note dated 7/13/26 at 2:53 p.m., identified an order for wound care to the right great toe. The order specified instructions to cleanse the area with house wound cleanser, pat dry, apply triple antibiotic ointment to the wound bed, cover with 4x4 gauze, and wrap with Kerlix (a breathable, stretchy rolled gauze used to secure dressings) every evening shift and as needed (PRN). The order further identified that the treatment was appropriate to discontinue once healed.Review of R8's medical record lacked a comprehensive wound assessment to include critical wound characteristics, including precise dimensions, the tissue type of the wound bed, the type and amount of drainage, the presence of odor, and the condition of the surrounding peri wound skin. By omitting these objective measurements and visual descriptions, the facility failed to establish a clinical baseline to track whether the cut was healing, static, or developing complications until resolved. Furthermore, this 7/13/26 order identified a location discrepancy, as it designated the right great toe for treatment instead of the left great toe where the injury originally occurred.R8's care plan dated 7/15/26, identified a focus of an actual abrasion to the left great toe related to friction. Interventions identified were to administer treatments per medical doctor (MD) orders, provide diet and supplements per MD orders, and report evidence of infection-such as purulent drainage (pus), swelling, localized heat, or increased pain-and notify the MD as needed (PRN).Review of R8's care plan entry identified an inaccurate clinical focus that attributed the skin injury to friction. This entry directly contradicted the facility's progress note dated 7/12/26, which documented that the injury was a cut sustained during a physical fall in the shower room.R8's weekly skin assessment dated [DATE], identified existing abrasion on left great toe, ongoing dressing in place. R8's order summary dated 7/16/26, identified an order for the left great toe specifying instructions to cleanse the area with house wound cleanser, pat dry, apply triple antibiotic ointment to the wound bed, cover with 4x4 gauze, and wrap with Kerlix every evening shift and as needed. The order further identified that the treatment was appropriate to discontinue once healed.R8's progress note dated 7/17/26 at 10:38 p.m., identified a treatment entry for the left great toe was refused by R8.R8's progress note dated 7/22/26 at 11:27 p.m., identified a treatment entry for the left great toe was refused because the R8 wanted to sleep.R8's weekly skin assessment dated [DATE], identified abrasion on left toe, dressing on. R8's weekly skin assessment dated [DATE], identified abrasion on left toe.R8's annual minimum data set (MDS) dated [DATE], identified R8's cognition was intact and application of dressings to feet.R8 lacked a weekly skin assessment for 8/5/26.R8's weekly skin assessment dated [DATE], identified abrasion on left toe, wound care completed.R8's treatment administration record (TAR) dated July 2026, identified another order dated 7/13/26, which was discontinued on 7/16/26. The record identified the following treatment was performed to the right great toe: cleanse with house wound cleanser, pat dry, and apply triple antibiotic to the wound bed. The entry further directed staff to cover the area with 4x4 gauze and wrap it with Kerlix every evening shift.Review of R8's TAR 7/13/26, entry identified a transcription error, as it designated the right great toe for treatment. This entry directly contradicted the initial progress note dated 7/12/26, which documented that the injury occurred on the left great toe.R8's TAR dated July 2026, identified a blank space for 7/16/26 and 7/18/26. These blank spaces indicated the wound treatment was not performed. On 7/17/26, 7/22/26, 7/25/26, 7/26/26, and 7/29/26, a 2 was documented within the treatment log space, which indicated a resident refusal of care.R8's TAR dated August 2026, identified a blank space for 8/5/26, 8/8/26, and 8/14/26. These blank spaces indicated the wound treatment was not performed. On 8/9/26, a 2 was documented within the treatment log space, which indicated a resident refusal of care. Furthermore, R8's TAR identified a weekly skin assessment was scheduled for 8/5/26. The assessment space documented a 2, which indicated a refusal.R8's progress note dated 8/17/26, identified R8 was sent to the emergency department.Review of R8's medical record lacked a comprehensive wound assessment to include critical wound characteristics, including precise dimensions (length, width, and depth in centimeters), the tissue type of the wound bed, the type and amount of drainage, the presence of odor, and the condition of the surrounding peri wound skin. The omission of these objective measurements and visual descriptions failed to establish a clinical baseline to track whether the cut was healing, static, or developing complications such as infection or tissue death until resolved.During an interview on 8/19/26 at 11:24 a.m., the Director of Nursing (DON) verified that R8's left great toe cut was not measured weekly or assessed to determine if a change of treatment was required. The DON stated that the facility conducted weekly measurements for diabetic or arterial ulcers, but did not perform them for skin tears, cuts, or bruises, noting that wound measurements would have to be located on the weekly skin assessments. Furthermore, the DON verified that if a blank space occurred on the record, it indicated that the treatment was not documented as performed. The DON stated that facility practice required staff to make three attempts when a resident refused a treatment and confirmed that the physician should be notified of such care refusals.R4: skin R4's face sheet printed 8/19/26, identified diagnoses of diabetes, peripheral artery disease (a circulatory condition where narrowed arteries reduce blood flow to the limbs, which deprives a wound of necessary oxygen and nutrients), congestive heart failure (a chronic condition where the heart does not pump blood as well as it should, which can cause fluid buildup and swelling in the legs and feet), and chronic kidney disease, stage 3b (a moderate-to-severe loss of kidney function that leads to a buildup of waste in the blood and further slows down the body's ability to repair skin injuries).R4's care plan dated 1/8/26, identified a focus of actual skin impairment involving a left below-knee amputation (BKA) revision and a new right BKA. The care plan documented that R4 underwent a bilateral (incision and drainage (I and D), -a surgical procedure to clear out an infection, and closure of the surgical sites on 6/16/26 and 6/22/26, with casts applied to the lower extremities. The care plan interventions dated 1/8/26, directed staff to administer treatments per MD orders, report evidence of infection-such as purulent drainage, swelling, localized heat, or increased pain-and notify the MD as needed (PRN). Another care plan intervention dated 7/20/26, directed staff to monitor circulation, movement, and sensation (CMS) -which are physical checks to ensure blood flow and nerve function are intact, to both lower extremities, noting the presence of casts over the surgical sites.R4's annual MDS dated [DATE], identified R4's cognition was intact, had an impairment in range of motion in her bilateral lower extremities and used a wheelchair for mobility. Further identified R4 had recent major surgery requiring skilled nursing facility active care and had a surgical wound.R4's progress note dated 8/7/26 at 2:53 p.m., identified an (Situation, Background, Assessment, Recommendation) SBAR document for a new open wound to the right below-knee amputation (BKA) stump. The note identified the wound was open, white and yellow in color, draining, and measured 3.5 centimeters (cm) by 1 cm in size. The background section identified diagnoses of an acquired absence of the right leg below the knee, peripheral vascular disease, and diabetes. The assessment section identified that the surrounding peri wound skin was intact with steri-strips (small adhesive strips used to close surgical incisions) and a healing incision line. The recommendation section identified that the nurse recommended the resident be seen in the emergency department (ED) for the new wound.R4's progress note dated 8/8/26 at 4:30 p.m., identified that provider ordered for R4 to be sent to the ED for evaluation.R4's after visit summary (AVS) dated 8/8/26, identified new discharge orders for wound care three times a day (TID) wet to dry (WTD). The orders directed staff to apply Vashe-soaked gauze, lightly moist and not soaked, to the open wound on the right lower extremity (RLE) BKA site. The instructions required staff to cover the area with dry gauze, an ABD, and an ACE wrap. Additionally, the orders directed staff to elevate the RLE as much as possible and avoid trauma to the leg. The summary concluded with the instruction not to wear the prosthetic.R4's progress note dated 8/8/26 at 8:00 p.m., identified the writer received a report from the hospital emergency department stating the R4 was stable, wound was cleaned, packed with gauze, and wrapped with Kerlix. The note concluded by documenting that no new orders were received at that time.R4's TAR dated 8/10/26, identified an order for the right lower extremity specifying wound care three times a day (TID). The order directed staff to apply Vashe-soaked gauze (a specialized antimicrobial wound cleansing solution) lightly moist, but not soaked, to the open wound on the RLE below the knee amputation (BKA) site. The instructions required staff to cover the area with dry gauze, an ABD (a thick, highly absorbent sterile dressing pad), and an ACE wrap (an elastic compression bandage). Additionally, the order directed staff to elevate the right lower extremity as much as possible and avoid trauma to the leg and scheduled wound care at 8:00 a.m., 2:00 p.m., and 9:00 p.m. On 8/12/26 at 8:00 a.m., a 3 was documented, indicating R4 was away from the facility. On 8/14/26 at 9:00 p.m. and 8/17/26 at 2:00 p.m., the log spaces were left blank, indicating the treatments were omitted. On 8/18/26 at 8:00 a.m., a 2 was documented, indicating a refusal of care. At 2:00 p.m., a 5 was documented, indicating the treatment was held. At 9:00 p.m. on 8/18/26, a 9 was documented, indicating to see the progress note.R4's non-pressure weekly tracker document dated 8/11/26, identified on 8/8/26, R4 had acquired a dehiscence of surgical wound on right residual stump measuring 1.6 cm x 1.5 cm x 0.7 cm. Wound bed was 100% slough (yellow or tan dead tissue) with light serous drainage with no tunneling or undermining. Treatment plan was to monitor in TAR until healed and assess for s/s of infection. Wound provider was notified 8/11/26.R4's wound evaluation and management summary dated 8/11/26, identified an open post-surgical wound to the right stump leg measuring 1.6 cm x 1.5 cm by 0.7 cm with 100 percent slough. The specialist's dressing treatment plan ordered a hypochlorous acid solution (Vashe) moist gauze to be applied to the wound bed, covered with an ABD pad and a six-inch ACE bandage twice daily and as needed (PRN) for 30 days.Review of R4's medical records identified a failure to ensure the timely and accurate implementation of physician-ordered wound care. Although the AVS established active treatment parameters on 8/8/26, the facility failed to implement the orders onto the TAR until 8/10/26, resulting in a two-day care gap. Furthermore, when the wound provider evaluated R4 on 8/11/26 and ordered the treatment frequency changed to twice daily, the facility failed to update the TAR to reflect this modification. This omission forced staff to continue operating on an incorrect three-times-a-day schedule while routinely omitting treatments and failing to address ongoing care disruptions. Furthermore, the presence of blank log spaces and unaddressed exception codes across consecutive days proves that despite scheduling the care three times a day, the facility routinely failed to provide the ordered treatments or manage ongoing care disruptions.R4's wound evaluation and management summary dated 8/14/26, identified the post-surgical wound to the right stump leg measured 1.1 cm by 2.6 cm by 0.5 cm with 100 percent slough. The exam identified 0.5 cm of undermining (a hollow channel extending under the lip of the intact wound edge) at 12 o'clock, and noted the wound progress was not at goal. The note documented that R4 was evaluated by orthopedics on 8/12/26 for wound dehiscence (the splitting open of a surgical incision) with no changes made to the dressing plan. The treatment plan continued the directive for Vashe moist gauze and ABD pad to be applied twice daily and as needed.R4's non-pressure weekly tracker document dated 8/18/26, identified a wound on the right residual stump measuring 0.9 cm by 1.5 cm by 0.5 cm. The tracker documented that the wound bed was 100 percent slough with light serous drainage and identified an undermining of 0.5 cm at 12:00. The record noted that the treatment plan was to monitor the wound on the TAR until healed and to assess for signs or symptoms of infection.During an observation and interview on 8/18/26 at 10:30 a.m., R4 was observed in bed with both amputation stumps wrapped. R4 stated her right leg dressing was completed that day and required a dressing change twice a day, noting that the left leg was completely healed. R4 stated she was transferred to the emergency room a couple of weeks prior because staff suspected the right stump was infected but reported that the incision had broken open and was itching.During an interview on 8/18/26 at 1:55 p.m., the DON verified that R4's wound treatments for the right stump were not always documented as completed. The DON stated that when R4 returned from the emergency department with new treatment orders, the nurse should have implemented the new order immediately to prevent a delay in treatment.R4 daily weights R4's face sheet printed 8/19/26, identified diagnosis of congestive heart failure.R4's care plan dated 1/6/26, identified a focus of cardiac disease related to congestive heart failure. Interventions dated 1/6/26, identified to obtain weights as needed/ordered, report significant change.R4's order summary dated 7/16/26, identified to weigh daily in AM before breakfast. Notify the provider if weight was greater than 127.86 pounds.R4's TAR dated July 2026, identified to weigh R4 daily in AM before breakfast and to notify the provider if weight greater than 127.86 pounds. On 7/18/26, space had an X through it, indicating the weight was not recorded. 7/22/26 a 5, was documented, indicating weight was held. On 7/31/26, a blank space identified the weight was not recorded.R4's July 2026, weight summary identified no weights were recorded on 7/18/26, 7/22/26 and 7/31/26.R4's progress note dated 7/22/26 at 2:56 p.m., identified R4 daily weight did not occur. R4's TAR dated August 2026, identified to weigh R4 daily in AM before breakfast and to notify the provider if weight greater than 127.86 pounds. On 8/7/26, a 9 was documented indicating to see the progress note. On 8/9/26, a blank space identified the weight was not recorded.R4's August 2026, weight summary identified no weights were recorded on 8/7/26 and 8/9/26.R4's progress noted dated 8/7/26 at 4:13 p.m., did not indicate a reason why R4's weight was not recorded.During an interview on 8/18/26 at 1:55 p.m., the DON verified R4's weights were not always documented as ordered by the physician and stated they should be documented and the provider should be notified. R7 daily weights:R7's face sheet printed 8/19/26, identified diagnosis of congestive heart failure.R7's care plan was reviewed and failed to identify a focus for congestive heart failure. The care plan lacked any interventions to provide daily physician-ordered weights.R7's order summary dated 7/14/26, identified an order to obtain daily weights. The order summary directed staff to notify the provider if R7's weight was greater than 2.5 pounds in 24 hours or 5 pounds in one week.R7's TAR dated July 2026, identified an order to weigh R7 daily and to notify the provider if the weight was greater than 2.5 pounds in 24 hours or 5 pounds in one week. On 7/15/26, 7/16/26, 7/21/26, and 7/30/26, a 9 was documented, indicating to see the progress note. On 7/17/26, a 6 was documented, indicating the treatment was not available. On 7/31/26, a blank space identified the weight was not recorded.R7's July 2026, weight summary identified no weights were recorded on 7/15/26, 7/16/26, 7/17/26 and 7/31/26.R7's progress note dated 7/15/26 at 2:32 p.m., identified R7's weight was not completed because she did not come out of her room. R7's progress notes dated 7/16/26 at 2:10 p.m. and 7/21/26 at 2:10 p.m., identified her daily weights were not recorded or taken.R7's daily weights were as follows:8/1/26: 276.8 pounds8/2/26: 277.2 pounds8/3/26: 279.7 pounds8/4/26: 279.2 pounds8/5/26: 279.6 pounds8/6/26: 280.4 pounds8/7/26: 282.1 pounds8/8/26: 282.1 pounds8/9/26: 279.9 pounds8/10/26: 285.9 pounds8/11/26: 279.7 pounds8/12/26: 278.7 pounds8/13/26: 278.9 pounds8/14/26: 283.9 pounds8/15/26: 277.0 pounds8/16/26: 284.5 pounds8/17/26: 281.2 pounds8/18/26: no weight recorded8/19/26: 281 pounds8/20/26: 280.8 poundsReview of R7's medical record identified multiple instances where R7's recorded weights exceeded the physician-ordered notification thresholds. On 8/7/26, the recorded weight of 282.1 pounds represented a 5.3-pound weight gain within one week, which exceeded the five-pound threshold. On 8/10/26, the recorded weight of 285.9 pounds represented a six-pound weight gain in 24 hours. On 8/14/26, the recorded weight of 283.9 pounds represented a five-pound weight gain in 24 hours. On 8/16/26, the recorded weight of 284.5 pounds represented a 7.5-pound weight gain in 24 hours. A review of R7's medical record identified that the facility failed to notify the primary care provider of these ordered weight parameters on any of the four dates when the notification thresholds were met.During an observation and interview on 8/20/26 at 3:37 p.m., R7 was observed in her room. R7 stated she was scheduled to be weighed every day but reported that staff missed several of the ordered measurements. R7 stated she knew daily weight monitoring was important because any significant weight gains required staff to notify the doctor to adjust her medications.During an interview on 8/20/26 at 11:59 a.m., the DON reviewed R7's medical record and verified that R7 met the provider's notification criteria on 8/7/26, 8/10/26, 8/14/26, and 8/16/26. The DON confirmed that a review of R7's medical record lacked any documentation indicating the primary care provider was notified of the weight gains on those dates. Furthermore, the DON verified that several daily weights were omitted since the order went in place. The DON stated that staff should have obtained the ordered weight, calculated the daily and weekly fluctuations, and immediately notified the physician when the established thresholds were exceeded. DON verified R7's care plan lacked a focus with interventions for monitoring congestive heart failure. Facility undated policy, Wound Treatment Management, identified it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy explanation directed that wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The policy guidelines further identified that treatment decisions and the ongoing monitoring of treatment effectiveness would be based on specific characteristics of the wound. The protocol required these documented characteristics to include the wound size, shape, depth, presence of tunneling or undermining, volume and characteristics of exudate, presence of pain, presence of infection, condition of the tissue in the wound bed, and the condition of the peri wound skin.The facility's clinical resource tool titled, CARE PATH Symptoms of Heart Failure (HF), copyright dated 2014-2021, identified specific clinical triggers that require immediate physician notification for a resident with known heart failure or risk factors. The protocol identified a weight gain of three pounds in three days or five pounds in seven days as an immediate notification criterion. Furthermore, the care path identified an inability to sleep without sitting up as a critical symptom of heart failure that requires evaluation. The document directed staff to monitor vital signs, track clinical responses, and notify the physician, nurse practitioner, or physician assistant immediately when these heart failure criteria are met.The facility's undated policy titled, Comprehensive Care Plans, identified it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy explanation and compliance guidelines specified that the comprehensive care plan will describe, at a minimum, any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. The guidelines further identified that the facility would attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.Facility policy regarding physician orders requested and not received.

Based on interview and document review, the facility failed to develop a comprehensive care plan with specific treatments, goals and interventions to manage severe leg swelling, open skin wounds, and heart failure for 1 of 1 resident (R7) reviewed for quality of care.Findings include R7's face sheet printed 8/20/26, identified diagnoses of lymphedema (severe fluid buildup and swelling caused by a blocked drainage system in the body), venous insufficiency (poor blood flow in the legs because weak valves let blood pool instead of pumping back to the heart), Xerosis cutis (abnormally severe dry skin caused by a lack of moisture and natural oils in the outer layer of the skin) and congestive heart failure (a condition where the heart muscle is too weak or stiff to pump blood effectively, causing fluid to back up into the lungs and body).R7's admission Minimum Data Set (MDS) assessment, dated 7/15/26, identified R7's cognition was intact and documented that R7 had 2 venous/arterial ulcers (open skin wounds caused by poor blood circulation) present. The assessment further identified the application of ointments or medications and non-surgical dressings to areas other than the feet and noted that R7 received diuretics (water pills used to rid the body of extra fluid and salt).R7's Care Area Assessment (CAA), dated 7/15/26, identified an alteration in skin integrity related to chronic venous insufficiency and lymphedema. The assessment noted ongoing medical treatment for increased swelling, redness, and weepiness (fluid leaking through the skin) of R7's legs, and explicitly stated the facility would monitor R7's skin status every shift and implement a goal to assist with the healing of these admission skin issues.R7's order summary, dated 7/18/26, identified active physician orders including an order dated 7/13/26 to elevate bilateral lower extremities, and an order dated 7/14/26 to administer Lasix (a diuretic used to reduce fluid buildup and swelling caused by heart failure) 40 milligrams (mg) by mouth daily for the diagnosis of congestive heart failure. Additionally, an order dated 8/4/26 directed staff to cleanse the bilateral lower legs with normal saline or wound cleanser, pat dry, apply Iodosorb gel (a medicated gel used to clean wet wounds, kill bacteria, and help them heal) to open areas, cover with abdominal pads, secure with a Kerlix roll and tape, and apply Ace wraps to the bilateral legs every day shift and as needed if saturated.R7's order summary, dated 7/18/26, identified active physician orders including an order dated 7/13/26, to elevate bilateral lower extremities and an order to take daily weights in the morning and notify the medical provider if the R7's weight increases by more than 2.5 pounds (lbs.) in 24 hours or 5 lbs. in one week (a tracking method used to catch dangerous, rapid fluid buildup from heart failure). Additionally, an order dated 7/14/26 directed staff to administer Lasix (a water pill used to reduce fluid buildup and swelling caused by heart failure) 40 milligrams (mg) by mouth daily for the diagnosis of congestive heart failure. Furthermore, an order dated 8/4/26 directed staff to cleanse the bilateral lower legs with normal saline or wound cleanser, pat dry, apply Iodosorb gel (a medicated gel used to clean wet wounds, kill bacteria, and help them heal) to open areas, cover with abdominal pads, secure with a Kerlix roll and tape, and apply Ace wraps to the bilateral legs every day shift and as needed if saturated.R7's care plan, dated 7/13/26, indicated the facility failed to identify the resident's active diagnoses of lymphedema, venous insufficiency, Xerosis cutis, or congestive heart failure. Furthermore, the care plan did not incorporate the medical provider's ordered interventions to elevate R7's bilateral lower extremities, monitor morning daily weights with provider notification parameters, administer daily Lasix, or execute the multi-step bilateral lower leg wound treatments utilizing normal saline, Iodosorb gel, abdominal pads, Kerlix, and Ace wraps. The care plan additionally failed to outline specific nursing interventions to safely manage and treat these overlapping vascular, cardiac, and skin integrity disorders, and omitted any measurable goals of care or timeframes to monitor treatment efficacy and promote wound healing.During an interview on 8/20/26 at 11:59 am, the director of nursing (DON) verified R7 did not have a skin care plan in place. The DON further verified that the care plan should have included R7's skin concerns with interventions in place, along with care-planning approaches, goals of care, and personalized interventions for congestive heart failure, venous insufficiency, Xerosis cutis, and the administration of Lasix.Facility policy, Comprehensive Care Plans, dated 2023, identified it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy further identified under Policy Explanation and Compliance Guidelines that the comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment, and all Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Additionally, the policy identified that the comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and noted that the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment, which will be utilized to monitor the resident's progress.

Based on observation, interview, and record review, the facility failed to ensure 3 of 3 residents (R2, R5, and R6) had specific physician-ordered parameters for mechanical positive airway pressure devices (CPAP/BiPAP) and failed to develop individualized, person-centered care plans. Findings include:CPAP (Continuous Positive Airway Pressure): This machine delivers a single, constant stream of air pressure through a mask to keep the airway continuously open during sleep. It is primarily used to treat obstructive sleep apnea by preventing the throat muscles from collapsing.BiPAP (Bi-level Positive Airway Pressure): This machine delivers two different levels of air pressure: a higher pressure when breathing in and a lower pressure when breathing out. It is used for residents who need extra help with breathing or those who cannot tolerate the constant pressure of a CPAP, often due to conditions like severe sleep apnea, COPD, or respiratory failure.R2's Face sheet printed 8/19/26, identified diagnoses of acute respiratory failure with hypoxia (sudden inability of the lungs to get enough oxygen into the blood), morbid obesity due to excess calories (severe overweight that threatens health) and pulmonary hypertension (high blood pressure in the lungs). Face sheet does not include diagnoses of obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts).R2's progress note dated 6/30/26 at 3:32 a.m., identified R2 complained of her CPAP machine was not working and that a power outage had caused it. This nurse and CNA attempted to get the CPAP machine to work and could not get it to restart, after several attempts.R2's Physician Assistant (PA) visit dated 6/30/26, confirmed a diagnosis of obstructive sleep apnea. The history of present illness noted that R2 experienced increased shortness of breath, persistent cough, and chest congestion, and her major concern was that her CPAP machine was broken and required a new one with updated settings.R2's order summary dated 7/1/26, identified CPAP: humidifier container for CPAP/BiPAP - Wash out each morning with mild soap and air dry - Use distilled water only in reservoir in the morning. Wipe CPAP/BiPAP mask, nasal pillow, tubing, and head gear daily with soap and water and damp cloth one time daily.Review R2's order summary identified it lacked specific physician-ordered parameters for the machine's clinical settings, including the required air pressure levels and designated hours of use. Furthermore, the order summary failed to identify which specific device, CPAP or BiPAP, the resident actually required.R2's medical doctor (MD) order dated 7/2/26, identified to set R2 up with a new ResMed BiPAP machine with settings of 13/9 cm H2O (centimeters of water, which is how machine air pressure is measured) and expiratory pressure relief (EPR)-(a feature that lowers pressure when breathing out) fulltime of 2 or 3.R2's Treatment Administration Record (TAR) was reviewed for July and August 2026 and failed to identify that the BiPAP was set up, monitored, or administered.R2's care plan was reviewed and lacked individualized, person-centered interventions for obstructive sleep apnea and BiPAP use. The care plan failed to include critical interventions such as skin integrity assessments for mask placement, monitoring for machine compliance, and routine device maintenance.R2's admission Minimum Data Set (MDS) assessment, dated 7/5/26, identified R2's cognition was intact and utilized non-invasive ventilator BIPAP on admission.R2's admission MD visit dated 7/16/26, identified R2 saw sleep medicine on 7/1/26, for a malfunctioning machine. The assessment and plan confirmed a new BiPAP machine was provided and recommended an overnight oximeter test (a non-invasive test that measures the oxygen level in the blood) once R2 became acclimated to the new device.During an interview on 8/19/26 at 4:08 p.m., R2 was seated in her wheelchair in her room. R2 stated, I came to this facility with a BiPAP, not a CPAP. R2 reported that on her first night at the facility (6/29/26), her machine broke due to electrical problems, and it took over a week to receive a new one after 7/6/26. R2 stated, The facility did nothing to assist me with this, I had to make several phone calls to get this machine. R2 further noted that once the new machine arrived, staff did hook up her BiPAP every night.Although nursing staff administered the BiPAP daily, they did so without checking or verifying that the machine was operating under the correct, physician-ordered parameters, as the facility lacked any documented settings or tracking mechanisms to ensure safe administration.During a telephone interview on 8/19/26 at 12:14 p.m., Registered Nurse (RN)-A stated she was working the night R2's machine stopped working. RN-A stated she checked the machine after an aide alerted her, and the R2 reported an energy glitch broke the device. RN-A stated, I can't remember if she had a CPAP or BiPAP. RN-A confirmed she did not notify the medical provider of the equipment failure and instead left a note for the nurse manager to order a replacement device.R5'sR5's face sheet printed 8/19/26, identified diagnoses of obstructive sleep apnea and pulmonary hypertension due to lung diseases and hypoxia (high blood pressure in the lungs caused by low oxygen levels).R5's medical provider order dated 3/24/25, identified an order for an Auto CPAP (automatically adjusts air pressure based on the user's breathing patterns) for a diagnosis of obstructive sleep apnea. The order specified a minimum pressure of 10 cm H2O and a maximum pressure of 20 cm H2O with the ramp time (a feature that starts the machine at a lower pressure and gradually increases it) set to patient comfort.R5's order summary dated 5/7/26, identified an order for CPAP to be placed on at bedtime on home settings with a 2-liter oxygen bleed (adding supplemental oxygen into the machine's airflow), with instructions to document refusal at bedtime.Review of R5's order summary identified it lacked specific, physician-ordered parameters for the machine's clinical settings, including the required air pressure levels, and instead relied on vague home settings.R5's quarterly MDS assessment, dated 6/24/26, identified R5's cognition was intact and utilized non-invasive ventilator and oxygen therapy. However, the assessment failed to identify whether a CPAP or BiPAP device was being utilized.R5's care plan was reviewed and lacked individualized, person-centered interventions for obstructive sleep apnea and CPAP use. The care plan failed to include critical interventions such as skin integrity assessments for mask placement, monitoring for machine compliance, and routine device maintenance.R5's progress note dated 7/6/26 at 9:49 p.m., identified an entry stating, CPAP on at bedtime on home settings with 2 liters of oxygen bleed. The note further identified that the CPAP machine was not functioning and the R5 stated it had a leak.R5's nurse practitioner (NP) visit dated 7/21/26, identified diagnoses of chronic respiratory insufficiency (long-term inability of the lungs to breathe properly), obstructive sleep apnea, and shortness of breath. The note identified that over the past 5 to 6 weeks, R5 experienced intermittent episodes of shortness of breath and a sensation of gasping for air upon awakening and had not been using his CPAP machine recently due to a large leak, a hose malfunction, and missing replacement supplies. The assessment and plan noted that parts were ordered, staff planned to set up the CPAP again that day, and his condition required oxygen supplementation of 1 to 5 liters/minute to maintain oxygen saturation above 90%.R5's medication administration record (MAR), dated July and August 2026, identified an entry for CPAP to be applied at bedtime with 2 liters of oxygen bled in daily at 8:00 p.m. The record documented a 9 on 7/9/26 indicating to see a progress note, and a 2 on 7/7/26 and 7/14/26 indicating the treatment was refused. A review of this MAR identified it lacked information defining what the required home settings were for the machine's air pressure levels. Furthermore, the MAR lacked any instructions to alert nurses to perform routine maintenance tasks, such as emptying the water chamber daily, letting it air dry, or utilizing distilled water only.During an observation and interview on 8/18/26 at 11:55 a.m., R5 was observed lying in bed with a CPAP machine on the bedside table. R5 stated he uses the machine for sleep apnea but reported that staff relied on him for the machine's clinical parameters, stating, I give the nurse the settings. I am not sure what the settings are at the top of my head. R5 further stated he experienced a heck of a time getting staff to empty and rinse the water chamber daily to prevent infection, noting, I had to repeatedly ask . sometimes ya really have to pester them to do it.R6R6's face sheet printed 8/19/26, identified diagnosis of obstructive sleep apnea and pulmonary hypertension. R6's physician order dated 7/7/26, identified an order for a Bi-Level PAP machine for a primary diagnosis of obstructive sleep apnea. The order specified machine settings of an IPAP (inspiratory positive airway pressure, the pressure when breathing in) of 17 cm H2O and an EPAP (expiratory positive airway pressure, the pressure when breathing out) of 11 cm H2O, to be administered during hours of sleep. The instructions further directed staff to set the heated humidity and hose on high.R6's TAR dated 8/17/26, identified an entry for BiPAP (bi-level positive airway pressure) on home settings to be applied at bedtime that was discontinued on 8/18/26. On 8/18/26, the TAR identified an entry for BiPAP on home settings (17/11) to be applied at 8:00 p.m. and removed at 8:00 a.m. The documentation log box for 8/18/26 was left blank.Review of R6's TAR entries identified a failure to establish clear, consistent parameters, as the records shifted from a vague home settings instruction to a conflicting home settings (17/11) direction. Furthermore, the blank log on 8/18/26 confirms the facility failed to document whether the respiratory treatment was actually administered or monitored.R6's care plan dated 8/17/26, identified a focus of at risk for respiratory impairment related to obstructive sleep apnea. Interventions dated 8/17/26, identified BiPAP use per MD orders, evaluate lung sounds and VS (vital signs) as needed, report abnormalities to MD, obtain labs as ordered and notify the MD with results, obtain pulse oximetry (a non-invasive test that measures the oxygen level in the blood) and report abnormal findings, provide assistance with (activities of daily living) ADL's to conserve energy, and report signs of infection or edema (swelling).Review of R6's care plan identified that despite listing BiPAP use per MD orders, it lacked specific, individualized, and person-centered interventions. The care plan failed to guide staff on critical respiratory care tasks, including verifying the specific machine pressure settings, inspecting the facial skin surrounding the mask for breakdown, checking the tubing for cracks, reporting mask leaks, and performing routine maintenance such as emptying and air-drying the water chamber daily or utilizing distilled water only.During a telephone interview on 8/19/26 at 2:39 p.m., R6 stated she did not have her BiPAP machine for the short amount of time she resided at the facility because there was no room for staff to set it up. R6 reported she had a sleep study completed on July 7th, had been in and out of the hospital with CHF (congestive heart failure, a condition where the heart doesn't pump blood as well as it should), and experienced gasping for air and stopping breathing 29 times an hour. R6 stated the doctor ordered the BiPAP machine for her, and it helped a lot.During an interview on 8/19/26 at 10:20 a.m., the Director of Nursing (DON) verified that the care plans for R2, R5, and R6 did not include respiratory device interventions and stated that they should. The DON stated that the care plans should identify the resident's specific respiratory risk along with specific goals and person-centered interventions. The DON verified that missing interventions included: providing heated humidity, applying the device at night and removing it in the morning, utilizing distilled water only, rinsing and air-drying the water chamber daily, and inspecting air filters monthly. Additionally, the DON stated staff should be directed to verify machine settings, report mask leaks, check tubing for cracks, inspect the facial skin surrounding the mask, and monitor for abdominal bloating or gas. The DON further noted that care plans should list Northwest Respiratory as the contact for equipment problems and confirmed that each resident's exact machine settings should be clearly stated in the physician orders, so nurses are able to accurately log and document the treatments on the TAR. Furthermore, the DON reviewed and verified that the TAR logs for R2 and R6 were left blank and confirmed that physician orders relying on vague home settings failed to provide nurses with the explicit parameters required for safe respiratory device administration.Facility policy was requested for mechanical positive airway pressure devices and was not provided.Undated facility policy, Comprehensive Care Plans identified that it is the facility's standard to develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives, timeframes, and resident-specific interventions to meet medical and nursing needs. The policy further noted that qualified staff must be notified of their specific roles for carrying out these interventions.

Based on interview and record review, the facility failed to ensure a clinically significant medication was transcribed correctly, made available, and administered as prescribed, leading to repeated omissions of a treatment used for chronic hyponatremia, for 1 of 1 residents (R2) reviewed for quality of care Findings include:R2's Face Sheet printed 7/16/26, identified R2 had diagnoses of hypo-osmolality (having too much water relative to salt in the blood, which makes the blood too diluted), hyponatremia (dangerously low salt levels in the blood, which can make a person confused or dizzy), diabetes, and chronic kidney disease (gradual loss of kidney function, which means the kidneys struggle to filter wastes and balance fluids in the body).R2's hospital after visit summary (AVS) dated 3/12/26, identified R2 was hospitalized from [DATE] to 3/12/26, and the records identified that R2 had medical comorbidities including chronic hyponatremia.R2's admission minimum data set (MDS) dated [DATE], identified R2's cognition was intact.R2's admission Care Area Assessment (CAA) dated 3/18/26, identified a problem with nutritional status noting that R2 would leave a significant proportion of meals daily. The assessment identified that a care plan would be implemented to track her food and fluid intake, and to monitor her laboratory values and weights.R2's care plan dated 5/6/26, identified a focus on the endocrine system related to diabetes and SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion, a condition where the body holds onto too much water and dangerously lowers blood salt levels). Interventions dated 5/6/26, identified that staff must administer medications per doctor's orders, enforce a strict 2-liter fluid restriction with no water mugs left at her bedside, and complete laboratory tests per the doctor's directions.R2's Physician Assistant (PA) admission visit, dated 3/19/26, identified that on the day of discharge from the hospital (3/12/26), R2's Lisinopril was held due to an elevated potassium level, and the hospital ordered a laboratory basic metabolic panel (BMP) redraw at the facility on 3/12/26 or 3/13/26 to monitor her electrolyte levels. The PA noted that these follow-up laboratory checks were not completed by the facility. As a result, the PA had to issue new orders to obtain a BMP at the next available laboratory draw, and her Lisinopril medication continued to be withheld.R2's laboratory results dated [DATE], identified that her sodium level was 131 mEq/L and her potassium level was 4.7 mEq/L.R2's progress note dated 4/5/26 at 2:05 p.m., identified reports of increased weakness and positional control while sitting, leaning to the left, and having a hard time feeding herself.R2's progress note dated 4/5/26 at 10:17 p.m., identified that R2 had increased weakness from baseline during transfers, leaned to one side while in a wheelchair, and required assistance to propel her wheelchair.R2's progress note dated 4/6/26 at 11:45 a.m., identified that the physician followed up with orders for BMP laboratory draw.R2's progress note dated 4/7/26 at 2:21 p.m., identified that R2 had generalized weakness in her extremities and required a Hoyer lift for the last few days due to leg weakness.R2's progress note dated 4/8/26 at 11:02 p.m., identified that R2 complained of not being able to lift her arms and was unable to reach for the call light. The note identified that the author observed R2 was unable to take her medications when given, requested the medications be placed in her mouth, stated, I can't lift up my arm anymore, and required more help with feeding and activities of daily living.R2's progress note dated 4/9/26 at 2:11 p.m., identified that BMP laboratory results obtained that morning were abnormal with a sodium level of 130 mEq/L, and that the provider gave verbal consent for R2 to be transferred to the hospital for an evaluation.R2's AVS dated 4/23/26, identified R2 was hospitalized from [DATE] to 4/23/26 for admitting diagnoses including hyponatremia and emergent spinal surgery. The records identified that her sodium level on 4/21/26 was 127 mEq/L and on 4/23/26 was 126 mEq/L. The records identified new discharge orders for [NAME]-Na.R2's Discharge summary dated [DATE], identified that the resident has chronic hyponatremia for which she was started on 30 grams of [NAME]-Na daily. The records identified active issues requiring follow-up by the primary care provider, including a specific instruction to recheck a BMP on 4/30/26.R2's hospital MAR dated 4/14/26 through 4/23/26, identified that R2 consistently received her prescribed 30-gram [NAME]-Na packets daily as ordered during her hospitalization.R2's medication administration record (MAR) dated April 2026, identified an entry for [NAME]-Na oral packet documented as 30 milligrams (mg) by mouth one time a day at 7:00 a.m.A review of the administration tracking codes for this entry revealed that on 4/24/26, a code, 9 was documented, indicating to see the progress note. On 4/25/26, a code 3 was documented, indicating absent from home without medications. On 4/26/26, a code 2 was documented, indicating the drug was refused. On 4/27/26, a code 6 was documented, indicating R2 was hospitalized .A review of the facility's records identified that this entry did not match the Discharge summary dated [DATE], which directed staff to give 30 grams with meals. Record review identified no documentation that facility staff contacted the provider to clarify the order timing or the typographical error listing mg instead of grams. Further identified no documentation that facility staff contacted the healthcare provider to clarify the order timing or the dosage discrepancy.R2's progress note dated 4/24/26 at 11:05 a.m., identified an administration note for [NAME]-Na oral packet was on order.R2's progress note dated 4/25/26 at 10:08 a.m., identified an administration note that the [NAME]-Na was on order.R2's progress note dated 4/26/26 at 9:49 a.m., identified an administration note for [NAME]-Na oral packet was on order.R2's progress note dated 4/26/26 at 12:29 p.m., identified that R2 had 2+ pitting edema on bilateral upper and lower extremities and crackles present in all lobes of her lung fields. The note identified that R2 was short of breath at rest and nursing staff questioned whether a fluid restriction was indicated.R2's progress note dated 4/27/26 at 8:56 a.m., identified that R2 had shortness of breath with difficulty taking deep breaths, bilateral arm and leg edema, and faint crackles in her lung fields. The note identified that R2 requested to be seen in the hospital one more time and the provider gave verbal consent for R2 to be transferred to the hospital emergency room.A review of R2's MAR and progress notes between 4/24/26 and 4/27/26, identified a total of 4 omitted doses of the prescribed [NAME]-Na medication. A review of the facility's clinical records identified no documentation that nursing staff notified the provider regarding these daily medication omissions, and identified no documentation that staff contacted the pharmacy to clarify the transcribed dosage discrepancy.R2's AVS dated 5/4/26, identified that R2 was hospitalized from [DATE] to 5/4/26, with an admitting diagnosis of profound hypo-osmolar hyponatremia with a sodium level of 113 mEq/L. The records identified that her hospital course was complicated by acute on chronic hyponatremia, and hospital medical staff documented that R2 was reportedly not receiving the recommended urea treatments during her prior admission. The records identified that her sodium level was 133 mEq/L on the day of discharge, noting she remained stable with stable sodium levels 72 hours prior to discharge, and she was directed to take urea 15-gram packets three times daily with meals.R2's progress notes dated 5/5/26 through 5/12/26, identified repeated administration entries for [NAME]-Na oral packets noting the medication was unavailable, out of supply, and awaiting pharmacy delivery. Specific entry times included 5/5/26 at 11:16 a.m., 1:50 p.m., and 8:13 p.m.; 5/6/26 at 10:59 a.m., 3:30 p.m., and 5:28 p.m.; 5/7/26 at 9:48 a.m., 12:02 p.m., and 7:30 p.m.; 5/8/26 at 12:08 p.m. and 6:10 p.m.; 5/9/26 at 10:39 a.m., 11:55 a.m., and 5:50 p.m.; 5/10/26 at 10:36 a.m., 12:57 p.m., and 5:02 p.m.; and 5/11/26 at 9:43 a.m., 12:53 p.m., and 5:47 p.m. The note dated 5/11/26 at 12:53 p.m. identified that the unit manager and Director of Nursing (DON) were aware the medication was missing. The note dated 5/12/26 at 6:02 p.m. identified that the supply was unavailable and the pharmacy could not dispense the medication at that time.R2's pharmacy manifest dated 5/11/26, identified that R2's [NAME]-Na 15-gram packets were delivered on 5/12/26, for a total of 5 packets. The records identified that a total of 24 packets were delivered again on 5/15/26. The records identified that on 5/21/26, an additional 8 packets were sent.A review of the facility's medication and delivery records identified that the 5 packets delivered on 5/12/26 were insufficient to meet the three-times-daily dosing requirement, resulting in subsequent documented medication shortages and omissions on the May MAR.R2's progress note dated 5/13/26 at 5:34 p.m., identified that the [NAME]-Na oral packet was refused by R2.R2's progress note dated 5/13/26 at 11:05 p.m., identified that R2 was declining in health status with increased weakness that left her unable to move or lift her hands.R2's progress note dated 5/14/26 at 7:17 a.m., identified that R2 was unable to move her hands or feet and required total assistance with all basic needs.R2's Physician Assistant (PA) progress note dated 5/15/26, identified that R2 was seen for follow-up on functional decline. The records identified that a facility change of condition report dated 5/14/26 noted R2 had a decreased appetite and food intake and had increased weakness that left her unable to move or lift her hands. The note identified that R2 was bedridden, required total assistance with eating, and was fully dependent on staff for all activities of daily living, and the provider issued a new referral for hospice to evaluate and treat.R2's progress note dated 5/16/26 at 11:27 p.m., identified that R2 had a poor appetite, consumed approximately 25% of her dinner, and required assistance with feeding because she was unable to lift her upper extremities.R2's progress note dated 5/17/26 at 7:09 p.m., identified an administration note for the [NAME]-Na oral packet noting the supply was not available and staff were awaiting delivery from the pharmacy.R2's progress note dated 5/20/26 at 7:13 p.m., identified an administration note for the [NAME]-Na oral packet noting staff were unable to find the medication.R2's laboratory results dated [DATE], identified that her sodium level was 129 mEq/L and her potassium level was 4.4 mEq/L.R2's progress note dated 5/21/26 at 7:03 a.m., identified that R2 consumed 300 ml of fluid during the shift.R2's progress note dated 5/21/26 at 2:13 p.m., identified that R2 had decreased oral intake, consumed approximately 25% of her breakfast and lunch, and was actively declining.R2's progress note dated 5/21/26 at 12:52 p.m., identified an administration note for the [NAME]-Na oral packet noting the medication was on order, the pharmacy was notified, and the pharmacy stated the medication would be sent with the second delivery run that night.R2's progress note dated 5/22/26 at 3:14 a.m., identified that R2 was experiencing extreme thirst.R2's progress notes dated 5/22/26 at 10:31 p.m. and 11:04 p.m., identified that R2 complained of shortness of breath, and the provider was notified and issued new orders for supplemental oxygen.R2's progress note dated 5/24/26 at 10:34 a.m., identified an administration note that R2 was sent to the hospital emergency department via ambulance.R2's progress note dated 5/24/26 at 10:34 a.m., identified an administration note that R2 was sent to the hospital emergency department via ambulance.R2's progress note dated 5/24/26 at 12:55 p.m., identified that R2 was short of breath throughout the night. The note identified that at the start of the day shift, R2 was yelling out for help, demanding to see a doctor, had audible wheezing and crackles upon auscultation, and was observed using accessory muscles with increased breathing effort, resulting in her emergency transfer to the hospital via ambulance.R2's MAR dated May 2026, identified an entry for the ordered [NAME]-Na oral packet, 15 grams by mouth with meals three times daily for hyponatremia, scheduled for 8:00 a.m., 12:00 p.m., and 6:00 p.m. A review of the administration tracking codes identified that all three daily doses were omitted from 5/5/26 through 5/11/26. The records identified that a code 9 was documented for omitted doses on 5/4/26 at 6:00 p.m., on 5/12/26 at 6:00 p.m., on 5/13/26 at 6:00 p.m., on 5/17/26 at 6:00 p.m., on 5/20/26 at 6:00 p.m., and on 5/21/26 at 12:00 p.m. Additionally, the tracking codes identified that a code 2 was documented for a refused dose on 5/13/26 at 12:00 p.m.A review of R2's MAR and progress notes between 5/4/26 and 5/21/26, identified a total of 28 omitted doses of the prescribed [NAME]-Na medication. A review of the facility's clinical records identified no documentation that nursing staff notified the physician, physician assistant, or nurse practitioner regarding these repeated medication omissions, and identified no documentation that the facility executed an emergency procurement plan to obtain the missing medication from an alternative pharmacy source.R2's AVS dated 5/28/26, identified a hospitalization from 5/24/26 to 5/27/26. Admitting diagnoses included sepsis, and other diagnoses included chronic hyponatremia due to SIADH. The brief hospital course identified that R2 presented from the skilled nursing facility after two days of increased work of breathing and hypotension and was managed with fluid resuscitation and antibiotics. The records identified that her electrolyte abnormalities, including hyponatremia, were monitored and repleted as needed, and she was discharged back to the skilled nursing facility with hospice support. During an interview on 7/16/26 at 1:02 p.m., the Director of Nursing (DON) identified that when medication was unavailable, the healthcare provider must be notified. The DON identified that no medication error reports were completed regarding R2's omitted [NAME]-Na doses, and the provider was not notified of the unavailable medication. DON stated his expectation would be to call the pharmacy when medication was unavailable and then to notify the provider for alternative treatment. DON indicated this would be a significant medication error for R2 because she had so many missed doses.During a phone interview on 7/16/26 at 4:27 p.m., pharmacy order entry technician (POET)-A identified that the pharmacy received R2's electronic medical record order on 4/23/26. POET-A identified that the order for [NAME]-Na was transcribed into the pharmacy system to give 30 mg (milligrams) daily for hyponatremia. POET-A identified that the reviewing pharmacist noted the medication comes in 15-gram packets and requested clarification on the dose. POET-A identified that the medication is classified as an over the counter (OTC) product, which requires prior authorization by the facility DON before it can be dispensed, and noted that the medication was not sent following the initial order due to the lack of administrative approval. POET-A identified that on 5/4/26, the pharmacy received a new order to give 15 grams by mouth with meals, which was profiled into the system. POET-A identified that on 5/11/26, the facility submitted an electronic approval alert, and the pharmacy sent a partial supply of 5 packets out of an 8-packet order on 5/11/26 because the pharmacy did not have a full supply in stock for the uncommonly dispensed medication. POET-A identified that the facility submitted a refill request on 5/14/26, and the pharmacy sent the amount they would need.During an interview on 7/16/26 at 5:03 p.m., consultant pharmacist (CP)-A identified that the pharmacy received the original [NAME]-Na order on 4/23/26 but did not dispense it because it was an OTC product requiring administrative billing approval from facility DON. CP-A identified that pharmacy records confirmed the medication was first dispensed on 5/12/26. Additionally, CP-A identified that because [NAME]-Na was a clinically significant medication for R2 to treat her history of SIADH and severe hyponatremia, the repeated missed doses constituted a significant medication error that increased her risk for worsening hyponatremia.During an interview on 7/20/26 at 3:21 p.m., the medical director identified that [NAME]-Na was prescribed to treat R2's hyponatremia. The medical director identified that omitting the medication placed R2 at risk for worsening or recurrent hyponatremia and could have contributed to her subsequent hospital admission with a low sodium level of 113. Additionally, the medical director identified that any time a prescribed medication is unavailable, nursing staff are expected to notify the provider immediately for alternative treatment options rather than allowing a resident to go without therapy.Facility policy, Medication Error dated 2025, identified that it is the policy of the facility to ensure residents receive care and services safely in an environment free of significant medication errors. The policy defined a significant medication error as one which causes the resident discomfort or jeopardizes his or her health and safety. The policy guidelines identified that medications must be administered according to physician's orders, and errors will be evaluated based on the resident's condition-such as a requirement for rigid control, strict intake and output measurement, or monitoring of laboratory values-and the frequency of the error, including if an omission occurs repeatedly. Additionally, the policy guidelines identified medication omissions as an administration error. The policy procedure identified that if a medication error occurs, the nurse must assess the resident's condition, notify the physician or healthcare practitioner as soon as possible, and complete an incident or occurrence report once the resident is stable.Facility policy, Medication Reordering dated February 2023, identified that it is the policy of the facility to accurately and safely obtain pharmaceutical services, including the provision of routine and emergency medications in a timely manner to meet the needs of each resident. The policy guidelines identified that the acquisition of medications should be completed in a timely manner to ensure medications are administered safely, and noted that in the event of new orders, the facility is allowed 24 hours to begin a medication unless otherwise specified by the physician.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 3 residents (R3) reviewed for pressure ulcers. Findings include:R3's face sheet printed 7/16/26, identified diagnoses including a T11-T12 fracture, spinal stenosis, diabetes, severe protein-calorie malnutrition, nutritional anemia, and a bladder disorder.R3's care plan dated 2/13/26, identified a focus for being at risk for alteration in skin integrity. Care plan interventions included observing R3's skin condition daily with daily care and reporting any identified abnormalities.Review of R3's weekly skin assessments dated 5/4/26, 5/11/26, 5/18/26, 5/28/26, 6/22/26, and 6/29/26, identified that no skin issues were documented.R3's NAR Bath Day Worksheet/Skin Update, dated 6/29/26, identified R3 received a shower and had no identified skin concerns.Review of R3's Situation, Background, Assessment, and Recommendation (SBAR) note dated 7/4/26, identified a newly noted wound on R3's coccyx with a documented width of 0.1 cm and a depth of 0.2 cm. The note identified that the facility failed to maintain a complete clinical record by leaving the template placeholders completely blank for the wound's length measurement, the appearance of the wound bed, the type of drainage, and the condition of the surrounding skin.R3's NAR Bath Day Worksheet/Skin Update, dated 7/6/26, identified R3 received a shower and had no identified skin concerns.R3's NAR Bath Day Worksheet/Skin Update, dated 7/13/26, identified R3 received a shower and had no identified skin concerns.During an interview on 7/15/26 at 4:14 p.m., the Director of Nursing (DON) verified that weekly nursing skin assessments were missing from R3's chart for the weeks of 7/6/26 and 7/13/26. The DON located R3's loose NAR Bath Day Worksheets for those dates and stated they were used in place of documented medical chart assessments. The DON confirmed that these worksheets were not a part of R3's permanent medical record, noting that they are filled out by aides, signed by nurses, and kept on the nurse manager's desk until they are eventually thrown away.Review of R3's clinical record identified the facility failed to maintain permanent, complete, and accurate records of the resident's skin assessments. Specifically, the facility utilized temporary nursing assistant worksheets as the official documentation of R3's weekly skin status, which were excluded from the permanent medical chart and routinely discarded.Policy regarding accurate medical records were requested and not received.

Based on observation, interview, and record review, the facility failed to implement individualized fall prevention interventions for 1 of 3 residents (R1) reviewed for accidents.Findings include R1's face sheet, printed 7/15/26, identified diagnoses of dementia, progressive supranuclear ophthalmoplegia (a progressive brain disorder that affects balance, walking, eye movements, thinking, and safety awareness), polyneuropathy (nerve damage that can cause weakness, numbness, and poor balance), other abnormalities of gait and mobility (difficulty walking and moving safely), and stress incontinence (loss of urine with movement or activity).R1's Significant Change Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment, spoke Mandarin as the preferred language, and required an interpreter to communicate with health care staff. The MDS further identified R1 required partial to moderate assistance with transfers and toileting and was always continent of urine.R1's Falls Care Area Assessment (CAA), dated 2/16/26, identified R1 was at risk for falls related to cognitive impairment, impaired functional abilities requiring assistance with transfers and toileting, and visual impairment. The Falls CAA identified the care plan would address interventions to minimize falls and injuries while maintaining R1's functional status.R1's Incident Report, dated 5/7/26 at 7:40 p.m., identified a witnessed fall occurred while a certified nursing assistant (CNA) was transferring R1 from the toilet to the recliner. During the transfer, R1 lost balance and tipped to the right side, landing in a sitting position on the floor. No injuries were identified. The report identified gait imbalance as a predisposing physiological factor and the transfer as a predisposing situational factor.R1's Situation, Background, Assessment, and Recommendation (SBAR) note, dated 5/7/26 at 11:15 p.m., identified R1 experienced a witnessed fall while a CNA was transferring R1 from the toilet to a recliner. During the transfer, R1 lost her balance and tipped onto her right side. No injuries were identified. The recommendation following the fall was to change R1's transfer status to two-person assistance.R1's social services note, dated 5/8/26, at 8:38 a.m., identified Family Member (FM)-A emailed with concerns regarding R1's fall and requested two staff assist with transfers. The concerns were forwarded to the unit manager and Director of Nursing (DON).R1's Interdisciplinary Team (IDT) Clinical Review, dated 5/8/26, at 9:30 a.m., identified the reason for review was R1's fall on 5/7/26. The review identified R1 tipped to the side while being assisted by one CNA. The care plan review identified R1's transfer status would be changed to assist of two due to increased weakness and impaired balance.R1's Fall Risk Observation/Assessment, dated 5/10/26, identified R1 had a fall risk score of 30 and was categorized as high risk for falls. The assessment identified a history of falls, unsteady balance, age [AGE] years or older, ambulation with problems using an assistive device, cognitive and behavioral symptoms, multiple health conditions/risk factors, and medications associated with fall risk.R1's care plan, dated 10/21/25, identified R1 was at risk for falls due to degenerative osteoarthrosis, spine and knee pain, neuropathy, cognitive impairment, progressive supranuclear palsy, and impulsivity. An intervention, revised 11/26/25, required staff to use a gait belt during transfers and maintain hold of the gait belt throughout the transfer due to R1's poor gait pattern. An intervention, revised 5/8/26, required two-person assistance for functional transfers and short-distance mobility using a gait belt and front-wheeled walker (FWW).Facility document, 2E report sheet, last updated 7/13/26. Identified R1 had diagnosis of dementia, only speaks mandarin, needed assist of 1 staff for adl's, and was a high fall risk. R1's Incident Report, dated 5/29/26 at 7:45 p.m., identified R1 requested assistance to use the bathroom after activating the call light. A certified nursing assistant (CNA) placed the walker in front of R1 and turned away to retrieve the gait belt. R1 stood without assistance, leaned to the right, and lost balance. The CNA assisted R1 to the floor. While lowering R1 to the floor, R1's right side rubbed against the recliner, resulting in an abrasion to the right side of the back. R1 complained of pain to the area. The report identified the immediate intervention was to educate R1 to wait for assistance with transfers.R1's SBAR note, dated 5/29/26 at 7:45 p.m., identified a witnessed fall after R1 requested assistance to the bathroom. A certified nursing assistant (CNA) placed a walker in front of R1 and turned away to retrieve the gait belt. R1 stood up unassisted, leaned to the right, and lost balance. The CNA assisted R1 to the floor. While lowering R1 to the floor, R1's right side rubbed against the recliner, resulting in an abrasion to the right side/back. R1 expressed pain/discomfort to the area. The immediate intervention was to educate R1 to wait for assistance with transfers.Neither the SBAR note nor the Incident Report identified whether staff followed R1's care plan requiring two-person assistance during transfers, whether a second staff member was present, or whether failure to implement the care plan contributed to the fall.During an interview on 7/15/26 at 2:20 p.m., the director of nursing (DON) confirmed only one staff member had assisted R1 during the 5/29/26 transfer and acknowledged R1's care plan requiring two-person assistance had not been followed.R1's IDT Clinical Review, dated 6/3/26, identified the reason for review was a fall after R1 tipped to the side while a CNA turned around. The background identified supranuclear palsy. The care plan review identified staff were to continue following R1's fall interventions and provide two-person assistance with transfers.R1's Incident Report, dated 7/8/26 at 10:00 a.m., identified staff heard a loud noise and found R1 lying on the floor with R1's head in the resident room and R1's lower body inside the bathroom. R1's walker was lying beside R1, R1's pants and incontinent brief were not pulled up, and the bathroom call light was within reach. The report identified R1 was self-transferring from the toilet when the unwitnessed fall occurred. R1 struck the back of the head and sustained a 2 cm x 2 cm raised, reddened area. Hospice evaluated R1, and R1 was transferred to the emergency department for further evaluation. The report identified gait imbalance and weakness as predisposing physiological factors.R1's Situation, Background, Assessment, and Recommendation (SBAR) note, dated 7/8/26 at 10:11 a.m., identified staff heard a loud noise and found R1 lying on the floor with R1's head in the resident room and R1's lower body inside the bathroom. R1's walker was lying beside R1, R1's pants and incontinent brief were not pulled up, and the bathroom call light was within reach. The note identified R1 was self-transferring from the toilet when the unwitnessed fall occurred. R1 struck the back of the head and sustained a 2 cm x 2 cm raised, reddened area. Hospice evaluated R1, and R1 was transferred to the emergency department for further evaluation.R1's Progress Note, dated 7/8/26 at 4:00 p.m., identified R1 returned to the facility from the emergency department following evaluation after the fall. The note identified no new injuries were identified, and R1 continued to complain of pain to the back of the head from the fall.During an interview on 7/14/26 at 11:50 a.m., Licensed Practical Nurse (LPN)-A stated she was working on 7/8/26 when R1 fell. LPN-A stated the nursing assistant (NA) transferred R1 onto the toilet and then left to assist another resident. LPN-A stated the NA asked LPN-A to watch R1; however, LPN-A became occupied with other duties. LPN-A stated she heard R1 fall while R1 was attempting to get off the toilet independently. LPN-A stated R1 sustained a bump to the back of the head that was painful. Hospice was notified, R1 was assessed, and R1 was transferred to the emergency department for evaluation. LPN-A stated the care plan was revised after the fall to include an intervention directing staff not to leave R1 alone on the toilet. LPN-A stated R1 forgets to ask for assistance.During an interview on 7/15/26 at 2:20 p.m., DON stated R1's 7/8/26 fall occurred after NA-C transferred R1 onto the toilet and then left to assist another resident. The DON stated NA-C asked LPN-A to watch R1. The DON stated LPN-A became occupied administering medications and was unable to observe R1. The DON stated R1 attempted to get off the toilet independently, fell, and sustained a hematoma to the back of the head. The DON stated hospice was notified and assessed R1, and R1 was transferred to the emergency department for evaluation. The DON stated a head computed tomography (CT) scan identified no intracranial bleeding. The DON stated the care plan was revised following the fall to include an intervention directing staff not to leave R1 unattended while using the toilet.Review of R1's 7/8/26 Incident Report and SBAR, together with interviews of the DON and LPN-A, identified staff did not implement R1's care plan requiring two-person assistance during transfers. Despite revising the care plan after the 5/7/26 fall to reduce future falls, staff transferred R1 to the toilet without the required assistance, left R1 unattended, and R1 attempted to transfer independently, fell, struck the head, and required emergency department evaluation.R1's IDT Clinical Review, dated 7/9/26 at 9:45 a.m., identified the reason for review was R1's unwitnessed fall from the toilet. The review identified R1 had a history of falls and impulsive decision making. Following the fall, the care plan was reviewed and revised to include an intervention directing staff not to leave R1 unattended in the bathroom.The Facility 2 East Report Sheet, last updated on 7/13/26, identified R1 had a diagnosis of dementia, spoke only Mandarin, required one-person assistance with activities of daily living (ADLs), and was at high risk for falls. The report sheet did not identify R1 required two-person assistance for transfers or toileting.The report sheet available to direct care staff continued to identify one-person assistance, which was inconsistent with R1's care plan requiring two-person assistance.R1's Visual/Bedside Kardex, printed on 7/15/26, identified R1 required assist of two for functional transfers and short-distance mobility with a gait belt and front-wheeled walker. The Kardex further identified R1, required assist of two for toileting and included a scheduled toileting program upon rising, before and after meals, at bedtime, and during night rounds.During an observation and interview on 7/14/26 at 11:10 a.m., R1 had activated the call light requesting assistance to use the bathroom and was seated on the edge of the bed. At 11:12 a.m., nursing assistant (NA)-A responded, applied R1's shoes and gait belt, and assisted R1 with a front-wheeled walker to the bathroom. During the transfer, R1 had difficulty pivoting to the left and required verbal cueing. After assisting R1 onto the toilet, NA-A removed the gait belt and remained with R1 while R1 used the toilet. NA-A stated staff remain with R1 because R1 is at high risk for falls, does not always remember to use the call light, and will attempt to transfer independently. NA-A further stated R1 has had multiple falls, and staff are required to remain with R1 while R1 is using the bathroom. At 11:24 a.m., NA-A reapplied the gait belt, provided perineal care, assisted R1 in pulling up the brief and pants, and assisted R1 back to bed using the front-wheeled walker while providing verbal cueing and maintaining hold of the gait belt. During the observation, NA-A completed both transfers without assistance from a second staff member.During an observation and interview on 7/14/26 at 1:39 p.m., NA-B assisted R1 to the bathroom using a gait belt and front-wheeled walker. NA-B remained with R1 while R1 was using the toilet. After toileting, NA-B assisted R1 back to bed using the gait belt and front-wheeled walker. NA-B stated R1 had fallen approximately one to two weeks earlier. NA-B stated staff must remain with R1 while R1 is on the toilet because R1 could fall if left alone. NA-B stated all staff should know R1 cannot be left alone in the bathroom because R1 is impulsive and not safe to get up independently. NA-B stated R1 requires frequent toileting and that most of R1's falls occur while attempting to get to the bathroom. During the observation, NA-B completed both transfers without assistance from a second staff member.During a phone interview on 7/14/26 at 1:43 p.m., using a speech interpreter (SI)-A, R1 stated the last fall occurred in the bathroom. R1 stated, I don't know why I fell. R1 stated the fall caused R1 to hit the back of the head and pointed to a bump on the back right side of the head. R1 rated the pain from the injury as a 2 to 3 on a 10-point scale. When asked if staff helped R1 to the bathroom, R1 stated, One of the staff is good; one is not really good at getting me to the bathroom. When asked what staff could do to help prevent future falls, R1 stated it was easy to fall because of pain from a previous right hip fracture that required surgical pinning. R1 stated the hip continued to hurt after surgery and made it difficult to walk.During a telephone interview on 7/15/26 at 9:30 a.m., the Hospice Registered Nurse Case Manager (RNCM)-A stated she had provided hospice services to R1 since 2/10/26. The Hospice RN stated R1's terminal diagnosis was Progressive Supranuclear Palsy (PSP), a progressive neurodegenerative disorder that affected R1's mobility and cognition. The Hospice RN stated R1's mobility had progressively declined from requiring one-person assistance to requiring two-person assistance with transfers and ambulation. The Hospice RN stated R1 demonstrated a shuffling gait, was unable to reliably move the feet forward, and had increasing difficulty communicating due to the progression of the disease. The Hospice RN stated R1's ability to wait for assistance was poor and, if R1 believed no one was coming, R1 would attempt to transfer independently. The Hospice RN stated R1 was a very high risk for falls due to declining cognition and mobility and confirmed R1 had experienced multiple previous falls. The Hospice RN stated hospice was notified immediately after the 7/8/26 fall and she evaluated R1 at the facility. The Hospice RN observed a small bump on the back of R1's head without bleeding or laceration and stated R1 complained of pain to the back of the head and buttocks. The Hospice RN stated R1 appeared alert, responsive, and at baseline neurologically. The Hospice RN stated she added an intervention to the hospice care plan directing staff not to leave R1 alone during bathroom use after the 7/8/26 fall. When asked whether R1 could have been safely left alone in the bathroom on 7/8/26, the Hospice RN stated, No.During follow-up interviews on 7/15/26 at 11:25 a.m., NA-A and NA-B stated they use the Kardex and report sheet to determine how to provide resident care. NA-A stated she believed R1 required one-person assistance for toileting and checked the Kardex, which did not identify the number of staff required. NA-A then reviewed the report sheet, which identified R1 required one-person assistance. After being informed R1's care plan had required two-person assistance for transfers since 5/8/26, both nursing assistants stated the Kardex, report sheet should have reflected the change. Both stated they were unaware R1 required two-person assistance for transfers. NA-A stated she had always transferred R1 with one staff member and had not experienced any problems. NA-A stated she transferred R1 alone twice on 7/14/26 and again on the morning of 7/15/26 because the report sheet directed one-person assistance. NA-A stated, If I was supposed to be using two staff since May, I had no idea. It's not on the report sheet and no one told me. NA-A further stated, I will be glad to use two staff if that's what we should be doing because we can't leave her unattended in the bathroom. Then another staff can watch her while the other staff answers a call light. NA-B stated she had always transferred R1 with one staff member. Both nursing assistants stated R1 was usually transferred by one staff member, and both stated they were not aware R1's care plan required two-person assistance.During an interview on 7/15/26 at 11:32 a.m., LPN-B stated she was R1's nurse on the 2 East unit and believed R1 required one-person assistance for toileting and transfers. After reviewing R1's care plan, LPN-B confirmed it had required two-person assistance for transfers since 5/8/26. LPN-B stated she was not aware of the change. LPN-B stated if staff were assisting R1 with only one person, they would not be following the care plan that was put in place to help prevent future falls.During an interview on 7/15/26 at 2:20 p.m., DON stated R1's care plan had required two-person assistance for transfers and toileting since 5/8/26, following R1's 5/7/26 fall, to reduce the risk of future falls. The DON explained staff are notified of changes in transfer status through shift report, the care plan, and the Kardex, and staff compliance is monitored through random audits, communication in the electronic medical record, and the daily huddle sheet. After being informed two different nursing assistants had been observed transferring and toileting R1 with one staff member, the DON stated staff should have been following the care plan and using the Kardex rather than the report sheet. The DON confirmed one-person assistance was not acceptable because R1 required two-person assistance to help prevent falls and reiterated the expectation that staff follow R1's care plan because R1 was at very high risk for falls.As a result, staff responsible for providing R1's care did not consistently know or implement the intervention requiring two-person assistance for transfers and toileting that had been put in place following the 5/7/26 fall to reduce the risk of future falls.Facility policy, Accidents and Supervision, revised 2023, identified the facility would provide each resident adequate supervision and assistive devices to prevent accidents by identifying hazards and risks, implementing interventions to reduce hazards and risks, monitoring the effectiveness of interventions, and modifying interventions when necessary. The policy further identified interventions were to be communicated to all relevant staff, documented, put into action, and monitored to ensure they were implemented correctly and consistently. The policy identified adequate supervision was based on the individual resident's assessed needs and identified hazards in the resident environment.Facility policy, Fall Prevention Program, revised 2023, identified each resident would be assessed for fall risk and receive care and services based on the resident's individualized level of risk to minimize the likelihood of falls. The policy identified high-risk residents were to receive interventions based on their assessed risk factors, including scheduled toileting assistance, and each resident's care plan was to be monitored for effectiveness and revised as needed. Following a fall, the policy directed staff to assess the resident, complete a post-fall assessment and incident report, notify the physician and family, review and update the care plan as indicated, document assessments and actions, and obtain witness statements when an injury occurred.

Based on observation, interview, document review the facility failed to ensure the physician was notified of a change in pressure ulcer status for 2 of 3 residents (R2, R3) reviewed for pressure ulcers who had pressures ulcers that deteriorated. Findings include R2's Face Sheet printed 7/16/26, identified R2 had diagnoses of diabetes, chronic kidney disease (gradual loss of kidney function), peripheral vascular disease (poor blood circulation), muscle weakness, difficulty in walking, bladder disorder (problems controlling the bladder), and retention of urine (trouble emptying the bladder completely).R2's after visit summary (AVS) dated 3/12/26, identified R2 was hospitalized from [DATE] to 3/12/26 with admitting diagnosis of bradycardia. AVS identified that R2 had blanchable redness to coccyx.R2's admission minimum data set (MDS) dated [DATE], identified R2's cognition was intact and R2 was at risk for pressure ulcers and did not identify any current pressure ulcers.R2's Situation, Background, Assessment, and Recommendation (SBAR) note dated 4/26/26 at 2:26 p.m. identified R2 had a stage 2 pressure ulcer on the coccyx and a stage 1 non-blanchable erythema on the buttocks area, with staff applying zinc oxide (a thick skin-protecting ointment typically used to shield raw or irritated skin from moisture and incontinence) and a sacral Mepilex dressing (a padded, absorbent foam bandage designed to protect wounds and cushion pressure points).R2's MD progress note dated 5/4/26, identified R2 was readmitted to the facility following a hospitalization from 4/27/26 to 5/4/26. The progress note further identified R2 had a Stage 2 sacral pressure injury and contact irritant dermatitis (a skin rash caused by direct contact with an irritating substance, such as urine or feces).R2's Weekly Wound Observation dated 5/4/26, identified R2 had a Stage 2 pressure ulcer to the coccyx measuring 3.0 centimeters (cm) x 2.5 cm x 0.1 cm, with a scant amount of serous drainage, no wound odor, and no signs of infection. The wound observation further identified the wound bed had granulation tissue present, which is a deeper tissue type that cannot be present in a partial-thickness Stage 2 pressure ulcer. A Stage 2 pressure ulcer only involves the top layers of skin and requires new skin cells, called epithelial tissue, to heal.R2's Weekly Wound Observation dated 5/12/26, identified a Stage 2 pressure ulcer to the coccyx measuring 6.0 cm x 4.0 cm x 0.1 cm, with a scant amount of serous drainage, no wound odor, and no signs of infection or inflammation. The observation further identified necrotic tissue was present in the wound bed, and the overall impression was unchanged since 5/4/26. Additionally, the observation identified the physician was last notified on 5/4/26.R2's Weekly Wound Observation dated 5/19/26 identified a Stage 2 pressure ulcer to the coccyx measuring 8.0 cm x 6.0 cm x 0.1 cm, with no drainage, no wound odor, and a date acquired of 5/4/26. The observation further identified the wound bed had necrotic tissue present with irregular edges. Additionally, the observation identified the physician was last updated on 5/4/26. However, the observation lacked written documentation identifying that the provider was notified of the continued wound expansion and tissue decline since 5/12/26.During an interview on 7/16/26 at 1:35 p.m., the newly assigned Wound Nurse, Registered Nurse (RN)-C, reviewed R2's clinical record and verified that the provider was not notified when the pressure ulcer worsened and stated that the provider should be notified when pressure ulcers worsen so they can decide if a new treatment should be put in place.During an interview on 7/16/26 at 1:02 p.m., the Director of Nursing (DON) stated that upon identification of a pressure ulcer, a comprehensive wound assessment must be completed immediately to include location, staging, wound dimensions, and a wound bed description tracking tissue type, exudate, odor, signs/symptoms of infection, peri wound, edge characteristics and the provider should be notified for a treatment order. The DON clarified that these assessments must be completed at least weekly and the provider should have been notified immediately after each significant change in the wound to ensure appropriate treatment. Upon review of R2's record, the DON confirmed that the pressure ulcer had worsened on 5/12/26 and 5/19/26, but the provider was not notified of these changes, and no new treatment orders were put in place.During an interview on 7/16/26 at 3:00 p.m., the Medical Director stated that when a resident's pressure ulcer increased in size and develops necrotic tissue, nursing staff must notify the provider. Upon review of the sequence of events regarding R2's sacral pressure ulcer, including the wound increasing in size with documented necrotic tissue on 5/12/26 and 5/19/26 while continuing to be incorrectly documented as a Stage 2 pressure ulcer, the Medical Director confirmed that a provider should have been notified on those dates so the treatment plan could be reevaluated.R3's Face sheet printed 7/16/26, identified diagnoses of T11-T12 fracture (a broken bone in the upper back), spinal stenosis of the lumbar region (narrowing of the lower spinal canal that causes nerve pain and numbness), diabetes, severe protein-calorie malnutrition (a severe lack of nutrients needed to maintain healthy skin tissue), muscle weakness, difficulty walking, lack of coordination, unsteadiness on feet, nutritional anemia (a lack of healthy red blood cells needed to carry oxygen to tissues), and a disorder of the bladder (problems controlling the bladder).R3's quarterly MDS dated [DATE], identified R3 had severe cognitive impairment and no current skin concerns.R3's weekly skin assessments dated 5/4/26, 5/11/26, 5/18/26, 5/28/26, 6/22/26, and 6/29/26, identified no skin issues were noted.R3's skin/wound progress note dated 7/4/26, identified an open wound on R3's coccyx during routine care. The progress note further identified the wound bed was open with no drainage, the surrounding skin was intact, and no wound odor was present. Additionally, the progress note identified the area was cleansed, zinc oxide (a thick white cream used to protect skin from moisture and friction) was applied, and the provider was notified and wound orders were requested.R3's Situation Background Assessment Response (SBAR) note dated 7/4/26, identified a newly noted, undocumented wound on R3's coccyx with a width of 0.1 cm and a depth of 0.2 cm. The SBAR note further identified the facility failed to record a length measurement, leaving the template placeholder blank. The SBAR note further identified that the facility failed to fill out the remaining clinical details on the form, leaving template placeholders blank for the appearance of the wound bed, the type of drainage, and the condition of the surrounding skin.Review of R3's clinical record identified the facility failed to accurately assess, monitor, and communicate significant changes in R3's skin condition to the physician. Specifically, the record identified that when reporting a newly discovered pressure ulcer on 7/4/26, staff transmitted an incomplete template to the physician that completely lacked the wound's length, color description, and drainage type.R3's nurse practitioner (NP) progress note dated 7/10/26, identified R3 was seen for a change in mental status, was seated in a wheelchair, and had documented histories of a spinal fracture and malnutrition. The progress note failed to identify any skin concerns and lacked any documentation indicating the provider was notified of R3's newly discovered coccyx pressure ulcer.Review of R3's clinical record identified the facility failed to accurately monitor, evaluate, and communicate significant changes in R3's skin condition to medical providers. Specifically, the record identified that during an advanced clinical visit on 7/10/26, the nurse practitioner documented no skin concerns were present, despite a separate facility wound alert being generated six days prior on 7/4/26.During an interview on 7/14/26 at 11:41 a.m., Trained Medication Assistant (TMA)-A stated that R3 had a small, open area on his coccyx that was identified a couple of weeks prior, which had not progressed or improved. TMA-A stated that she notified the nurse right away when it was discovered and assumed staff were still applying zinc oxide because R3 did not have a dressing on his wound when she assisted him out of bed that morning. TMA-A described the open area as a stage 2 wound about the size of a pea with a pink wound bed and no visible drainage.During an interview on 7/15/26 at 11:47 a.m., RN-A stated he was completely unaware that R3 had a pressure ulcer on his coccyx until reviewing the 7/4/26, electronic progress notes with the surveyor during the interview. RN-A confirmed there were no active medical treatment orders.During an interview on 7/15/26 at 12:13 p.m., Nurse Manager (NM)-A stated that a small wound was documented on R3's coccyx on 7/4/26 but assumed it had healed despite a complete lack of follow-up documentation. NM-A verified that an SBAR alert was transmitted on 7/4/26 but confirmed there was no recorded provider response or subsequent clinical monitoring.During an interview on 7/15/26 at 3:24 p.m., Registered Nurse (RN)-C, the wound nurse, stated that upon identification of a new pressure injury, a nurse must complete a comprehensive weekly wound assessment-including measurements, wound bed description, drainage, surrounding skin condition, localized pain, and signs of infection. RN-C specified that these findings must be transmitted to the physician via an SBAR alert to secure initial treatment orders, the weekly wound observation tool must be initiated, and the resident must be placed on the weekly wound provider tracking list for evaluation. Upon review of R3's record, RN-C confirmed that R3 was never placed on the facility's wound provider rounding list and verified she was completely unaware that R3 had any active skin concerns.During a clinical observation on 7/15/26 at 3:48 p.m., The surveyor observed RN-C (the wound nurse) perform a skin inspection on R3. Examination of R3's backside revealed two distinct pressure ulcers. The first wound, located on the coccyx, measured 1.0 cm by 0.8 cm with a wound bed covered in necrotic gray slough; RN-C verified that this pressure ulcer was unstageable due to the inability to visualize the wound base. The second wound, located on the right buttock, was a Stage 2 pressure ulcer measuring 0.9 cm long, 0.7 cm wide, and 0.2 cm deep with a red, beefy wound bed and dark surrounding skin.During an interview on 7/15/26 at 4:14 p.m., the Director of Nursing (DON) verified that R3 had an unstageable pressure ulcer and a Stage 2 pressure ulcer with no comprehensive assessments or clinical treatment orders in place. The DON acknowledged that an open area was identified on R3's bottom on 7/4/26 but confirmed that the assessment was not comprehensive and that the facility failed to secure a response or treatment orders from the provider after transmitting the SBAR alert.During an interview on 7/16/26 at 3:12 p.m., the Medical Director reviewed the sequence of events regarding R3's pressure ulcers and stated that upon identifying the coccyx wound on 7/4/26, nursing staff should have immediately notified the provider so treatment orders could be put in place. The Medical Director noted he could not definitively interpret why subsequent weekly skin assessments on 7/6/26 and 7/13/26 documented no skin concerns when there was no documentation that the initial wound had resolved and R3 was subsequently found to have a Stage 2 and an unstageable pressure ulcer on 7/15/26.

Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, evaluate, and implement individualized interventions to prevent and treat pressure ulcers, including timely physician notification following significant changes in wound condition, for 2 of 3 residents (R2 and R3) reviewed for pressure ulcers.Findings include:R2's Face Sheet printed 7/16/26, identified R2 had diagnoses of diabetes, chronic kidney disease (gradual loss of kidney function), peripheral vascular disease (poor blood circulation), muscle weakness, difficulty in walking, bladder disorder (problems controlling the bladder), and retention of urine (trouble emptying the bladder completely).R2's after visit summary (AVS) dated 3/12/26, identified R2 was hospitalized from [DATE] to 3/12/26 with admitting diagnosis of bradycardia. AVS identified that R2 had blanchable redness to coccyx.R2's Braden Scale dated 3/15/26, identified a score of 17, which indicated R2 was at risk for pressure ulcers. The assessment further identified R2 had slightly limited sensory perception, was chairfast with a severely limited ability to walk, had slightly limited body mobility, and had a potential problem with friction and shear.R2's admission minimum data set (MDS) dated [DATE], identified R2's cognition was intact, did not walk, used a wheelchair for mobility, and required partial to moderate assistance with toileting hygiene, lower body dressing, and experienced occasional bowel and bladder incontinence. The MDS further identified R2 was at risk for pressure ulcers and did not identify any current pressure ulcers. Finally, the MDS identified no skin treatments were implemented for prevention, including a pressure-reducing device for the chair or bed, and no turning and repositioning program was noted.R2's care area assessment (CAA) dated 3/18/26, identified R2 was at risk for developing pressure ulcers. The CAA further identified contributing factors included incontinence and a need for touching assistance or supervision with bed mobility, such as rolling and sitting up. To minimize these risks, the CAA identified that staff would check R2's skin weekly, monitor food and fluid intake, and assist R2 with repositioning at least every two hours.R2's care plan initiated 3/17/26, identified a focus alteration in skin integrity related to readmit on 5/4 with stage 2 pressure area to coccyx/sacral area. The care plan identified interventions dated 3/17/26, included barrier cream to peri area/buttocks as needed, encourage to reposition as needed; use assistive devices as needed, observe skin condition with ADL care daily; report abnormalities, pressure redistributing device on bed/chair, mattress on bed and cushion in wheelchair (w/c), provide preventative skin care routinely and PRN (as needed), and use pillows/positioning devices as needed.R2's admission medical doctor (MD) progress note dated 3/19/26, identified R2 was admitted for rehabilitation following a fall at home, had a history of poor food intake, and had diagnoses of diabetes, nerve damage, kidney disease, anemia, and a history of chronic lower extremity wounds.R2's Braden Scale dated 3/22/26, identified a score of 19, which indicated R2 was not at risk for pressure ulcers.R2's Braden Scale dated 3/29/26, identified a score of 14, which indicated R2 was at moderate risk for pressure ulcers.R2's NAR Bath Day Worksheet/Skin Update, dated 4/5/26, identified R2 received a shower and had no identified skin concerns.R2's hospital After Visit Summary (AVS) dated 4/23/26, identified R2 was hospitalized from [DATE] to 4/23/26 for cervical myelopathy (spinal cord compression), a bladder mass, pneumonia, hypoalbuminemia (low protein levels), and weakness. The AVS further identified that R2 underwent emergent neck surgery on 4/17/26, resulting in persistent quadriparesis (weakness in all four limbs) with no movement in the legs or left arm. Additionally, the AVS identified R2 required total assistance for all mobility, required an indwelling urinary catheter, and required specialized therapy for positioning and skin protection.R2's Braden Scale dated 4/24/26, identified a score of 11, which indicated R2 was at high risk for pressure ulcers. The assessment further identified R2 had completely limited sensory perception, skin was occasionally moist, and R2 was chairfast and completely immobile. Additionally, the assessment identified R2's nutrition was probably inadequate, and a potential problem with friction and shear existed.R2's Braden Scale dated 4/26/26, identified a score of 13, which indicated R2 was at moderate risk for pressure ulcers.R2's NAR Bath Day Worksheet/Skin Update dated 4/26/26, identified R2 received a shower and next to skin concerns the word, yes, was circled. The document further identified a picture of the backside of a body was present below this and the coccyx area was circled but did not identify any written documentation of what the skin concern was.R2's Situation, Background, Assessment, and Recommendation (SBAR) note dated 4/26/26 at 2:26 p.m. identified R2 had a stage 2 pressure ulcer on the coccyx and a stage 1 non-blanchable erythema on the buttocks area, with staff applying zinc oxide (a thick skin-protecting ointment typically used to shield raw or irritated skin from moisture and incontinence) and a sacral Mepilex dressing (a padded, absorbent foam bandage designed to protect wounds and cushion pressure points). However, the note lacked any written documentation regarding the specific measurements of the pressure ulcers, a description of the wound beds, or the presence of any drainage.R2's SBAR note dated 4/27/26 at 8:56 a.m. identified R2 had spinal myelopathy with cervical fusion, quadriplegia deficits, was short of breath, and had bilateral limb edema, resulting in a referral to the emergency department. However, the note lacked any written documentation regarding skin assessment, wound measurements, or the condition of the previously identified coccyx and buttocks pressure ulcers prior to transfer.Review of R2's clinical record identified the facility failed to thoroughly evaluate, follow up, and implement appropriate interventions for an identified skin concern. Specifically, a skin concern on R2's coccyx was noted during a shower on 4/26/26, but the facility failed to document any descriptive details regarding the condition of the skin or complete a comprehensive wound assessment. The record further identified that staff applied zinc oxide and a sacral Mepilex dressing to the area but lacked any written documentation identifying a physician's order was obtained for these specific wound treatments or that a professional wound evaluation was performed prior to the resident's transfer.R2's hospital Certified Wound Care Nurse (CWCN) progress note dated 4/28/26, identified R2 had a Stage 2 sacral pressure injury with partial-thickness pink and yellow tissue in the wound bed. The progress note further identified ordered wound treatments included twice-daily cleansing with Vashe wound cleanser (a gentle liquid solution used to wash away bacteria, clean out wounds, and remove dead tissue), applying an acetic acid cloth (a cloth soaked in a mild acid solution used to stop dangerous bacteria from growing) for two hours twice daily, applying PluroGel wound gel (a specialized gel that keeps the wound moist and helps soften and remove dead tissue), and covering the area with a Mepilex border foam dressing. Additionally, required interventions included offloading heels on pillows at all times, full 30-degree turns side-to-side every two hours while in bed, repositioning every hour while in a chair, keeping the head of the bed below 30 degrees, and using breathable incontinence underpads instead of adult briefs while in bedR2's medical doctor (MD) progress note dated 4/30/26, identified R2 was hospitalized due to complications from spinal cord surgery, severe muscle weakness, and poor food intake. The MD note further identified R2 had persistent quadriplegia (total paralysis of all four limbs) with zero movement in the lower legs, required full assistance for all mobility, required an indwelling urinary catheter, had swallowing problems requiring a modified diet, and suffered from malnutrition.R2's hospital After Visit Summary (AVS) dated 5/4/26, identified R2 was hospitalized from [DATE] to 5/4/26 for severe hyponatremia. The AVS further identified that on 4/28/26, a Stage 2 pressure injury to the sacrum was identified that had been present for six days. Additionally, the AVS identified R2 had total paralysis in the arms and legs, a chronic urinary catheter, and required hospital wound care recommendations for acetic acid dressings, a moisture barrier, and pressure redistribution.Review of R2's clinical record identified the facility failed to comprehensively assess, monitor, and evaluate the resident's skin condition upon readmission. Specifically, hospital records identified that a Stage 2 sacral pressure injury was discovered on 4/28/26 that had been present for six days, identifying the wound was present when R2 was readmitted to the facility on [DATE]. However, review of the facility's clinical records between 4/23/26 and 4/27/26 revealed that upon readmission, the facility failed to accurately document or measure the wound, failed to track its clinical characteristics, and failed to implement physician-ordered interventions, implementing un-ordered treatments instead on 4/26/26.R2's MD progress note dated 5/4/26, identified R2 was readmitted to the facility following a hospitalization from 4/27/26 to 5/4/26. The progress note further identified R2 had a Stage 2 sacral pressure injury and contact irritant dermatitis (a skin rash caused by direct contact with an irritating substance, such as urine or feces). Additionally, the progress note identified that active orders and recommendations from the hospital wound care team included acetic acid dressings, a moisture barrier, and pressure redistribution. Finally, the progress note identified R2 remained totally dependent for mobility, with a neurological exam showing no perceptible movement of the arms and legs.R2's Braden Scale dated 5/4/26 identified a score of 13, which indicated R2 was at moderate risk for pressure ulcers. The assessment further identified R2 had slightly limited sensory perception with difficulty communicating discomfort, and skin was occasionally moist. Additionally, the assessment identified R2 was chairfast and completely immobile, making no body position changes without assistance. Finally, the assessment identified R2's nutrition was probably inadequate, and a potential problem with friction and shear existed.R2's order summary dated 5/4/26, identified active orders to cleanse the sacrum area with Vashe wound cleanser, pat the area dry, and apply a moist 0.25% acetic acid cloth over the affected area for two hours twice daily on the day and evening shifts. The order summary further identified that in between treatments; staff were ordered to apply a 3 millimeter (mm) layer of PluroGel wound gel directly to the wound bed and cover it with a sacral Mepilex border dressing during the day and evening shifts.R2's Weekly Wound Observation dated 5/4/26, identified R2 had a Stage 2 pressure ulcer to the coccyx measuring 3.0 centimeters (cm) x 2.5 cm x 0.1 cm, with a scant amount of serous drainage, no wound odor, and no signs of infection. The wound observation further identified the wound bed had granulation tissue present, which is a deeper tissue type that cannot be present in a partial-thickness Stage 2 pressure ulcer. A Stage 2 pressure ulcer only involves the top layers of skin and requires new skin cells, called epithelial tissue, to heal.R2's Treatment Administration Record (TAR) dated May 2026, identified an active order to cleanse the buttocks, peri-rectal skin, perineum, and groin area with foam cleanser, pat dry, and apply a moist 0.25% acetic acid cloth over the affected area for two hours twice daily on the day and evening shifts. The TAR further identified that between treatments, staff were ordered to apply a three-millimeter layer of PluroGel wound gel directly to the wound bed and cover it with a sacral Mepilex border dressing during the day and evening shifts. However, review of the TAR identified the facility failed to implement this ordered plan of care as scheduled:-5/5/26 at 6:00 a.m.: The number 9 was documented, identifying the treatment was omitted.-5/6/26 at 6:00 a.m.: The entry was left completely blank, identifying the treatment was not completed.-5/6/26 at 2:00 p.m.: The number 9 was documented, identifying the treatment was omitted.R2's progress note dated 5/5/26 at 3:11 p.m., identified an administration note for an active wound treatment order was not completed. However, the note lacked any written documentation explaining the clinical reason why the ordered treatment was omitted or what alternative interventions were implemented to protect the resident's skin.R2's progress note dated 5/6/26 at 10:19 p.m., identified an administration note for an active wound treatment order was not completed. However, the note lacked any written documentation explaining the clinical reason why the ordered treatment was omitted or what alternative interventions were implemented to protect the resident's skin.Review of R2's clinical record identified the facility failed to implement ordered individualized interventions to treat R2's pressure ulcer. Specifically, the record identified that out of four scheduled wound treatments on 5/5/26 and 5/6/26, the facility failed to complete three of them, resulting in two documented omissions and one completely blank entry.R2's Verbal Physician's Order dated 5/6/26, identified an order for a health shake twice daily for nutritional support and wound healing.R2's Verbal Physician's Order dated 5/8/26, identified an active order for an alternating air mattress to assist with wound healing and comfort, requiring staff to check mattress function and settings every shift.R2's Weekly Wound Observation dated 5/12/26, identified a Stage 2 pressure ulcer to the coccyx measuring 6.0 cm x 4.0 cm x 0.1 cm, with a scant amount of serous drainage, no wound odor, and no signs of infection or inflammation. The observation further identified necrotic tissue was present in the wound bed, and the overall impression was unchanged since 5/4/26. Additionally, the observation identified the physician was last notified on 5/4/26. However, the observation lacked accurate clinical staging by continuing to classify a wound with necrotic tissue as a Stage 2 pressure ulcer, and lacked any written documentation identifying the specific percentage of dead tissue present or that the provider was notified that the wound had doubled in size.Review of R2's clinical record identified the facility failed to accurately monitor, evaluate, and notify the physician of a significant change in the resident's skin condition. Specifically, the record identified R2's pressure ulcer doubled in size and developed dead tissue between 5/4/26 and 5/12/26, but the facility failed to notify the physician of this decline. Additionally, the record identified the facility failed to accurately track and stage the wound by documenting granulation and necrotic tissue within a Stage 2 classification, as a Stage 2 pressure injury is defined as partial-thickness skin loss that does not contain necrotic or granulation tissue, and failed to identify the percentage of dead tissue present.R2's Physician Assistant (PA) progress note dated 5/15/26 identified R2 was seen for a declining functional status, was bedridden, was unable to verbalize needs, had a decreased appetite, and experienced pain during repositioning. The note further identified that R2 was dependent on staff for turning every two hours, and repeated active orders to cleanse the sacrum and buttocks with Vashe, apply an acetic acid damp cloth, apply PluroGel wound gel, and cover with a Mepilex dressing. However, the note lacked any written documentation identifying that the provider physically assessed the condition of the pressure ulcer, evaluated the clinical efficacy of the current treatment plan, or addressed the significant wound expansion and tissue decline.R2's Braden Scale dated 5/17/26, identified a score of 13, which indicated R2 was at moderate risk for pressure ulcers.R2's Weekly Wound Observation dated 5/19/26 identified a Stage 2 pressure ulcer to the coccyx measuring 8.0 cm x 6.0 cm x 0.1 cm, with no drainage, no wound odor, and a date acquired of 5/4/26. The observation further identified the wound bed had necrotic tissue present with irregular edges, and the surrounding peri-wound area was pink and natural. Additionally, the observation identified the physician was last updated on 5/4/26. However, the observation lacked accurate staging by continuing to classify a wound with necrotic tissue as a Stage 2 pressure ulcer and lacked any written documentation identifying the specific percentage of necrotic tissue present or that the provider was notified of the continued wound expansion and tissue decline since 5/12/26.R2's progress note dated 5/24/26 at 10:34 a.m., identified R2 was sent to the emergency department (ED).R2's incident progress note dated 5/24/26 at 12:55 p.m., identified the night shift reported R2 was short of breath throughout the night, receiving medications and a rescue nebulizer treatment. The note further identified that at the start of the day shift, R2 was yelling for help, demanding a doctor, and exhibiting increased breathing effort. Additionally, the note identified that staff placed R2 on 2 liters of oxygen and transferred R2 to the ED via ambulance.R2's AVS dated 5/28/26, identified R2 was hospitalized from [DATE] to 5/28/26 for sepsis. The AVS further identified R2's sacral pressure injury was unstageable wound with necrotic eschar and surrounding erythema. The AVS additionally identified that trauma surgery and wound care teams evaluated the wound and recommended twice daily Vashe dressings and a specialty mattress, but bedside debridement (removal of dead tissue) was stopped because R2 declined due to pain. The AVS also identified R2 had severe quadriparesis, remained bedbound with total dependence for daily activities, had moderate malnutrition, and was discharged back to the facility with a referral for hospice services.During an interview on 7/16/26 at 3:00 p.m., the Medical Director stated that when a resident's pressure ulcer increased in size and develops necrotic tissue, nursing staff must notify the provider. Upon review of the sequence of events regarding R2's sacral pressure ulcer, including the wound increasing in size with documented necrotic tissue on 5/12/26 and 5/19/26 while continuing to be incorrectly documented as a Stage 2 pressure ulcer, the Medical Director confirmed that a provider should have been notified on those dates so the treatment plan could be reevaluated.R2's Weekly Wound Observation dated 5/28/26, identified a Stage 2 pressure ulcer to the coccyx and sacrum measuring 8.0 cm x 7.5 cm x 0.1 cm, with no drainage, no wound odor, and a date acquired of 4/28/26. The observation further identified the wound bed had 100% necrotic tissue present with edges flush with the peri wound. R2's peri wound had erythema (redness), inflammation, and induration (hardness) present. Additionally, the observation identified the physician was last updated on 5/28/26, and the current treatment plan included cleansing the area, applying PluroGel to the wound bed, and covering it with a sacral Mepilex dressing changed daily and as needed.Review of R2's clinical record identified the facility failed to accurately monitor, evaluate, and correctly stage R2's worsening skin condition. Specifically, the record identified R2's pressure ulcer rapidly expanded from 3.0 cm x 2.5 cm on 5/4/26, to 6.0 cm x 4.0 cm on 5/12/26, to 8.0 cm x 6.0 cm on 5/19/26, and to 8.0 cm x 7.5 cm by 5/28/26. Additionally, the record identified the facility failed to accurately track and stage the wound by continuing to classify it as a Stage 2 pressure ulcer, despite explicitly identifying that the wound bed was covered in necrotic tissue. Furthermore, the record identified the facility failed to notify the physician of any changes in the wound condition between 5/5/26 and 5/28/26 and failed to implement any new treatment orders during this period of declineR2's Braden Scale dated 5/30/26, identified a score of 14, which indicated R2 was at moderate risk for pressure ulcers.During an interview on 7/16/26 at 1:35 p.m., the newly assigned Wound Nurse, Registered Nurse (RN)-C, reviewed R2's clinical record and stated that the initial 4/26/26 progress note identified a stage 2 pressure ulcer to the coccyx and a stage 1 non-blanchable ulcer on the buttocks but contained no measurements. RN-C stated that the 5/5/26 assessment did not identify the amount of epithelial tissue in the wound bed. Regarding the 5/12/26 assessment, RN-C stated the wound was staged wrong, it got bigger and necrotic, it failed to identify the percentage of necrosis, and it would be unstageable. RN-C stated that the 5/19/26 assessment said the wound was unchanged, but it got bigger and would still be unstageable. RN-C further stated that the 5/28/26 assessment still listed the wound as a stage 2 despite documenting 100% necrosis. Finally, RN-C verified through the medical record that the provider was not notified when the pressure ulcer worsened and stated that the provider should be notified when pressure ulcers worsen so they can decide if a new treatment should be put in place.During a telephone interview on 7/16/26 at 5:16 p.m., RN-B, the former nurse manager, stated that during the assessment on 5/12/26, patchy necrotic tissue and eschar formation were present on R2's pressure ulcer, meaning the wound was almost unstageable. RN-B acknowledged that the wound should have been documented as unstageable, that she missed it, and that if she didn't document that the provider was not notified it was not done. RN-B further stated that the assessment on 5/19/26 should have also been designated as unstageable, and that she should have documented the percentage of necrotic tissue and notified the provider. RN-B concluded that regardless of her belief that it was a Kennedy terminal ulcer, she still should have comprehensively assessed the pressure ulcer, added R2 to the facility's wound rounds, and notified the doctor to determine if the treatment order required modification.During an interview on 7/16/26 at 1:02 p.m., the Director of Nursing (DON) stated that upon identification of a pressure ulcer, a comprehensive wound assessment must be completed immediately to include location, staging, wound dimensions, and a wound bed description tracking tissue type, exudate, odor, signs/symptoms of infection, peri wound, edge characteristics and the provider should be notified for a treatment order. The DON clarified that these assessments must be completed at least weekly and the provider should have been notified immediately after each significant change in the wound to ensure appropriate treatment. Upon review of R2's record, the DON confirmed that the pressure ulcer had worsened on 5/12/26 and 5/19/26, but the provider was not notified of these changes, and no new treatment orders were put in place. The DON verified that the assessments should have been more comprehensive and that the pressure ulcer was staged incorrectly. The DON stated that because necrotic tissue was present, the wound should have been identified as unstageable rather than Stage 2, and the provider should have been notified immediately to determine if a new treatment order was required after each time the pressure ulcer worsened. R3's Face sheet printed 7/16/26, identified diagnoses of T11-T12 fracture (a broken bone in the upper back), spinal stenosis of the lumbar region (narrowing of the lower spinal canal that causes nerve pain and numbness), diabetes, severe protein-calorie malnutrition (a severe lack of nutrients needed to maintain healthy skin tissue), muscle weakness, difficulty walking, lack of coordination, unsteadiness on feet, nutritional anemia (a lack of healthy red blood cells needed to carry oxygen to tissues), and a disorder of the bladder (problems controlling the bladder).R3's care plan dated 2/13/26, identified a focus at risk for alteration in skin integrity related to diabetes, nutritional deficit-malnutrition, spinal stenosis of lumbar area with neurogenic claudication, fracture T11-12-TLSO brace (a rigid plastic back brace used to support the spine) on for comfort, B&B incontinence, and decline in ADL and mobility status. The care plan identified interventions dated 2/13/26, included barrier cream to peri area/buttocks as needed, use pillows/positioning devices as needed, encourage fluids, float heels as able, monitor skin under (braces-TLSO) for breakdown, observe skin condition with ADL care daily; report abnormalities, obtain labs as ordered and notify MD of results, pressure redistributing device on bed/chair, pressure relieving mattress on bed and cushion in w/c, and provide preventative skin care routinely and PRN.R3's CAA dated 2/18/26, identified R3 was at risk for pressure ulcers due to potential skin breakdown, mobility impairments, and incontinence. The CAA further identified R3 required partial to moderate assistance with rolling left to right, moving from sitting to lying, and moving from lying to sitting on the side of the bed. Additionally, the CAA identified intrinsic risk factors included altered mental status, cognitive loss, poor nutrition, the use of antidepressants, and status as a new admission.Review of R3's Braden Scale dated 4/21/26, identified a score of 14, indicating a moderate risk for pressure ulcers. The assessment identified R3 was chairfast with very limited mobility, making only occasional slight changes in body position independently. The assessment further identified R3's nutrition was very poor, and a problem with friction and shear existed because R3 required moderate to maximum assistance to move and frequently slid down in the bed or chair.R3's quarterly MDS dated [DATE], identified R3 had severe cognitive impairment, did not walk, and required substantial to maximal assistance to roll from side to side. The MDS identified R3 was dependent on staff for transfers and repositioning, was occasionally incontinent of bladder, and was at risk for pressure ulcers. The assessment further identified no current skin concerns, but noted that no preventative skin treatments were implemented, including a pressure-reducing device for the chair or bed, and no turning and repositioning program.R3's weekly Braden Scale assessments dated 4/27/26, 5/4/26, and 5/11/26, identified scores of 16, 16, and 17, respectively, which indicated R3 continuously remained at risk for the development of pressure ulcers.R3's weekly skin assessments dated 5/4/26, 5/11/26, 5/18/26, 5/28/26, 6/22/26, and 6/29/26, identified no skin issues were noted, and no preventative measures were in place.R3's NAR Bath Day Worksheet/Skin Update, dated 6/29/26, identified R3 received a shower and had no identified skin concerns.Review of R3's clinical record identified the facility failed to implement individualized interventions to prevent pressure ulcers. Specifically, the record identified that during six consecutive weekly skin assessments between May and June, the facility repeatedly identified R3 had no preventative measures in place, despite separate facility assessments identifying R3 was completely dependent for mobility, chairfast, and severely malnourished.R3's skin/wound progress note dated 7/4/26, identified an open wound on R3's coccyx during routine care. The progress note further identified the wound bed was open with no drainage, the surrounding skin was intact, and no wound odor was present. Additionally, the progress note identified the area was cleansed, zinc oxide (a thick white cream used to protect skin from moisture and friction) was applied, and the provider was notified and wound orders were requested.R3's Situation Background Assessment Response (SBAR) note dated 7/4/26, identified a newly noted, undocumented wound on R3's coccyx with a width of 0.1 cm and a depth of 0.2 cm. The SBAR note further identified the facility failed to record a length measurement, leaving the template placeholder blank. The SBAR note further identified that the facility failed to fill out the remaining clinical details on the form, leaving template placeholders blank for the appearance of the wound bed, the type of drainage, and the condition of the surrounding skin.Review of R3's clinical record identified the facility failed to accurately assess, monitor, and communicate significant changes in R3's skin condition to the physician. Specifically, the record identified that when reporting a newly discovered pressure ulcer on 7/4/26, staff transmitted an incomplete template to the physician that completely lacked the wound's length, color description, and drainage type.R3's NAR Bath Day Worksheet/Skin Update, dated 7/6/26, identified R3 received a shower and had no identified skin concerns.R3's nurse practitioner (NP) progress note dated 7/10/26, identified R3 was seen for a change in mental status, was seated in a wheelchair, and had documented histories of a spinal fracture and malnutrition. The progress note failed to identify any skin concerns and lacked any documentation indicating the provider was notified of R3's newly discovered coccyx pressure ulcer.Review of R3's clinical record identified the facility failed to accurately monitor, evaluate, and communicate significant changes in R3's skin condition to medical providers. Specifically, the record identified that during an advanced clinical visit on 7/10/26, the nurse practitioner documented no skin concerns were present, despite a separate facility wound alert being generated six days prior on 7/4/26, because the facility failed to inform the nurse practitioner of the pressure ulcer or ensure R3's backside was physically inspected.R3's NAR Bath Day Worksheet/Skin Update, dated 7/13/26, identified R3 received a shower and had no identified skin concerns.During an interview on 7/14/26 at 11:41 a.m., Trained Medication Assistant (TMA)-A stated that R3 had a small, open area on his coccyx that was identified a couple of weeks prior, which had not progressed or improved. TMA-A stated that she notified the nurse right away when it was discovered and assumed staff were still applying zinc oxide because R3 did not have a dressing on his wound when she assisted him out of bed that morning. TMA-A described the open area as a stage 2 wound about the size of a pea with a pink wound bed and no visible drainage. TMA-A further identified that R3 was bladder incontinent and was at a high risk for pressure ulcers due to his advanced age and low body weight.During an interview on 7/14/26 at 11:50 a.m., Licensed Practical Nurse (LPN)-A stated that she did not think anyone on the 2 [NAME] unit had any pressure ulcers and noted that the wound provider was at the facility that day and had already changed all resident dressings.During an observation on 7/15/26 at 11:41 a.m., R3 was seated in a wheelchair in his room with a wheelchair cushion in place. When interviewed, R3 stated that his bottom was a little sore, and he was unsure if he had a sore on his bottom or not. R3 was cognitively unable to answer whether facility staff assisted him to get up or repositioned him to relieve pressure off his bottom.During an interview on 7/15/26 at 11:46 a.m., Nursing Assistant (NA)-B stated that she assisted R3 out of bed that morning and did not notice any skin concerns.During an interview on 7/15/26 at 11:47 a.m., RN-A stated he was completely unaware that R3 had a pressure ulcer on his coccyx until reviewing the 7/4/26, electronic progress notes with the surveyor during the interview. RN-A confirmed there were no active medical treatment orders in place for R3's pressure ulcer and that his skin care plan lacked any repositioning program to offload pressure from his bottom. RN-A further stated that the nursing assistant who assisted R3 out of bed that morning failed to notify him of any skin concerns. RN-A verified that R3 was at high risk for pressure ulcers because he was fr

Based on observation, interview, and record review the facility failed to implement and monitor known aspiration precautions for residents with dysphagia, including ensuring correct diet texture, prescribed liquid consistency, supervision during meals, and safe meal positioning. This resulted in an Immediate Jeopardy (IJ) for R1 when the facility failed to ensure these requirements were consistently communicated to and followed by nursing and dietary staff for R1 which resulted in R1's hospitalization for diagnoses of pneumonitis due to inhalation of food and vomit and following hospitalization, the facility failed to follow R1's prescribed diet putting R1 at risk for additional choking and or aspiration events. Additionally, the facility failed to ensure the correct liquid consistency was provided according to the dietary order and failed to comprehensively assess and monitor R6 following a coughing episode for signs and symptoms of aspiration, placing R6 at risk for aspiration-related complications.The IJ began on 3/26/26, when R1 with known dysphagia and aspiration precautions, was permitted to eat unsupervised in bed and experienced a suspected aspiration event requiring hospitalization. The facility failed to implement corrective action which resulted in incorrect diet type served to R1 on 4/8/26 and 4/9/26. The Administrator and director of nursing (DON) were notified of the IJ on 4/10/26 at 2:26 p.m. The IJ was removed on 4/11/26, but non-compliance remained at the lower scope and severity level D, which indicated no actual harm, with the potential for more than minimal harm that is not immediate jeopardyFindings include Mechanical soft diet: texture-modified diet designed for people who have difficulty chewing or swallowing, such as those with dysphagia (difficulty swallowing) or missing teeth. Mechanical soft diet allows foods that are soft, moist, and easy to manipulate in the mouth. Foods are typically cut into small pieces no larger than 1/4 to 1/2 inch or blended to a soft consistency. Meats, vegetables and fruits can be chopped, minced, or ground. Foods should be moistened with gravies, sauces, milk, or cooking liquids to make them easier to swallow. Breads and cereal can be softened with milk, yogurt, or sauces to create a slurry-like consistency.Mildly thick liquids: are slightly thicker than water, designed to flow more slowly for safer swallowing, and often used for people with dysphagia. This reduces the risk of choking or aspiration for people with swallowing difficulties. Generally, one tablespoon of powdered thickener to four ounces of liquid stirred vigorously will create the desired consistency.R1's face sheet dated 4/9/26, identified diagnoses of stroke, dysphasia, and hemiplegia (complete paralysis on one side of body) and hemiparesis (weakness on one side of body) affecting left side of body.R1's hospital After Visit Summary dated 2/23/26, identified R1 admitted to the hospital due to stroke. R1 was discharged to facility with a diet of mildly thick liquids and mechanical soft food. Safety precautions included raised head of bed, awake/alert, slow rate, small bites/sips, and frequent oral care. Medication was recommended whole with puree. Speech language pathologist (SLP) to continue to follow for cognitive-communication and dysphagia management.During an interview on 4/8/26 at 10:59 a.m., RN-B stated prior to a resident admitting to the facility, the nurse would receive a phone call from the nurse at the hospital that informed the facility staff which diet the resident required. The facility admission packet included a form the admitting nurse would fill out that was then passed out to the nursing assistants (NA) and nurses. If a resident required supervision to eat, the resident would be brought to the dining room and either the nurse or NAs would supervise them. An aspiration event would include choking which dictated the resident was unable to eat without supervision.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognition issues. R1 had a mechanically altered diet, held food in mouth/cheeks or residual food in mouth after meals, and was edentulous (lacked teeth). R1 required partial/moderate assistance to eat.R1's care plan dated 2/23/26, identified R1 had diagnoses of dysphasia, aphasia (complete inability or refusal to swallow), however did not identify R1's risk for aspiration/choking. The care plan directed that R1 required contact/limited assistance of one for eating. The care plan revised on 2/26/26 directed staff to provide R1 assistance with drinking and to alternate small bites and sips, and use a teaspoon for eating. Although the care plan directed staff assistance, the care plan did not address level of supervision and appropriate positioning while eating. The care plan revised on 4/2/26 directed staff to provide R1 diet as ordered.R1's physician order dated 2/23/26, identified R1's diet was mechanical soft texture and mildly thick consistency.R1's Montreal Cognitive Assessment (MoCA) (test used to determine cognitive impairment) dated 2/25/26, indicated R1 had significant cognitive deficits. The assessment also included R1 was unable to complete full cognitive screening tool due to repeatedly expressed desire to urinate and defecate. Will continue to assess as R1 is able to participate.R1's progress note dated 2/28/26, identified R1 was approached several times before breakfast and lunch to get up and refused. R1 ate both meals in bed.R1's progress note dated 3/1/26, identified Staff offered to get R1 out of bed for breakfast and lunch. R1 stated no shower, no get up. I eat here.R1's care plan 3/1/26, staff check mouth after meal for pocketed food and debris, report to nurse, provide oral care to remove debris. R1's Comprehensive Nutrition assessment dated [DATE], identified R1 was on a regular diet with mechanical soft texture and mildly thick consistency for liquids. Chewing/swallowing problems: modified textures/consistencies.R1's Care Conference Summary dated 3/2/26, indicated R1 had a mechanical soft diet with thickened liquids and required variable assistance with food and fluids. R1 required set-up assistance, supervision, and CGA (contact guard assist) as needed for intake.R1's progress note dated 3/3/26, identified R1 maintains relatively good position in chair or bed most of the time but occasionally slides down. AT RISK. (The specific risk was not documented in note.) SLP note on 3/3/26, identified family in room during session. Discussed communication cards family had been bringing R1 and practiced use of these for wants/needs/thoughts. Family had questions regarding R1's movement and sensation of arm and leg-encouraged to speak with other disciplines when visiting.R1's progress note dated 3/5/26, identified R1 ate the evening meal in bed.R1's Speech Language Pathology (SLP) Summary of Daily Skilled Services dated 3/18/26, identified R1 completed a visuospatial/executive functioning, concentration, and direction following task which he completed with overall moderate level of deficits requiring moderate and verbal cues. A second MOCA was completed on 3/19/26, with R1 scoring 6/30 with ongoing significant deficits present. MoCA scores of <10 is suggestive of severe cognitive impairment. Key areas of the MoCA examine Visuospatial and Executive Functions, Naming, Memory, and Attention.SLP Summary of Daily Skilled Services dated 3/19/26, R1's current diet changed from mechanical soft/chopped to mechanical soft/ground. R1's progress note dated 3/20/26, identified SLP recommended a video swallow study to rule out aspiration and determine the most appropriate, least restrictive solid and liquid consistencies.SLP Summary of Daily Skilled Services 3/25/26, R1 had thin liquids in his room. Educated nursing staff on need for mildly thick liquids until video swallow study completed. Thickened liquid appropriately. SLP Summary of Daily Skilled Services dated 3/26/26, R1 had audible expiratory wheezing and increased work of breathing during session. Encouraged R1 to be out of bed for meals to prevent aspiration. Continue to ensure appropriate solid and liquid levels are received as thin liquids were previously given. Staff educated. Review of R1's record revealed R1's care plan was not updated to include the directive for R1 to be out of bed for meals or safe swallowing strategies.During a telephone interview on 4/9/26 at 3:45 p.m., SLP-A stated the Brief Interview for Mental Status (BIMS) (cognition test used by nursing staff to determine cognition) was not as comprehensive of an assessment as the MoCA. SLP-A had a live translator help conduct R1's MoCA and completed it on 2/26/26. SLP-A recommended staff to assist at meals and have supervision for safe swallowing as R1 had cognition and learning recall issues. SLP-A talked with staff to get R1 out of bed for meals and staff would say R1 refused. R1 did not always have appropriate liquids provided to him and that was from both the facility and family. R1 should have had supervision while he was eating and drinking to ensure he was following compensatory strategies. SLP-A could not recall if she had written specific orders for nursing staff to supervise R1, but professional standard dictated not to have R1 eat independently or in bed. On 3/26/26, SLP-A communicated to nursing staff about compensatory strategies to use with R1 during eating and drinking. During an interview on 4/9/26 at 2:09 p.m., licensed practical nurse (LPN)-A stated the therapy department had expressed many times that R1 needed to be up for meals and out of bed. R1 refused to get out of bed to eat many times. LPN-A stated she would encourage R1 to get out of bed for meals because it would be easier to swallow and better to eat if he was in a wheelchair. LPN-A was not aware of staff watching R1 when he ate in his room. LPN-A could not recall having a conversation with SLP-A on 3/26/26, regarding R1 having expiratory wheezes, getting out of bed for meals, or having supervision when he ate.During an interview on 4/9/26 at 1:49 p.m., nurse manager (NM)-A stated on 3/26/26 she had not received any communication from SLP-A that R1 should not eat in bed and needed supervision with eating and drinking. SLP-A would evaluate residents to ensure they are not at risk eating in their rooms. NM-A thought a lot of residents continued eating in their rooms post covid because they enjoy their own space. NM-A stated staff did not keep track of residents when they eat in their rooms.R1's progress note dated 3/26/26 at 10:42 p.m., R1 appeared to choke while eating dinner around 6:10 p.m. Registered nurse (RN)-A heard R1 cough from down the hall and saw R1 trying to spit out. R1 had the head of bed all the way up and was able to cough up phlegm but explained he still felt like something was inside his throat. Vital signs: temperature 97.5 degrees Fahrenheit, blood pressure 163/83 mmHg (millimeters of mercury), heart rate 87 bpm (beats per minute), respiration rate 22, and oxygen saturation 93% (percent) on RA (room air). R1 was sent to the hospital for further evaluation.R1's dietary ticket for dinner dated 3/26/26, included nectar thickened liquids, straws ok. Ground Philly steak for sandwich* pureed hot dog bun, sauteed peppers and onion-chop, mashed potatoes, capri vegetable blend-chop, chilled pears, and cottage cheese. Nectar thickened milk, coffee or hot tea. The ticket did not identify what the Asterix represented. During an interview on 4/8/26 at 3:04 p.m., nursing assistant (NA)-C stated R1 had trouble with swallowing and required thickened liquids and either minced & moist or pureed food. NA-C explained she worked on 3/26/26 and gave R1 his dinner tray in bed. NA-C did not remain in the room to assist or watch R1 eat his meal but R1's head of bed was all the way up. At around 6:00 p.m. NA-C saw nurses going towards R1's room. R1 stated he felt like he had something in his mouth and coughed up a huge chunk of phlegm. NA-C stated the phlegm was about the size of a nickel. R1 was sent to the emergency department as a precaution because he choked on food.During an interview on 4/8/26 at 2:58 p.m., nursing assistant (NA)-B worked the evening of 3/26/26. NA-B stated R1's head of bed was all the way up and R1's meat was mechanical soft texture. NA-B was not on the unit when R1 choked but returned to the unit and saw NA-C and RN-A run to R1's room. During an interview on 4/8/26 at 3:14 p.m., registered nurse (RN)-A stated on 3/26/26, she was by the nurse's station when she heard R1 cough. R1's head of the bed was all the way up. R1 was spitting up a lot of whitish/yellow colored phlegm. R1 was able to talk. R1 was the only person in the room, he did not have staff supervise him while he ate. R1's food was mechanical soft hot dog and beans with thickened drinks. RN-A was unaware how it was determined R1 could eat without supervision. R1 spent a lot of time in his room eating by himself. R1 had refused to leave his room and would not get up to eat in his wheelchair. RN-A thought residents with a previous history of aspiration or on super thickened liquids would require supervision while eating but that determination was made by someone other than nurses. RN-A sent R1 to the emergency department to be evaluated for concerns of aspiration. When R1 left, he still felt like something was stuck in his throat.R1's hospital After Visit Summary dated 3/30/26, identified R1 was admitted on [DATE] for pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit after a suspected aspiration event while eating at his facility. SLP was consulted for evaluation of dysphagia related to history of stroke and aspiration event. R1 had a video swallow study completed and was recommended to have a modified diet of mildly thick liquids International Dysphagia Diet Standardization Initiative (IDDSI Level 2) and soft, bite-sized solids (IDDSI Level 6), with aspiration precautions and ongoing supervision during meals. R1 was discharged back to the facility on 3/30/26. The IDDSI identified mildly thick liquids flow off spoon, sippable, pour quickly from spoon and slower than thin drinks, and mild effort is required to drink this thickness through standard bore straw. Soft and bite-sized solids were indicated as 'bite-sized' pieces as appropriate for size and oral processing skills, soft, tender and moist throughout but with no separate thin liquid, chewing required before swallowing, a knife was not required to cut this food, can be mashed/broken down with pressure from utensil, and can be eaten with a fork, spoon or chopsticks.During an interview on 4/8/26 at 12:23 p.m., LPN-D stated R1 used to eat in his room a lot, mostly sitting straight up in bed. At the time of the incident on 3/26/26, staff did not have to supervise R1 while he ate or drank. LPN-D stated the facility did not have an assessment that identified if a resident was able to eat independently.During an observation on 4/8/26 at 9:16 a.m., R1 was not in his room. On R1's nightstand there were eight brown bananas, three Activia yogurts, one thickened apple juice container, an unopened can of coke, an unopened Boost, unlabeled hard candies, a muffin, and thickened water in a water pitcher. At 10:55 a.m., R1 was alone in his room in his bed with head of bed up halfway with food items on the nightstand. R1's physician order dated 4/1/26, identified R1's diet was mechanical soft texture, nectar thick liquids, and soft and bite size for dysphagia.R1's dietary tray card for lunch dated 4/8/26, directed staff to serve R1 ground honey glazed ham, pureed candied sweet potatoes, pureed roasted broccoli florets, pureed dinner roll/bread, pureed cranberry crunch bar, and nectar thickened coffee or hot tea.During an observation on 4/8/26 at 12:40 p.m., R1 was in the dining room with a plate of food in front of him. R1's plate had regular sized cooked broccoli with stems intact, minced ham with juices, pureed orange colored substance, and a pureed dessert. R1 was eating the meal with a teaspoon. Surveyor reported the wrong consistency food to NA-A. At 12:45 p.m. NA-A stated R1 had regular broccoli that was not the right diet consistency. R1 should have chopped up broccoli. NA-A stated she would remove the broccoli and take it to the kitchen so that it could be made to the right consistency. At 12:48 p.m., NA-A had not removed broccoli from R1's plate and R1 took a piece of broccoli and ate it. NA-A took R1's broccoli from his plate and returned to the dining room at 12:52 p.m., with a plate of chopped broccoli that she gave to R1.During an interview on 4/8/26 at 1:19 p.m., registered dietician (D)-A stated residents on dysphagia mechanical soft diet should have broccoli chopped up. D-A verified R1 was on a dysphagia mechanical soft diet and R1 should have been served chopped up broccoli at lunch, not regular broccoli.During interview on 4/8/26 at 3:52 p.m., cook (CK)-B stated the food they made was based on a production count report. CK-B stated meal tickets were set on meal trays to indicate what food and drinks the residents needed, but the trays often had food which did not match the meal tickets.During an interview on 4/9/26 at 10:38 a.m., CK-A stated mechanical soft food was ground very fine and the vegetables & bread would be a creamy, blended texture. CK-A also stated chopped food would be considered mechanically soft. Chopped means knife and mechanical with blender will be finer and they use that terminology for the cooks.During an interview on 4/9/26 at 10:55 a.m., dietary manager (DM)-A stated ground texture was very small, bite size pieces consistent with sloppy joe or taco meat. Puree food is put through the chopper and is baby food consistency. Mechanical soft texture is not pureed but a little more than ground consistency. If a resident had a mixture of textured foods, the diet ticket would have special texture on it which indicated the meat was pureed and the rest of the food would be mechanical soft. R1's diet ticket was for ground meat and pureed everything else. DM-A's dietary computer system identified R1 had mechanically soft textured food and nectar thickened liquids. DM-A stated she updated the order on 4/8/26, the day after R1 had returned from a hospital stay. DM-A was unsure why R1's diet ticket stated pureed and ground texture. DM-A reviewed the information in the computer, printed a diet ticket, and the ticket printed pureed. It is saying mechanical soft so why it is printing pureed anything is beyond me. DM-A stated she was going to remove R1 from the system, add him again, print off the ticket, and review the diet ticket with CK-A. DM-A reviewed the diet ticket from 3/26/26, and stated R1 had ground Philly steak with a pureed hot dog bun. DM-A stated she did not have access to the facility electronic health record and relied on nursing staff to bring a handwritten diet communication form to her when a resident admitted or had a diet change. DM-A was currently training a dietary aide on the computer system to add residents and diet orders so that she was not the only one doing it.During an interview on 4/9/26 at 12:41 p.m., NA-E stated if she questioned a resident's prescribed diet order, she would look it up on the Kardex. NA-E reviewed R1's Kardex. NA-E stated R1's Kardex identified to provide supervision, small bites, used a small spoon, R1 pocketed food, and to report to nurse if something changed. NA-E stated she assumed R1's meal ticket should say small, easy to chew bites. After the meal, R1 should rinse his mouth or brush his teeth. He's not thickened liquids so not worried but if he was I would look to make sure he doesn't have thin liquids. NA-E reviewed and verified R1's Kardex did not identify he was on thickened liquids which was inconsistent with the diet order dated 4/1/26.During an interview on 4/9/26 at 12:46 p.m., trained medication aide (TMA)-A stated if she was unsure of a resident's diet she would ask staff that were more familiar with the resident and verify the diet with the dietary meal ticket. TMA-A would notify the nurse manager if the Kardex and dietary ticket did not match. TMA-A stated if a resident had a change to the care plan, staff would be notified on a paper sheet that NAs would typically sign to verify they were updated.During an observation on 4/9/26 at 12:55 p.m., NA-E asked RN-B which residents were on thickened liquids. NA-E stated only R1 was on thickened liquids but then corrected himself and stated that R1 and R6 were the only two residents on thickened liquids.During an interview on 4/9/26 at 12:56 p.m., RN-B stated the meal trays come with a ticket and each resident has one printed. The ticket identified what the resident requested to eat and their diet type. RN-B told NA-E who had thickened liquids because she was temporary agency staff and not facility staff, RN-B reported she did not know the residents very well.R6's face sheet dated 4/10/26, identified diagnoses of unspecified dementia, and dysphagia of the oral (voluntary control of chewing, bolus formation, and moving food to back of mouth) and oropharyngeal (difficulty swallowing) phases.R6's comprehensive MDS dated [DATE], identified R6 had moderate cognitive impairment. R6 required setup or clean-up assistance with eating. R6 had a mechanically altered diet and no natural teeth.R6's care plan dated 10/21/25, identified risk of inadequate oral intake due to hospice status. R6 would not exhibit chewing or swallowing problems with current diet texture as evidenced by no signs or symptoms of aspiration, choking, or complaints of difficulty eating. Interventions included on 1/8/26, pureed diet and nectar thick daughter request (speech order).R6's physician order dated 2/27/26, identified regular diet, pureed texture and nectar thick liquids.R6's Visual/Bedside Kardex Report (abbreviated care plan) dated 4/10/26, identified a section titled Eating/Meals that included: provide diet as ordered. 1/8/26, pureed diet and NECTAR thick daughter request (speech order).During an observation and interview on 4/9/26 at 1:06 p.m., R1 and R6 were in the dining room, sitting at their respective tables, waiting for lunch to be served. R6's diet slip directed staff to serve nectar thick liquids and pureed food. R6 was drinking a white, thin liquid substance from a coffee cup. At 1:09 p.m., R6 began repeatedly coughing and spitting the liquid out. Surveyor intervened reported the concern to TMA-A who went to R6, looked in the cup and stated she would have to review the Kardex and diet ticket to know what consistency liquids R6 required. RN-B also went to R6's table and looked in her coffee cup. RN-B stated R6 had regular, thin consistency hot milk in her coffee cup. RN-B removed R6's coffee cup and took it to the kitchenette to thicken it. R6 continued to cough and have a runny nose. R6 was coughing up thick, white phlegm onto her shirt and napkin. At 1:14 p.m., RN-B returned R6's thickened milk to her, did not perform a respiratory assessment and walked away. NA-E and TMA-A handed out trays to residents at their tables while R6 continued to cough. At 1:17 p.m., TMA-A delivered R1's food to him in the dining room. R1's tray ticket identified ground chicken and pureed everything else. All the words were crossed off and handwritten all mechanical soft according to orders. R1's plate had pureed consistency food. Surveyor intervened -reported the concern to TMA-A who stated R1's liquid was more of a honey consistency than nectar consistency, and R1 had the wrong diet consistency on his plate. TMA-A questioned if the handwritten order on the diet slip was the most up to date. TMA-A questioned RN-B on which consistency of food R1 should have. RN-B reviewed R1's chart and confirmed R1 should have nectar thick liquid and mechanical soft diet. RN-B stated R1 does aspirate pretty easily so the pureed diet was not a bad thing but not what was ordered. At 1:21 p.m., RN-B called the kitchen to verify the pureed food was what R1 was supposed to have. Dietary aide (DA)-B verified R1 received the wrong meal and liquids and walked away without providing R1's correct diet type. At 1:27 p.m., R1 continued to eat the pureed with a teaspoon and coughed after taking a bite. At 1:42 p.m., DA-A came to the dining room with a new plate of food. DA-A removed the lid on the tray and the food was the same pureed food consistency that R1 was already eating. DA-A stated dietary manager (DM)-A gave her the meal. NA-E and RN-B verified the meal was still incorrect according to the ticket. At 1:46 p.m., DM-A came to the dining room and examined R1's meal and orange juice and stated it was the wrong consistency according to his diet and liquid orders. DM-A stated prepackaged nectar thick orange juice was in the refrigerator and staff must not have been aware.During an interview on 4/10/26 at 11:24 a.m., hospice case manager (HCM)-A stated hospice would want to know if there were concerns of R6 aspirating. HCM-A reviewed R6's chart and stated hospice had not been contacted about R6's aspirating/coughing incident with her liquids. This was news to us.During an interview on 4/9/26 at 1:24 p.m., registered nurse (RN)-C stated residents received their meals according to the meal ticket placed on their meal trays. Staff referred to the care plan to know the most up to date diet for residents. When residents received the incorrect diet type, staff would replace the meal then education was provided to nursing and kitchen staff. RN-C stated staff could downgrade a resident's diet but not upgrade a diet. Residents with aspiration risk ate where staff could supervise them or staff were to stay in residents' rooms for supervision with meals. When residents at risk for aspiration refused to get out of bed or go to dining room area to eat, staff would attempt to reapproach/redirect. RN-C stated residents with aspiration risk worked with speech therapy, and therapy communicated recommended interventions to staff verbally or with a paper communication log kept at the nursing station.During an interview on 4/9/26 at 5:16 p.m., the director of nursing (DON) stated all residents needed some supervision to eat related to age and body reflexes not as strong. A stroke placed a resident at high risk and needed supervision. Residents were encouraged to come out of their rooms to eat but ate with their head of bed up if they chose to eat in bed. The facility did not have enough manpower to sit in residents' rooms every meal when the residents chose not to come out to the dining area. Speech therapy communicated recommendations through one-to-one conversation and a document placed in a binder at the nursing station. Recommendations were communicated to the DON and nurse managers and care planned. The DON expected staff to follow diet orders and intervene immediately if given an incorrect diet.During a follow-up interview on 4/10/26 at 8:16 a.m., NM-A stated R1 ate in bed a lot. NM-A stated it would not be a good idea to have R1 eat in bed as he had a recent stroke and dysphagia. NM-A stated without direct supervision while eating and drinking staff would not know if R1 was following safe strategies with eating and drinking. NM-A stated the facility could not provide enough aides to supervise R1 when he ate in his room. NM-A stated the facility would complete Risk versus Benefits for residents that eat in their rooms but residents with dysphagia need to eat in the dining room.During an interview on 4/10/25 at 8:21 a.m., NA-D stated speech therapy recommendations were found under their kiosk with the care plan. NA-D stated resident meal tickets reflected what residents needed for meals. NA-D reviewed a report sheet and stated the report should tell them what kind of assistance the residents needed with meals and who was at risk for choking but did not. LPN-D entered the interview and showed NA-D to look on the banner in the computer for any special instructions on diets and meals. LPN-D stated staff checked resident care plans and Kardex. LPN-D and NA-D reviewed R1's banner which identified R1 required nectar thickened liquids and dys mech (dysphagia mechanical) soft textures and did not include any other special instructions.During a follow-up interview on 4/10/26 at 11:22 a.m., the DON expected staff to attend to resident coughing or choking as soon as possible. The DON expected nursing assistants to stay with coughing or choking residents until a nurse was present. The nurse was to assess if the resident was coughing or choking to ensure their airway was clear and see if resident was able to clear airway on own, sit resident up if not already, and instruct resident to tuck their chin. If the resident did not clear airway on own, then nurses performed the [NAME] maneuver and progressed to CPR (cardiopulmonary resuscitation) and called 911 if needed. The nurse was to enter a progress note to communicate what occurred. Staff referred residents to speech therapy to determine if they required any diet changes and were to notify the provider. Nurses were able to downgrade resident diets if needed before further evaluated. The DON stated it was important to ensure residents received nutrition in the safest way possible.During an interview on 4/9/26 at 3:20 p.m., the medical director (MD) expected staff and residents to follow resident orders. The MD stated residents have the right to refuse orders and expected the facility to notify the provider group of refusals. The MD expected the facility to notify the provider if residents' family members did not follow provider orders. The MD expected the facility to follow their policies and procedures for speech therapy recommendations and stated the providers normally wrote an order for agreed upon speech therapy recommendations. The MD stated the level of risk for not following orders of a resident at risk for aspiration depended on the specific resident and orders.The facility policy Foreign Body Airway Obstruction Management (Choking) dated 2024, identified residents with impaired swallowing, neurological disorders or dental issues were at an increased risk for foreign body airway obstruction and timely intervention to relieve obstruction was imperative to offset complications. The policy directed the facility to determine which residents were at a higher risk for foreign body obstruction/choking episodes and care plan accordingly. Consult a speech language pathologist as needed. The facility was to ensure residents with impaired swallowing issues and were on an altered diet received the appropriate diet.The facility policy Therapeutic Diet Orders undated, identified the facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. The policy identified dietary and nursing staff were responsible for providing diets in the appropriate form and/or the appropriate nutritive content as prescribed.The IJ that began on 3/26/26 was removed when it was determined and verified through observation, interview and document review the facility implemented the following on 4/11/26:Help ticket placed by dietary manager to resolve the issue of tray tracker inconsistencies with tray tickets.Audit completed of tray tickets to ensure the match dietary orders completed 4/10/26.Progress notes from the past 30 days reviewed to ensure no other choking incidents documented on 4/6/26.Residents that receive mechanically altered diets received education on importance of being out of bed and in dining room for meals.Audit completed by therapy department on all residents with recommended supervision.Care plans/Kardex updated to indicate supervision required.Education with clinical staff on mechanically altered diet policy, diet consistency, verifying correct diet accuracy prior to serving meals, supervision during meals, change of condition assessment on 4/10/26-4/13/26.Speech communication will include verification of what specific supervision is needed for those with altered diets and will be given verbally to nursing staff, written on Therapy Communication to Nursing form, and uploaded into residents medical record, care plan, and staff tasks to complete.Nurse will be present in dining room for meals to ensure appropriate diets are served and monitor residents for choking.Residents on mechanically altered diet will

Based on observation, interview and record review, the facility failed to ensure food stored in the refrigerator were labeled, dated and free of expired foods. This deficient practice had the potential to affect all residents, staff and visitors who received food from facility kitchen.Findings include: During the initial kitchen tour on 3/9/26 at 10:34 a.m., cook (C)-A greeted surveyor inside the kitchen. The following items were observed in the fridge expired and undated food:-Sliced Ham, expired on 3/2/26-no date on lettuce, browning and wilting Additionally, the following items were observed in the freezer:-box of food sitting directly on the freezer floor-box on top shelf of freezer touching freezer fan blade During the follow up kitchen tour on 3/12/26 at 12:25 p.m., district manager (DM) stated the expired sliced ham, and undated lettuce had been thrown out. DM confirmed the box on the floor of the freezer had been placed on a shelf. DM confirmed the box touching the freezer fan blade had been pushed back away from the fan blade. DM stated undated items should be thrown out immediately and foods in the fridge longer than 3 days should be thrown out. DM stated it is important to use expiration dates to ensure palatability and to prevent food borne illnesses. DM stated it is important to keep food boxes correctly place to ensure freezer equipment continues to work as intended. A facility policy was requested and not received.

Based on observation, interview, and document review, the facility failed to comprehensively assess transfers with a mechanical lift or develop and implement policies to ensure safety and supervision for 7 of 7 residents (R6, R36, R2, R8, R51, R60, R62) reviewed for accidents. Additionally, the facility failed to identify fall risk resulting in two falls for 1 of 1 resident (R77) reviewed for repeated falls.Findings include: R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified severely impaired cognition and required maximal assistance for mobility. R6's diagnoses included Parkinson's, dementia, major depressive disorder and lack of coordination. R6's care plan (CP) created on 9/14/24, identified mobility was an area of concern, indicated was not ambulatory and needed transfer assistance of 2 and mechanical lift (EZ stand). Furthermore, the CP identified an area of concern, indicated was at risk for falls due to dementia, impaired coordination and mobility, medications, impulsiveness and safety awareness. R36's MDS comprehensive assessment dated [DATE], identified moderate cognitive impairment and left sided weakness in upper and lower extremities. R36's diagnoses included dementia, hemiplegia (left side affected), and congestive heart failure. R36's care plan created on 3/14/24, identified mobility was an area of concern, indicated transfers with assist of 2 and (sit to stand lift) EZ stand. Furthermore, the care plan identified was at risk of falls due to impaired mobility, left side weakness and dementia. R2's MDS quarterly assessment dated [DATE], identified severely impaired cognition and dependent mobility. R2's diagnoses included anxiety, dementia and cardiorespiratory issues. R2's care plan revised on 10/27/25, identified activities of daily living was an area of concern related to mobility status and dementia. The care plan indicated transfers with the assistance of two and EZ stand lift for all transfers. Furthermore, the care plan identified was at risk for falls due to impaired mobility, dementia and medications. R8's MDS quarterly assessment dated [DATE], identified severely impaired cognition and substantial/maximal assistance with transfers. R8's diagnoses included non-traumatic brain dysfunction, dementia and seizure disorder. R8's care plan was created on 6/4/23, identified activities of daily living were an area of concern, due to dementia, leg pain, decrease mobility and resistance to assistance. Perform cares in pairs, transfer with assist of 2 and an EZ stand. R51's MDS quarterly assessment dated [DATE], identified severely impaired cognition and dependent on all areas of mobility. R51's diagnoses included atrial fibrillation, type II diabetes, depression and dementia. R51's care plan created on 3/8/23, identified activities of daily living were an area of concern, due to weakness, stroke and cognitive impairment. Assist of two and EZ stand with transfers. Furthermore, identified falls were an area of concern, due to weakness, dementia and cognitive deficits. R60's MDS quarterly assessment dated [DATE], identified severely impaired cognition and dependent on all areas of mobility. R60's diagnoses included dementia, psychotic and mood disturbances and anxiety. R60's care plan revision on 10/7/24, identified activities of daily living was an area of concern, due to the disease process of Alzheimer's. Transfer with assistance of two and EZ stand. Furthermore, an area of concern was at risk for falls due to being unaware of safety needs and history of falls. R62's MDS comprehensive assessment on 2/20/26, identified severely impaired cognition and dependent on mobility. R62's diagnoses included osteoporosis, hemiplegia and dementia. R62's care plan revision on 6/9/25, identified activities of daily living was an area of concern, due to disease process, physical limitations, cognitive losses with spastic hemiplegia. Transfer assist of two and sit to stand lift. Furthermore, an area of concern was at risk for falls related to cognition, unaware of safety needs, incontinence, history of traumatic brain injury and cerebral vascular accident with spastic hemiplegia (type of cerebral palsy that affected one side of body, muscle weakness and stiffness). During observation on 3/10/26 at 11:02 a.m., R6 was in room, sitting in wheelchair repeating the word, help. Registered nurse (RN)-D-went into room and asked if R6 needed anything. RN-D wheeled R6 to shower room. Nursing assistant (NA)-F and NA-G hooked up the sling to EZ stand, elevated R6, moved the stand over the toilet lowered her down at 11:13 a.m. Staff left R6 attached to the stand and staff left room. At 11:17a.m., the staff returned to the shower room. There was a large amount of urine on the floor, the EZ stand and R6. RN-D left and returned with clean bottoms and socks, while NA-G and NA-F cleaned the floor, EZ stand, and R6. During observation on 3/12/26 at 2:30 p.m., R2 was wheeled into shower room, hooked up to the EZ stand by NA-I and NA-H elevated and brought to toilet and lowered her down, remained hooked up to EZ stand on the toilet. NA-I stayed with resident except when she left to go find assistance, for approximately 2 minutes. The staff provided cares and transferred her back into wheelchair. During interview on 3/12/26 at 11:28 a.m., NA-J stated residents that use the EZ stand for transfers to the toilet were brought into the shower room, since the bathrooms in their rooms were too small to use. She stated the process for EZ stand was to explain to resident what was happening, as cares were being provided. The EZ stand remained connected to the resident on the toilet because it was safer, kept the resident from falling forward. It was common practice for staff not to stay in shower room with resident. During interview on 3/12/26 at 12:35 p.m., RN-D stated the process for using the EZ stand was to have two staff members when doing transfers. The residents remained hooked in sling connected to EZ stand while on the toilet. The residents were left alone in the shower room. During interview on 3/12/26 at 1:54 p.m., physical therapist assistant (PTA)-A stated it was not acceptable for residents to be hooked up to the EZ stand and left alone. There was an assessment for safety of being left alone on the toilet and the resident had to be independent. However, the residents that used the EZ stand on that floor needed continuous supervision. The EZ stand should be removed while resident is on the toilet. During interview on 3/12/26 at 4:38p.m., director of nursing (DON) stated the expectations for use of shower room to toilet residents with the use of the EZ stand was to follow the transfer status lift, it required two staff members, hook up the resident, position properly and safely, bring them as close to the toilet as possible and lower. The EZ stand remained attached to the resident while using the toilet. A staff member needed to be in the line of sight of resident. DON stated he was not aware that staff were leaving residents unattended and hooked up to the EZ stand while in the shower room. The manual for the Drive EZ Sit to Stand lift indicated: How to transfer the Patient to the desired surface 1.Have the wheelchair, bed or commode ready: If transfer the patient to a commode, position the patient over the commode. 2. Press the (M1) DOWN button and lower the patient onto the desired surface. 3. Lock the rear swivel casters of lift. 4. Unhook the sling from all attachment points on the lift. 5. Instruct the patient to lift their feet off the footplate. 6. Remove the sling from around the patient. 7. Pull the lift away from the wheelchair, bed or commode. The policy Safe Resident Handling/Transfers dated 2023 stated: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks of injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device. Staff members are expected to maintain compliance with safe handling/transfer practices. R77: R77's admission Minimum Data Set (MDS) was not available at time of survey. A facility document title Nursing-Admissions/readmission Observation dated 3/5/26, noted R77 was alert and oriented to person, place, time, and situation. R77's cognition was intact. R77 requires transfer assistance, assistance with activities of daily living (ADL), and assistance managing new colostomy. R77's diagnoses included intestinal obstruction requiring a new colostomy (a surgical procedure that creates an opening (stoma) in the abdomen, allowing stool to exit the body when the colon cannot function normally), Parkinson's, urinary retention, and generalized muscle weakness. R77 was admitted to the facility on [DATE] at approximately 2:00 p.m. R77's baseline care plan dated 3/6/26 contained only information about resident socialization and activities. The baseline care plan lacked information about fall risk, how to minimize falls, how to minimize injuries related to falls, and resident-specific fall interventions. R77's electronic medical record (EMR) lacked a fall assessment. Review of R77's progress notes revealed: -Fall 3/8/26 at 11:09 p.m. R77 was found sitting up on the floor with his back against the bed, legs extended, with grippy socks. R77 sustained a bruise on his left buttock. Resident stated he was reaching for his urinal. -Fall 3/8/26 at 8:32 a.m. R77 was found on the floor between his bed and the bathroom door. No injuries were noted. Resident stated he was trying to get to bathroom. During an observation on 3/9/26 at 2:09 p.m., R77 was in his wheelchair in his room, stated he wanted to get up and needed help with his ostomy. R77's roommate encouraged him to wait for staff assistance. R77 kept stating he needed to get up and use the restroom and get this thing in his abdomen taken care of. During an observation on 3/9/26 at 2:11 p.m., nursing assistant (NA)-A entered R77's room to assist resident to the bathroom and change his clothing. R77 stood up with assistance from NA-A and appeared unsteady on his feet. During an interview on 3/9/26 at 3:07 p.m., NA-A stated each resident should have a Kardex (documentation system that enables nurses to write, organize, and freely reference key resident data). However, NA-A stated R77 did not have a completed Kardex. NA-A stated if a resident didn't have a Kardex, they would get information about a resident during shift change report. NA-A was unable to verbalize the information that was given about R77 during shift change report. Additionally, NA-A could only state R77 required assistance with ambulation but could not state how R77 ambulated. NA-A couldn't state whether R77 was a fall risk or if he had any fall interventions. During an interview on 3/9/26 at 3:10 p.m., NA-B stated R77 did not have a Kardex yet. NA-B stated she would look at R77's care plan since he didn't have a Kardex. NA-B stated she was unsure if R77 was a fall risk since he didn't have a care plan. NA-B couldn't state any resident-specific fall interventions for R77. During an interview on 3/10/26 at 10:37 a.m., licensed practical nurse (LPN)-A stated each resident should have a Kardex and a care plan indicating if they are a fall risk and what interventions work to prevent falls. LPN-A confirmed R77 did not have a Kardex or a resident-specific fall care plan. LPN-A confirmed R77 had fallen twice in less than 12 hours. LPN-A stated it is important to have both a Kardex and fall care plan because staff need to know how to care for each resident and prevent injuries if the resident falls. During an interview on 3/10/26 at 10:41 a.m., director of nursing (DON) stated the resident was admitted to the facility in the afternoon on 3/5/26. The DON stated the resident should have a completed baseline care plan completed in the first 48 hours after admission. The DON stated the baseline care plan should contain information about fall risk, how to prevent falls, and resident-specific interventions to prevent falls. The DON confirmed that the R77 did not have a Kardex, and the baseline care plan had not been completed within 48 hours after admission. The DON confirmed R77's falls were due to him reaching for something. The DON stated R77 should have a care plan entry for fall risk with resident specific interventions to include bed in lowest position, appropriate footwear, and commonly used items within reach. The DON stated it is important to have a completed Kardex and fall care plan to ensure residents are safe. A facility policy titled Fall Prevention Program dated 11/2025, each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observation, interviews, and document review, the facility failed to provide a home like dining experience in 2 dining rooms when meals were left served to residents on a plastic food tray.Findings include:During an observation on 3/9/26 at 12:44p.m., of the 3rd floor dining room, lunch trays were brought up in a cart, the staff passed out the trays and left food items on plastic trays in front of residents.During an observation on 3/9/26 at 6:03p.m., of the 2nd floor dining room, dinner trays were brought up in a cart, the staff passed out the trays and left food items on plastic trays in front of the residents.During observation on 3/10/26 at 12:33 p.m., of the 3rd floor dining room, lunch trays were brought up in a cart, the staff passed out the trays to the residents and left food items on the plastic trays.During observation on 3/11/26 at 8:48 a.m., of the 3rd floor dining room, breakfast trays were brought up in a cart, staff passed out the trays and left food items on the plastic trays in front of the residents.During an interview on 3/10/26 at 1:15p.m. licensed practical nurse (LPN)-A stated the residents had always been served their food on the trays and placed in front of them.During interview on 3/11/26 at 9:00a.m., certified nursing assistant (can)-F stated the residents had always had their food served on trays and placed in front of them.During interview on 3/11/26 at 10:00 a.m., R40 stated he would like the meals served on time, and not on trays and added it was not home.During interview on 3/11/26 at 11:00a.m., R45 stated feeling like the dining experience was being in school in a juvenile setting when the food is set in from of us on trays during mealtime. In addition, the staff place the hot foods next to the cold foods on the tray. R45 indicated asking staff to separate the food.A policy entitled, Serving a Meal dated 3/23, included to serve nutritional meals that met the needs of the residents. Additionally, arrange the dishes and silverware so the residents can reach them easily. It was often helpful to take dishes off tray.

Based on observation and interview, the facility failed to dispose of discontinued, expired, and discharged residents' medications. This had the potential to affect any resident who received medication from all facility medication rooms.Findings include:On [DATE] 10:00 a.m., 1st floor medication storage had 23-40 medication cards from discharged residents awaiting destruction and several bottles of over-the-counter expired bottles awaiting disposal. Registered nurse (RN)-B confirmed the medications on the counter were awaiting destruction and was unsure of the process of medication destruction. RN-B stated, the nurse manager took care of it, and we do not have one right now.The 1st floor med room storage had the following current resident medications awaiting destruction.R 81-Flomax capsule 0.4mg (Tamsulosin HCL) Take 0.4 milligrams (mg) by mouth daily-Inderal LA oral capsule Extended Release 24 hours (Propranolol HCL), Take 1 cap my mouth in the evening.- Lipitor oral tablet (Atorvastatin Calcium), take 10 mg by mouth at bedtime-Synthroid Oral tablet (levothyroxine Sodium), take 112 micrograms (mcg) by mouth in the morning.-Venlafaxine HCL ER oral capsule extended release 24 hours (venlafaxine HCL), take 37.5 mg by mouth one time a day every other day-Zyloprim oral tablet (Allopurinol), take 300 mg by mouth one time a day.-Methocarbamol oral tablet, Take 1000 mg by mouth 4 times a day.-Allegra Allergy oral tablet (Fexofenadine HCL), take 180 mg by mouth every 24 hours as needed.R15- Allegra Allergy oral tablet (Fexofenadine HCL), take 180 mg by mouth on time a day-Crestor oral tablet (Rosuvastatin Calcium), take 10 mg by mouth at bedtime.-Lasix oral tablet (Furosemide) take 40 mg by mouth one time a day.-Rozerem oral tablet (Ramelteon), take 8 mg by mouth at bedtime.- Synthroid Oral tablet (levothyroxine Sodium), take 125 mcg by mouth in the morning.-Lopressor oral tablet (Metoprolol Tartate) Take 12.5 mg by mouth 2 times a day-Omeprazole oral tablet, take 20 mg by mouth 2 times a day.- Zyloprim oral tablet (Allopurinol), take 100 mg by mouth 2 times a day.- Neurontin oral capsule (Gabapentin), take 300 mg by mouth 3 times a day.Tegretol oral tablet (carbamazepine), take 200 mg by mouth 4 times a day.-Benzonatate oral capsule, take 100 mg by mouth every 4 hours as needed for cough-Carafate oral tablet 1 gram, take 1 gram by mouth as needed 2 times a day as needed.- Melatonin Oral tablet, give 6 mg by mouth at bedtime as needed.-Ondansetron HCL oral tablet, take 1 mg by mouth every 8 hours as needed.On [DATE] 10:42 a.m., the 2nd floor medication storage room had 6 medications on the counter. Licensed practical nurse (LPN)-A acknowledged the 6 medication cards were from discontinued medications orders and discharged residents. LPN-A stated was unsure of the medication destruction process and stated that the night shift was responsible for medications destruction.The 2nd floor medication storage room had 6 medication cards belonging to R42 and R52 awaiting destruction.During observation on [DATE] at 11:51 a.m., registered nurse, (RN)-F, RN-F confirmed, medication cards kept on the counter were from discontinued orders, and discharged patients awaiting destruction. RN-F was unsure of facility medication destruction process and who was responsible for medication destruction.The 3rd floor medication room storage had following current resident medications awaiting destruction.R48-Atorvastatin 10 mg 1 tab started, 2/26R78-Escitalopram 20 mg, started [DATE]-Metoprolol 25 mg, 3 cards-Bupropion hcl 159 mg, tab started [DATE]R30-Clindamycin 150 mg caps started [DATE]--Torsemide 20 mg 2 tabs daily for 3 days then continue 1 tab dailyR2-Hyoscyamine 0.125 mg tab, started [DATE]R13- Ondansetron hcl 4 mg tab, started [DATE]R6-Famotidine 20mg, give 1 tabletR51- Eliquis 5 mg, give 1 tablet by mouth twice a dailyR34-Trazodone 50-gram tablet, give 1.2 tablet by mouth at bedtime as needed sleepR13- Sertraline 25 mg, give 1 tablet by mouth daily take with 50 mg for total dose of 75 mgR22-Ondansetron 4 mg tablet, give one tablet by mouth every 8 hrs. as needed for up to 7 daysR6Benzonatate 100 mg capsule, give one capsule by mouth three times daily as neededR78-Quetiapine 25 mg, give 1.2 tablet by bedtimeR31-Iprat-albut 0.5 (2.5) mg/3ml inhale 3mL vial ben three times daily for SOB.R62-Paxlovid 300-100mg doseR80- Cyanocobalamin 1000mcg/ml inject 1 milliliter (ml) intramuscular (IM) weeklyIt also contained 1 bottle of OTC acetaminophen 325 mg open [DATE] exp on bottle 2/2026, 1 bottle of aspirin over the counter 81 mg, expired [DATE], and 1 canister of inhaler -Formoterol Fumarate 20mcg/2ml.During an interview on [DATE] at 1:34p.m., the director of nursing (DON) stated, medication destruction was to be completed by 2 nurses, 1 nurse logged the medications, and the 2nd nurse completed the destruction by disposing of the tablets in a Stericycle water activated solution. DON expected medications destruction to be completed as soon as possible. During an interview with the facility pharmacist on [DATE] at 2:34 p.m., pharmacist reported being unfamiliar with the current medication destruction process for the facility and advised to refer to the facility policy.A policy for medication storage was requested but not received prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed to self-administer medications for 1 of 1 resident (R4) reviewed for self-administration of medication (SAM).Findings include: R4's quarterly Minimum Data Set (MDS) assessment, dated 2/23/26 indicated R4 was cognitively intact, had no upper body impairment, was independent with personal hygiene, and required set-up to supervision for upper and lower body dressing.R4's diagnoses list included diabetes, end-stage kidney disease, heart failure, and morbid obesity. R4's self-administration care plan dated 11/20/25 lacked self-administration of nystatin powder (medication used to treat fungal infections). R4's provider orders included: Nystatin powder 1 application to affected areas under right breast and skin folds topically twice a day and as needed.R4's medical record lacked a self-administration assessment for applying Nystatin powder. During observation and interview on 3/10/26 at 3:45 p.m., R4 stated she keeps her nystatin powder locked up in the canvas bag located on her bed. During interview on 3/11/26 at 9:43 a.m., licensed practical nurse (LPN)-A stated R4 administers own injections and completes blood sugar check with nursing supervision and performs her own vitals. LPN-A stated R4 refuses the nystatin powder however it is kept in the medication cart. LPN-A looked in the medication and treatment cart however could not find R4's nystatin powder. During observation and interview on 3/11/25 at 10:12 a.m., R4 indicated she puts the nystatin powder on herself twice a day. R4 stated she feels the area under her abdomen has improved however confirmed she is unable to see what the area looks like. R4 opened the locked canvas bag on her bed that contained a bottle of nystatin powder dated November of 2025. R4 stated she likes that particular bottle because it is easier to use. When she runs out, she has the nursing staff order a new bottle and dump the contents of the new bottle into the bottle she likes. R4 stated the nurses do not offer to put the nystatin powder on. During observation and interview on 3/11/26 at 11:05 a.m., LPN-A arrived to perform R4's dressing change. After the dressing change, LPN-A asked permission to wash under R4's abdominal folds and apply the nystatin powder. R4 stated then I'll have to unlock my bag and proceeded to unlock her canvas bag and hand the nystatin powder to LPN-A. LPN-A then washed and dried under R4's abdomen, applied the nystatin powder, and handed the powder back to R4 to lock in her bag. After leaving the room, LPN-A stated R4 has never allowed her to wash the area or apply the nystatin powder. When asked if R4 keeps the nystatin powder in her room, LPN-A stated I'm going to say yes since I couldn't find it in the cart. LPN-A stated residents who want to self-administer a medication are assessed for it and have to have something in the orders or care plan. LPN-A stated she has never done a self-administration assessment for R4. During an interview on 3/11/26 at 3:18 p.m., registered nurse (RN)-A stated a self-administration assessment is performed to determine a resident is able to safely administer medications. The assessment involves resident's ability to identify what the medication is, what it is for, and the correct dosage. Residents also must be able to demonstrate safe storage of the medication and have the manual dexterity to administer the medication safely. When the assessment is completed the nursing staff, director of nursing, and nurse practitioner meet to discuss if self-administration is appropriate. If the resident is deemed appropriate, the medical provider or nurse practitioner will sign off allow the resident to administer the medication. RN-A stated there was a time R4 was able to administer a lot of the prescribed medications however the facility has dialed back what R4 is allowed to do as they were finding oral medications on the floor. Currently R4 is able to check blood sugar and administer some injectable medications with staff set up and supervision as well as independently administer inhaled medications. RN-A verified R4 did not have a self-administration assessment completed for the nystatin powder. During an interview on 3/12/26 at 9:31 a.m., the director of nursing stated self-administration assessments are required to determine if a resident is able to determine the purpose of safely administering, and store medications. A policy titled Resident Self-Administration of Medication revised January 2026 indicated A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, interview, and record review, the facility failed to update the provider timely of ordered medication refusals for 2 of 2 residents (R4, R44) reviewed for medication administration. Findings include: R4: R4's face sheet indicates R4 was readmitted to the facility on [DATE] after a 12-day hospital stay for a below the knee amputation. R4's quarterly Minimum Data Set (MDS) assessment, dated 2/23/26, indicated R4 was cognitively intact, had no upper body impairment, was independent with personal hygiene, and required set-up to supervision for upper and lower body dressing. R4's diagnoses list included diabetes, end-stage kidney disease, heart failure, and morbid obesity. R4's care plan indicated R4 is resistive/noncompliant with treatments/cares related to manipulative behaviors, loss of independence and control with a goal of understanding the consequences of refusal/noncompliance. R4's provider orders dated 11/18/25 indicated: Nystatin powder (medication used to treat fungal infections) 1 application to affected areas under right breast and skin folds topically twice a day and as needed. R4's medication administration record (MAR) indicated the following refusals of the Nystatin powder: Nov. 2025: 21 of 26 possible administrations Dec. 2025: 54 of 62 possible administrations Jan. 2026: 49 of 62 possible administrations Feb. 2026: 43 of 56 possible administrations During an interview on 3/11/26 at 9:43 a.m., licensed practical nurse (LPN)-A stated R4 has yet to allow me to put it [nystatin powder] on her. During an observation and interview on 3/11/26 at 11:05 a.m., LPN-A entered R4's room to perform a dressing change. After performing the dressing change, R4 allowed LPN-A to wash under her abdominal folds and apply the nystatin powder R4 kept in a locked bag on her bed. Upon leaving R4's room, LPN-A stated R4 has never allowed her to wash under the abdominal folds and apply the powder. LPN-A stated R4's abdominal folds looked a little red and did not look like it had any powder on it. During an interview on 3/11/26 at 2:52 p.m., the facility nurse practitioner stated R4 has a history of refusing medications and treatments however was not notified R4 has consistently refused the nystatin powder since November 2025. The nurse practitioner stated she would expect to be notified so she can speak to the resident about the refusal and have an interdisciplinary team meeting regarding the refusal. During an interview on 3/11/26 at 3:01 p.m., registered nurse (RN)-G stated if a resident consistently refuses a medication or treatment, the clinical manager is notified. RN-G would also notify the provider if they were in the facility to speak to the resident about either discontinuing the order or changing it to as needed. During an interview on 3/11/26 at 3:18 p.m., RN-A stated residents who consistently refuse a medication/treatment are educated why the medication is important and what may happen they continue to refuse it. If the resident still refuses, the provider is notified and asked to discontinue the order. RN-A stated she was not aware R4 was consistently refusing the nystatin powder therefore she was guessing they didn't notify the provider either. During an interview on 3/12/26 at 8:39 a.m., licensed practical nurse (LPN)-B stated if a resident consistently refuses a medication or treatment, she would let the clinical manager know and send a message to the provider. LPN-A stated R4 is known to refuse treatments, medications, and cares when offered, preferring to do things on her time. LPN-A stated R4 refuses to allow nursing staff to put on nystatin powder. During an interview on 3/12/26 at 9:31 a.m., the director of nursing stated if a resident consistently refuses a medication/treatment, the provider is updated so order can be discontinued so the staff are not consistently documenting refusals. The director of nursing stated the provider was notified of the refusals February 2026. Documentation provided by the director of nursing indicated notification sent to the provider on 2/20/26 of R4 refusing all medications and treatments specifically on 2/20/26. The documentation provided also indicated on 2/28/26 communication was sent to the provider regarding R4 refusing the treatment to her surgical wound. Neither notification mentioned R4 had consistently refused the nystatin powder since November 2025. R44: R44's admission MDS assessment, dated 2/20/26, indicated intact cognition, R44 required partial/ moderate assistance with toileting hygiene. R44's diagnoses included chronic respiratory failure with hypoxia, dependence on supplemental oxygen, acute kidney failure, hypertensive heart and chronic kidney disease with heart failure, Type2 diabetes mellitus, Chronic Pulmonary edema, moderate persistent asthma, dependence of renal dialysis. R44's was admitted 0n 02/5/26 and orders dated 2/05/25 included: oxygen 2 liters via nasal cannula continuously. During observation on 03/10/26 11:11 a.m., R44 came down the unit hallway on her motorized scooter with no oxygen in use. R44 stated, the portable oxygen tank was empty and was in search of staff to have the tank filled. The director of nursing (DON) filled in the portable oxygen tank for R44 at 11:115 a.m. R44 took the oxygen tank from the DON and passed RN-B in the hallway and went back to her room with no oxygen in use. During observation on 03/10/26 11:23 a.m., and 11:28 a.m., oxygen tank was filled but not in used by R44. During an interview on 03/10/26 1:38 p.m., RN-B stated they had seen R44 at times with no oxygen in use, was not sure if R44 oxygen order was continuous or as needed and had told R44 at times to put the oxygen back on. During an interview on 03/10/26 2:28 p.m., the DON stated they had seen R44 with no oxygen in use. DON stated R44 declined oxygen use and stated, I don't need it, when DON had offered to turn on the portable oxygen tank after the tank was filled. DON also stated, I have never seen her with her oxygen in use. R44's oxygen order of 2 liters via nasal cannula continuous was communicated to DON and DON stated, I will call the provider to get an order to wean her off oxygen. Based on communication with R44's primary care provider, medical doctor (MD) on 03/12/26 at 2:00 p.m., MD expected the facility to have sent an SBAR (situation, background, assessment, recommendation) and an updated vital sign for ongoing need for supplemental oxygen. Review of an undated facility policy titled, Notification of changes, indicates, circumstances requiring notification include Circumstances that require a need to alter treatment.

Based on observation, interview, and document review, the facility failed to complete baseline care plan within 48 hours of admission for 1 of 1 resident (R77) reviewed for care plans.Findings include:R77's admission Minimum Data Set (MDS) assessment was not available at time of survey. A facility document title Nursing-Admissions/readmission Observation dated 3/5/26, noted R77 was alert and oriented to person, place, time, and situation. R77's cognition was intact. R77 requires transfer assistance, assistance with activities of daily living (ADL), and assistance managing new colostomy, (a surgical opening in the colon that allows stool to exit the body through a stoma into an external pouch).R77's diagnoses included intestinal obstruction requiring a new colostomy, Parkinson's, urinary retention, and generalized muscle weakness.R77's electronic health record (EHR) indicated R77 was admitted to the facility on [DATE] at approximately 2 p.m. EHR lacked evidence a baseline care plan had been initiated within 48 hours of admission.During an interview on 3/10/26 at 1:49 p.m., physician assistant (PA)-A stated it is his expectation that the baseline care plan be created in the first 48 hours after admission. PA-A stated the baseline care plan is important, so staff know how to provide basic cares such as hygiene, ambulation, skin concerns, fall interventions, and any resident-specific concerns. PA-A stated the baseline care plan for R77 was especially important due to the complexity of his hospital stay prior to admission to facility.During an interview on 3/10/26 at 2:00 p.m., director of nursing (DON) stated the process for admitting a resident included: the health unit coordinator (HUC) transcribed admission orders based on the hospital dismissal summary or after visit summary the facility received, a nurse reviewing those orders, and loading the orders into the medication admission record (MAR) and treatment admission record (TAR) in the EMR. Additionally, the nurse would enter a baseline care plan based on those orders. The comprehensive care plan would be completed after the facility could evaluate all areas of resident care in the coming weeks. The DON stated the HUC had transcribed the orders, however, the nurse had not reviewed the orders and uploaded the orders to the MAR and TAR and no baseline care plan was completed. The DON stated the baseline care plan is important so staff can care for the residents' basic needs, establish likes and dislikes, and make sure the residents are safe.An undated facility policy titled Baseline Care Plan, the baseline care plan will be developed within 48 hours of a resident's admission.

Based on observation, interview, and document review the facility failed to provide professional standards of practice when staff completed treatments without a provider order, failed to request orders for treatment, and failed to document treatment completion for 1 of 1 resident (R77) reviewed for ostomy cares.Findings Include:R77's admission Minimum Data Set (MDS) assessment was not available at time of survey. A facility document title Nursing-Admissions/readmission Observation dated 3/5/26, noted R77 was alert and oriented to person, place, time, and situation. R77's cognition was intact. R77 requires transfer assistance, assistance with activities of daily living (ADL), and assistance managing new colostomy (a surgical procedure that creates an opening (stoma) in the abdomen, allowing stool to exit the body when the colon cannot function normally),.R77's diagnoses included intestinal obstruction requiring a new colostomy, Parkinson's, urinary retention, and generalized muscle weaknessR77's care plan dated 3/6/26, lacked direction or interventions of how to care for the colostomy.R77's admission orders included empty bag every shift and record amount; the admission orders and baseline care plan lacked specific appliance change instructions (i.e., bag type, bag size, skin protectants, skin barriers, and bag removal).During observation on 3/9/26 at 2:11 p.m., R77 was waiting in his room for facility staff to assist him to the bathroom; while waiting R77 pulled off the colostomy bag and tossed it into the garbage can in his room. Facility staff arrived, closed room door, and assisted resident with changing his clothing and applying a new colostomy bag. According to the American Nurses Association (ANA) an RN's scope of practice is to implement orders, not to create them. The authority to create orders rests with authorized prescribers like physicians and nurse practitioners. Further, RN's need a provider's order to provide medical treatment, such as colostomy site care.During an interview on 3/10/26 at 10:37 a.m., licensed practical nurse (LPN)-A stated R77's colostomy care information should be in his admission orders or his baseline care plan. LPN-A confirmed R77 did not have colostomy care orders and did not have a colostomy care plan. LPN-A stated since the colostomy care information was not in the orders or care plan, she would look at R77's hospital dismissal instructions to verify what colostomy supplies R77 required. LPN-A stated she was unsure what colostomy supplies were used for R77's current colostomy bag. LPN-A stated the last colostomy bag change was not documented appropriately because the colostomy orders had not been entered so staff would not have a place to chart the colostomy bag change. LPN-A stated staff could have also done a progress note to document the last colostomy bag change; LPN-A verified this was also not completed. LPN-A stated staff should have requested a provider order after changing the colostomy bag; LPN-A verified this was also not completed.During an interview on 3/10/26 at 10:41 a.m., director of nursing (DON) stated R77 should have had colostomy care admission orders and a baseline colostomy care plan. DON stated the baseline care plan for R77 was incomplete; with no colostomy care information entered. DON further stated the current colostomy orders lacked specific care information such as bag type and size, skin protectants, and frequency of changes. The DON stated treatments such as colostomy care would require a provider order. The DON stated any treatment provided to residents should be documented in the residents' chart. The DON stated if a treatment is needed and completed urgently, the staff providing the treatment should immediately request an order from the provider for the treatment. Further, the DON stated it is an expectation any time a treatment is provided, with or without an order, be documented in the resident chart. The DON confirmed a treatment was performed without an order, an order was not subsequently requested, and the treatment was not documented.During an interview on 3/10/26 at 1:49 p.m., physician assistant (PA)-A stated it was his expectation admission orders, and baseline care plan be entered immediately so staff know how to care for and provide treatment to the resident with a colostomy. Additionally, if staff did not have an order for treatment, they should reach out to the provider immediately to obtain an order. Further, PA-A stated he expected all treatments to be documented so facility staff knew about the treatments the resident was receiving.A document titled Registered Nurse Job Description dated 8/2/23, registered nurses provide professional nursing care to residents in accordance with physician orders and facility policies.

Based on observation, interview and document review, the facility failed to revise and update a care plan for 1of 1 resident (R33) reviewed for care plan timing and revision.Findings include:R33's Minimum Data Set (MDS) assessment, dated 12/3/25, indicated intact cognition, R33 was independent with transfers, w/c mobility and required limited assist with bed mobility. R33 's diagnoses included chronic systolic and diastolic (congestive) heart failure (a serious condition of the heart's ability to pump blood efficiently), Chronic obstructive pulmonary diseases (an ongoing lung condition caused by damage to the lungs), generalized osteoarthritis.R33's care plan dated 11/19/25 indicated R33 was allowed to smoke independently in designated smoking areas, needed reminders and assistance to use smoking apron, and smoking materials needed to be secured at the nurses' station or other designated areas for storage.R33's Smoking Assessment completed on 2/20/26, indicated R33 was safe to smoke without supervision, demonstrated safe smoking practices, no indication of smoking apron use, and facility stored lighter and cigarettes.R33's care plan was not updated to reflect the changes noted in the 2/20/26 smoking assessment.R33's MAR/TAR (medications administration/ treatments administration record) dated 3/10/26 lacked smoking assessment recommendations/interventions.R33's Task Description list (task assigned to nursing assistants) dated 3/1/26 lacked smoking tasks.During an observation on 3/9/26 at 6:46 p.m., R33 took her smoking materials from her room and continued to go out to the designated smoking area. R33 did not use a smoking apron. R33 demonstrated safe smoking practices.During an interview on 3/09/26 3:03 p.m., R33 stated, she kept her smoking materials locked in her room, smoked 1-2 cigarettes a day, and reported no smoking apron use while smoking.During an interview 3/10/26 10:49 a.m., registered nurse (RN-B) stated was not sure if R33 went out to smoke or was getting some fresh air. RN-B stated, that information will be on the MAR/TAR, and a staff member would have been assigned to R33, if R33 was a smoker.During an interview on 3/10/26 11:20 a.m., nursing assistant (NA-E)stated, R33 used to smoke, and had not seen R33 smoke today. NA-E stated, I will ask the nurse, the DON or look at Task Description list. During an interview on 3/10/26 at 2:27 p.m., the director of nursing (DON), explained the process of assessment to care planning and updates. DON stated, after the Smoking Assessment was completed, nursing was responsible for updating the care plan, staff was notified, and information was available on the Task List and in the care plan. DON stated, no point of care notification is sent out to notify staff of updates, staff are expected to review care plan for updates.During an interview on 3/12/26 at 8:45 a.m., DON stated, R33 stored smoking materials in her room, R33 was safe to smoke independently and R33 needed no smoking apron.Facility policy on care plan revision and update requested and not provided.

Based on observation, interview, and document review, the facility failed to comprehensively assess each fall, identify causal factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, and failed to comprehensively evaluate and implement fall interventions for 3 of 3 residents (R1, R2, and R3) reviewed for resident safety. The facility's failures resulted in an immediate jeopardy (IJ) for R1 who sustained fractures after his first and second fall.The IJ began on 5/23/25, when the facility failed to complete a comprehensive fall assessment along with root cause analysis and implement appropriate interventions after R1 attempted to self-transfer, resulting in an unwitnessed fall requiring hospitalization with a right frontal sinus fracture. Upon return from the hospital, on 6/10/25, R1 again attempted to self-transfer resulting in an unwitnessed fall requiring hospitalization where R1 sustained two left pubic bone fractures with bleeding and hematoma formation surrounding the fractures. The vice president of success (VPS)-A, vice president of human resources (VPHR)-A and director of nursing (DON) were notified of the IJ on 7/24/25 at 5:51 p.m. The IJ was removed on 7/28/25 at 2:02 p.m. after it could be verified that the facility had implemented an acceptable removal plan, however, non-compliance remained at D isolated severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.Findings include:R1's admission Evaluation dated 5/19/25 at 6:00 p.m., identified that R1 verbalized understanding of call light/bell and was unable to use devices so a soft touch call light was provided. R1's activity of daily living (ADL) care plan identified R1 required extensive assist of one staff with bed mobility and personal hygiene. R1 required extensive assist of two staff with transfers and toileting. R1 was alert to person and was aphasic (difficulty finding words, nonsensical speech). R1 had bladder incontinence one to two times daily during the day and evening. R1 exhibited, dizziness or lightheadedness, vertigo (feeling of spinning or whirling), impulsivity or poor safety awareness, and moved too quickly. R1 exhibited gait and balance problems.R1's care plan identified a focus date 5/19/25, at risk for falls related to Arteriovenous Malformation (AVM)-(a condition where an abnormal tangle of blood vessels connecting arteries and veins, bypassing the normal capillary network in the brain that can cause bleeding and a lack of oxygen to reach the tissues which can put the person at risk for hemorrhage or ruptures that can lead to a stroke), hydrocephalus-(-condition where cerebrospinal fluid (CSF) builds up in the brain's ventricles, leading to increased pressure on brain tissue that can cause headaches, nausea, vomiting, vision problems, and difficulty with walking and balance, and cognitive deficit following a brain bleed), and medications. Interventions dated 5/19/25, included to encourage to transfer and change positions slowly, reinforce wheelchair safety as needed such as locking brakes, report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status post fall, reinforce need to call for assist and scoop mattress. On 5/22/25, interventions included anti-rollbacks to wheelchair, fall mat beside bed-left side toward door, medications as ordered, medication regiment review, soft touch call light and therapy to eval and treat as ordered.R1's medical doctor (MD) progress admission note dated 5/22/25, identified reason for admission was hydrocephalus and metabolic encephalopathy- (a condition that causes brain dysfunction that can cause confusion, memory problems, and changes in mood or behavior). COGNITION: R1 exhibited a severe to profound cognitive-communication impairment characterized by deficits in orientation, attention (focused, sustained, alternating, divided), memory (immediate, delayed), visual perceptual skills (L inattention), problem solving/reasoning (insight/awareness, safety), and significantly delayed processing speed. R1 was impulsive and motor restless, requiring consistent redirection. No vital signs were taken for this visit and R1 was drowsy, but arousable and largely unintelligible. Further identified R1 had a fall within the last year.R1's admission Minimum Data Set (MDS) dated [DATE], noted R1 had moderately impaired cognition. Further identified R1 needed substantial to maximal assist of one staff with bed mobility, transfers and toileting. R1 had one fall with no injury and was occasionally incontinent of bladder and bowel. R1's Unwitnessed Fall document dated 5/23/25 at 5:50 p.m., identified R1 was found sitting on the floor in an upright position with legs extended next to his wheelchair in his room. R1 was wearing shoes and had his tray table in front of him. Family member (FM)-A reported she left R1 for a moment to get water and when she came back R1 was sitting on the floor and staff were in the room. Immediate Action taken: R1 was assessed, initial blood pressure (B/P) was elevated, but after assisting into bed B/P was checked and was 128/78. Heart Rate (H/R) was 113, Respiratory Rate (RR) was 20. Temp was 98.1, oxygen (O2) saturations 96% on 3 liters per nasal canula (NC). R1 was able to move all extremities and denied hitting his head. Corresponding Post Fall Assessment document dated 5/23/25 at 5:50 p.m. revealed incomplete sections; it did not identify R1's fall history, physical, mental/behavioral status, or medications status of R1 prior to fall. New immediate intervention was R1 was reminded to call for assist when needing help and further identified R1 was last seen 2 minutes ago by FM-A., however, did not identify when R1 was last assisted by staff and/or what services were last provided prior to the fall. R1's progress note dated 5/23/25 at 5:50 p.m., identified R1 had an unwitnessed fall, was on heparin injections every eight hours, had a history of metabolic encephalopathy, was able to move all extremities, denied hitting his head, neuro at baseline, and no bruises noted on head. Skin tear to left elbow measured 3 centimeters (cm) x 2 cm x 0.5 cm. R1 was sent to the hospital for evaluation due to being on a blood thinner.In review of R1's fall record for 5/23/25, there was no indication R1's care plan was updated to include the new interventions nor was the care plan updated to include the reminders to use the call light for assistance. Further not evident a comprehensive analysis was completed that identified modifiable and non-modifiable risk factors that may have contributed to the fall so that appropriate individualized interventions could be developed and implemented to prevent and/or mitigate the risk for recurrent falls and/or falls with major injury. Additionally, according to R1's record there was no indication of interdisciplinary team (IDT) involvement. R1's Care Area Assessment (CAA) dated 5/28/25, identified section 11. Falls, actual problem. One fall noted since admission. Out to emergency room (ER) for assessment and admitted to the hospital. Care plan considerations identified an alteration in mobility with risk of falls related to recent cardio vascular accident (CVA) with aphasia- (can include difficulty finding words, speaking in short phrases, struggling to understand others, and problems with reading and writing, cognitive/communication deficit, safety awareness issues), metabolic encephalopathy, hydrocephalus, left side neglect, insomnia, ongoing need for percutaneous endoscopic gastrostomy (PEG) tube with tube feedings per order, medications with current need for assistance to complete ADL's, toileting, and mobility tasks. R1 continued to work with physical therapy/occupational therapy (PT/OT) for rehab. Discharge plans at this time are uncertain, dependent on his final abilities/status. Continued to need assist from staff to complete his transfers. No adverse issues noted with medications. Interventions noted to be ongoing per care plan.R1's Hospital Discharge summary dated [DATE], identified R1 was hospitalized from [DATE] to 6/9/25. Details of hospital stay identified reason for admission was initial head injury, history of falling and pneumonia. Hospital course identified R1unfortunately sustained a fall at his skilled nursing facility (SNF) on 5/23/25, related to his impulsiveness and weakness. CT scan of R1's head showed fracture lines extending through the frontal sinus with communication intracranially and new extra axial fluid collection adjacent to the fracture lines [indicates a serious injury involving the skull, where a break in the frontal bone has opened a path into the brain, leading to an accumulation of fluid outside the brain and within the skull].Decision was made to focus on keeping R1 comfortable with comfort focused care and will be discharged back to the skilled nursing facility.R1's MD Progress note, dated 6/10/25, identified a readmission visit, brief summary of hospitalization form 5/23/25 to 6/9/25, identified R1 suffered an unwitnessed fall at SNF on 5/23, subsequently readmitted to the hospital and the ED workup demonstrated frontal sinus fracture. Narrative history identified that FM-A cited R1's urinary and stool incontinence as well as impulsivity and safety concerns as barriers to returning home. Regarding stool incontinence, R1 has significant diarrhea and cannot seem to get up and go to the bathroom on time. FM-A described R1's impulsivity and that he does not realize that he isn't safe to walk and often tries to get up and go on his own. FM-A has noticed more cognitive decline in the last few weeks.Although R1's physician note dated 6/10/25 identified safety concerns with impulsivity, indicated R1 had an unawareness of his limitations in ability to walk, tried to self-transfer, and had urinary and bowel incontinence with significant diarrhea, there was no indication of comprehensive bowel and bladder assessment that would determine an individualized toileting program nor an assessment that determined R1's required level of supervision to mitigate risk of falls related to impulsivity, self-transfers, and incontinence. R1's Unwitnessed Fall document dated 6/10/25 at 4:00 p.m., identified R1 was found lying on his right side with his head facing the bed. R1 said yes when asked if he hit his head, stated he was trying to get up. R1 complained of right hip pain 9/10, PRN (ad needed) Tylenol 500 mg was administered, pain was still 9 out of 10 thirty (30) minutes later and was not able to bear weight on his right side. R1 was sent to the hospital for further evaluation. Further identified R1 was confused, room had poor lighting, was transferring self. Lacked mental status assessment. Corresponding Post Fall assessment dated [DATE] at 4:00 p.m., did not list date and time of most recent falls, indicated R1 was last seen at 5:00 p.m., (even though documentation identified the fall occurred at 4:00 p.m.) by registered nurse (RN)-B. Further identified R1 was wearing socks/stockings and was getting up from a chair at the time of the fall. Care plan portion identified the new immediate intervention was shoes put on and call light within reach, however care plan was not updated.R1's progress note dated 6/11/25 documented approximately 8.0 hours after the fall at 12:04 a.m., identified R1 had a fall at around 4:00 p.m., [6/10/25] complained of 9/10 pain, was given Tylenol 500 milligrams (mg), was still in pain and unable to bear weight on right side and was sent to the hospital. In review of R1's 6/10/25 fall record did not in include a comprehensive analysis; the record did not include physical status, medication(s) administered, when R1 was last assisted, and which services were provided prior to the fall.R1's emergency room (ER) progress note dated 6/10/25, identified the chief complaint was at approximately 2:00 p.m. (time conflicted with the facility documentation that identified 4:00 p.m.), R1 suffered an unwitnessed ground level fall at SNF. He was amnestic to the events of the fall, was found by nursing staff and emergency medical services (EMS) was called. History identified R1 had a fall at SNF on 5/23/25, his workup demonstrated a frontal sinus fracture with right frontal complex fluid collection. On arrival to the emergency department (ED), computed tomography (CT) scans demonstrated R1 had an acute nondisplaced left superior and inferior pubic rami fractures-(cracks in the bones of the pelvic ring on the left side), acute intramuscular left obturator hematomas- (blood collected in the muscles of the left obturator region, indicating bleeding), acute bleeding from peri vesicular space adjacent to pubic ramus-(blood loss into the space around the bladder, located next to the broken pubic bone). R1 was admitted to medicine floor.R1's IDT Clinical review progress note dated 6/11/25 at 10:05 a.m., identified R1 had a fall on 6/10/25, root cause analysis was impulsivity, and intervention was to do frequent purposeful rounding.R1's care plan had an added intervention dated 6/11/25, to do frequent purposeful rounding, however, did not specify the intervals of frequent rounding R1 required nor address what type of footwear needed. During a phone interview on 7/23/25 at 1:09 p.m., FM-A stated R1 could not safely get up by himself that's why he was at the facility to work with therapy. Since the day R1 was admitted FM-A told the facility R1 needed constant supervision because he was so impulsive, but did not feel like anyone listened to her. FM-A was at the facility in his room every day from about 9:00 a.m. to around 5:00 p.m. and then another family member would come for a couple hours in the morning and a couple hours in the evening after she left until R1 was asleep. Family thought this was necessary because they had noticed no staff would ever come into R1's room to check on R1 or offer toileting; family were the ones that had to put on the call light when R1 needed help. R1 was very impulsive, a typical day, no matter where he was or what he was doing, he would try to get up. FM-A told the facility R1 needed more than a low bed and a floor mat to keep him from falling, she told staff he needed supervision to which staff responded- they would do the best they can do. On 5/23/25, R1 was in his wheelchair, his tray table was in front of him with food on it. FM-A had told him she would go refresh his ice water, don't move, and would be right back. FM-A explained on her way back she heard a ruckus and heard a nursing assistant yelling someone help me we have a fall. FM-A indicated R1 sustained a skin tear which was bleeding and he was sent to the hospital where he was found to have some kind of a sinus fracture. FM-A stated I knew he was going to fall he did not have enough supervision or safety interventions in place. R1 came back from the hospital on 6/9/25, a day later he fell again fractured his pelvis and broke his hip. R1 was sitting in his recliner on 6/10/25, between 1:00 p.m. and 1:30 p.m., he was covered in a blanket, and was dozing off so she thought it would be a good time to go to the store. FM-A told staff she would be back in an hour; she wasn't gone 30 minutes when the facility called to inform her R1 had fallen and was now complaining of a sore left hip. FM-A asked the staff what happened, and they told her they didn't know. The ER doctors said he broke his left hip and pelvis, and they really couldn't do anything for his type of injury and the only choice was comfort care. FM-A stated R1 needed more supervision but felt this was not provided by the facility and now he [R1] was gone. During an interview on 7/28/25 at 11:53 a.m., registered nurse (RN)-A stated she was the one who admitted R1. He was very impulsive and slightly aphasic; he would climb out of his wheelchair without saying what he was doing. R1's family was here all the time they were always afraid he was going to fall because he was so impulsive. RN-A was unaware R1 had a fracture after his first fall. RN-A was asked at what point they would do increased supervision for a fall prevention intervention. RN-A indicated R1 probably required one-to-one supervision but did not think the facility provided that level of care. During an interview on 7/29/25 at 2:33 p.m., RN-B indicated when R1 was first admitted the family was toileting him not the facility staff. The family was worried about him falling because R1 was so impulsive, so they were here a lot. RN-B was working when R1 fell on 6/10/25. RN-B stated she could not remember how he was found on the floor and that the documentation in his medical records did not identify that. When RN-B walked into R1's room to assess him, he was on the floor lying on his right side in front of his recliner without his shoes on and only regular socks. RN-B did not investigate the fall to determine if R1's basic needs were met such as the last time he was assisted with toileting or if he was incontinent at the time of the fall. R1 was having severe pain, and they decided to send him to the hospital for further evaluation. RN-B stated she documented the root cause of the fall as not wearing shoes but stated she did not update the care plan to reflect that. During an interview on 7/23/25 at 2:56 p.m., nurse manager (NM)-A described R1 as complex, cognition varied, was incontinent of bladder, required extensive assist with ADLs and was very impulsive with his movements. NM-A further indicated R1's family spent a great deal of time with R1 because they were afraid R1 was going to fall due to his impulsivity. NM-A explained when a resident falls, the floor nurse should first assess the resident for injury, notify physician and family, document findings in risk management, in progress note, and on the post fall assessment. The nurse was supposed to put an immediate fall prevention intervention in place and that would be documented in the post fall assessment. The interdisciplinary team (IDT) would then meet Monday through Friday at 9:00 a.m., where falls would be reviewed to ensure each resident had a root causal analysis with an appropriate intervention added to the care plan. NM-A was unsure who was responsible to ensure each resident's care plan was updated. NM-A stated R1 had a fall on 5/23/25, the fall was not comprehensively assessed to determine a root cause and there was no new intervention developed/implemented to his care plan for future fall prevention. NM-A stated R1 was sent to the hospital on 5/23/25 and did not return to the facility until 6/9/25, he was hospitalized for pneumonia. R1then fell on 6/10/25; that fall was not comprehensively analyzed either. NM-A stated IDT met on 6/11/25, to discuss root cause and they came up with R1 fell due to impulsivity and put an intervention in place to do purposeful frequent rounding. However, identified that intervention would not be measurable and was not able to articulate how staff would know when to round on R1 or how to document. NM-A stated at the very least the care plan should have been developed/implemented to ensure appropriate footwear was on since R1 had regular socks on. R1 was a resident who needed frequent supervision due to his impulsivity. During an interview on 7/24/25 at 3:20 p.m., director of nursing (DON) explained the process for a resident with an unwitnessed fall included the nurse completed a full body assessment for injury and start neuro checks. After it was determined the resident was safe staff were to notify the physician and family. The nurse should then document the fall in risk management which included completing the incident report and post fall assessment along with making a progress note. The floor nurse should then put an immediate intervention in place. DON indicated IDT met Monday through Friday and discussed each fall in real time except for falls that happened on the weekends to ensure there was a root cause and prevention intervention documented in the resident care plan. If IDT met about a residents fall there would be an IDT note in the resident's progress notes. R1 had a complex medical history and came to facility with neurological problems and had impulsivity and R1's family stayed with R1 most of the day because they were scared, he would fall. DON indicated they tried to put several interventions in place to prevent his falls but did not consider increased supervision as one of the interventions. R1 had an unwitnessed fall four days after his admission on [DATE]. The facility did not ensure R1's basic needs were met indicating the fall assessment was not comprehensive. DON was unable to articulate why IDT never met to try and find a root cause and appropriate fall prevention intervention to prevent future falls and indicated it may have been because R1 was hospitalized from [DATE] to 6/9/25. DON was unaware that R1 sustained a right frontal sinus fracture from R1's fall and stated NM-A would have been responsible to thoroughly read through the hospital record upon readmission to determine that. DON stated R1 fell on 6/10/25, and IDT met the following day and determined the root cause to be impulsivity with a prevention intervention to do frequent purposeful rounding that was updated on R1's care plan. DON stated the intervention would not be measurable and was not able to articulate how staff would know when to round on R1 or how to document said intervention. R1's care plan should have been developed/implemented to ensure R1 was wearing appropriate footwear and should have had increased supervision due to his impulsivity.The immediate jeopardy for R1 was removed on 7/28/25, at 2:02 p.m., when it was verified, the facility developed and implemented the following:-Reviewed falls policy and remained current -Completed comprehensive fall risk assessments on all residents, reviewed/revised/implemented care plan with appropriate interventions.-Identified like residents who were at high risk for falls with falls since 5/23/25 and reviewed/revised care plans with appropriate fall interventions in place.-All staff were provided education on the fall program policy, comprehensive fall assessments, root cause analysis and ensuring fall prevention interventions are care planned and implemented as it pertained to their scope of practice. R2R2's admission Evaluation dated 5/2/25, identified R2 required limited assist of one staff for transfers, bed mobility, toileting and personal hygiene. Level of consciousness not assessed. R2 was continent of bladder and on diuretics. Balance identified R2 was impulsive and had poor safety awareness. Fall history of one to two falls within the last 30 days. Agitated behavior that occurred less than daily in the last seven days. R2 was at risk for falls. Care plan portion identified goals to minimize risk for falls and injury related to falls. Interventions included bed in low position and encourage to transfer and change positions slowly.R2's care plan identified a focus dated 5/2/25, at risk for falls related to right sided hemiplegia (paralysis on one side of the body) and right sided hemiparesis (weakness on one side of the body) secondary to a cerebral vascular infarction (stroke). Interventions dated 5/2/25, was to encourage to transfer and change positions slowly. On 5/9/25, included to have commonly used articles within easy reach, therapy eval and treat as ordered and use wheelchair for independent locomotion and walker with gait belt and assist of one for ambulation.R2's admission MDS dated [DATE], identified R2 had severely impaired cognition, diagnoses of ischemic stroke with hemiplegia affecting right dominant side, dysarthria-(a motor speech disorder that makes it difficult to speak clearly due to impaired muscle control in the face, mouth, or respiratory system that can impact articulation, voice quality, and speech rhythm), diabetic neuropathy-(nerve damage caused by diabetes, often leading to numbness, tingling, and pain in the extremities, particularly the hands and feet), osteoarthritis of right knee, pain in right shoulder and right foot, and urinary retention. R2 required partial to moderate assist with hygiene and transfers and required substantial to maximal assist with dressing and donning and doffing footwear. In addition, R2 had a fall within the last 30 days prior to admission.R2's CAA dated 5/9/25, identified Falls as an actual problem. No falls noted since admission. Care plan considerations identified R2 had alteration in mobility with risk for falls following hospital stay for pneumonia, underlying hemiplegia, diabetes mellitus (DM), acute kidney injury (AKI), chronic kidney disease (CKD), right foot pain, and medications that could affect his overall mobility status. R2 continues to work with PT/OT for rehab. Currently needs assist with completing ADL's, toileting, and mobility tasks. Lived with family with plan to return back to that living situation, pain management continues to be ongoing, noted to have right foot and shoulder pain. Staff will continue with ongoing assistance. Interventions remain ongoing per care plan to assist with preventing any future falls.R2's Unwitnessed Fall document dated 5/11/25 at 1:00 p.m., identified R2 was found sitting between the leg rests of the wheelchair. R2's shoe Velcro was caught in leg rest. R2 stated, he was trying to go to the bathroom. R2 denied hitting his head. Further identified R2 had improper footwear and was transferring self. The form was not completed; did not address mental status, predisposing environmental and physiological factors. Corresponding Post Fall assessment dated [DATE] at 1:00 p.m., identified R2 did not have a fall history, indicated R2 was last seen at 3:00 p.m., by registered nurse (RN)-B. Further identified R2 was going to the bathroom at the time of the fall and that R2 had unsteady gait. Mental status prior to the fall and after the fall identified that R2 was confused some of the time. Care plan portion identified the new immediate intervention was to ensure the call light was within reach, however review of R1's care plan revealed the care plan was not updated.R2's progress note dated 5/11/25 at 3:11 p.m., identified R2 was found sitting between the leg rest of the wheelchair, R2's shoe Velcro was caught in leg rest. R2 stated he was trying to go to the bathroom and denied hitting head.R2's IDT Clinical Review progress note dated 5/12/25 at 9:41 a.m., identified root cause of R2's fall was to catch Velcro on the wheelchair. Intervention was to make sure Velcro was trimmed and remove the foot pedals.In review of R2's 5/11/25 fall record identified no indication a comprehensive fall analysis had been completed to determine appropriate individualized interventions were developed and implemented. Further, even though the fall record identified R2 fell trying to get to the bathroom, R2's care plan did not include a toileting schedule when R1 required assist of one staff with toileting.R2's Unwitnessed Fall document dated 6/4/25 at 3:10 p.m., identified activity manager reported that R2 was on the floor. Was trying to get up and his wheelchair wheels did not lock. Upon assessment writer found R2 lying on his back on the floor, denied hitting head. R2 did not sustain any injuries from the fall, DON on duty notified along with family. R2's progress note dated 6/4/25 at 3:56 p.m., identified that activity manager reported that R2 was on the floor, upon assessment writer found R2 lying on his back on the floor, denied hitting head. R2 did not sustain any injuries from the fall. Although R2's care plan was updated on 6/6/25, to have R2 evaluated by therapy as needed to assist for safe transfers and walking. Review of R2's OT and PT notes identified he had been receiving both therapy services since 5/5/25. In review of R2's 6/4/25 fall documentation revealed no indication of IDT involvement. Further the records did not include a comprehensive analysis to determine modifiable and non-modifiable risk factors so that individualized interventions could be developed and implemented to prevent and/or mitigate R2's risk of re-current falls. R2's quarterly MDS dated [DATE], identified R2 had severely impaired cognition, required limited assist with bed mobility, transfers and toileting and had two or more falls without injury.R2's Unwitnessed Fall document dated 6/9/25 at 4:50 p.m., identified an aide found R2 sitting on the floor next to his bed and stated, I was trying to clean the floor. R2 denied hitting head and pain form falling. R2 was alert and oriented to the event. DON and family notified. Document was not completed- lacked predisposing physiological factors. Corresponding Post Fall assessment dated [DATE] at 4:50 p.m., identified the aforementioned information and included the following additional information; R2 had one to two falls in the last 30 days but lacked dates and times of falls; safety check (record does not address why R2 was on 15-minute checks) was provided 15 minutes prior to the fall at 4:20 p.m. he was sitting in his wheelchair but did not identify when he was last assisted. R2 had a behaviors that occurred daily or more: wandering, verbally abusive, physically abusive, calls out, socially inappropriate, noisy, screams, disrobes, self-abusive, rummages hoards etc.Identified R2 had call light within reach and bed locked. Care plan portion identified R2 was educated to call for help before getting up, R2 was on 15-minute safety checks by writer to prevent falling. Writer an aide needs to check on resident. Care plan was not updated. R2's progress note dated 6/9/25 at 5:31 p.m., identified aide found R2 sitting on the floor in room.R2's IDT Clinical Review progress note dated 6/10/25 at 12:30 p.m., identified root cause of fall was R2 continued to walk with wheelchair, prevention intervention was to educate R2 on need not to use wheelchair as a walker.In review of R2's 6/9/25 fall record there was no indication of a comprehensive fall analysis that identified root cause, and the care plan was not updated to reflect the15-minute checks. During an interview on 7/28/25 at 11:10 a.m., nursing assistant (NA)-B stated she was the aide responsible for R2. R2 did walk but he was very unsteady and did try and get up frequently. NA-B thought he was independent with toileting and ADLs and was unaware he had falls. NA-B indicated R2 was incontinent at times and stated she would look at the Kardex to determine how often to offer toileting or any safety checks. During an interview on 7/23/25 at 3:35 p.m., NM-A stated after reviewing falls on 5/11/25, 6/4/25, and 6/9/25, they were not comprehensively assessed to determine if R2's basic needs were met as he needed staff assist with ADLs. R2's fall on 5/11/25, should have addressed his toileting routine/needs but it did not. The fall on 6/4/25, should have addressed his wheelchair brakes and it did not. The fall on 6/9/25, was not root caused and the intervention to the care plan was not updated until 6/24/25. During an interview on 7/24/25 at 3:18 p.m., DON indicated R2's falls on 5/11/25, 6/4/25, and 6/9/25 were not comprehensively assessed and interventions were not always implemented or related to the root cause. DON stated R2's fall on 5/11/25 had to do with toileting, R2 has incontinence, and the care plan should have addressed that. In relation to the fall that occurred on 6/9/25, she was unaware the unaware the nurse had him on 15-minute checks or why, the fall should have been comprehensively assessed to determine if his basic needs were met so we could figure out a more appropriate fall preventions intervention.R3R3's admission Evaluation dated 6/2/25 at 12:00 p.m., identified that R3 required extensive assist of one staff with bed mobility, transfers and toileting. R3 was alert to person, place and time, had bladder incontinence one to two times daily during the day and evening once or more a shift and had difficulty initiating urine flow. R3 had a history of falls: one to two falls in the last 30 days, last two months and last six months. R3 was at risk for falls with a goal to minimize the risk for falls. No fall interventions identified.R3's care plan identified a focus date 6/2/25, at risk for falls due to: Parkinsonism, dementia with cognitive losses, restless leg syndrome, bladder incontinence, constipation, decline in mobility status. In

Based on interview and document review the facility failed to comprehensively assess and monitor for a change in condition after a fall with a head strike for 1 of 1 residents (R1) who had a history of significant bleeding disorder. This resulted in delay of diagnoses and treatment for a subdural hemorrhage (brain bleed) and left hip contusion. The facility's failures resulted in actual harm for R1. Findings include: R1's hospital discharge summary dated 10/26/23, identified R1 had been admitted to the hospital on 10/16/23, with chief complaint of generalized weakness and acute blood loss anemia. R1 had a history of acquired platelet dysfunction with multiple bleeding events leading to frequent hospitalization . R1 was discharged from the hospital to the facility in stable condition on 10/26/23. R1's Face Sheet identified R1 had diagnoses of myelodysplastic syndrome (a group of cancers in which immature blood cells in the bone marrow do not mature or become healthy blood cells,) thrombocytopenia (a condition that occurs when the platelet count in your blood is too low,) and muscle weakness. R1's activities of daily living care plan, dated 10/27/23, identified R1 required assist of one with toileting, transfers, and ambulation with a device. R1's care plan did not identify R1 had a bleeding disorder. R1's occupational therapy (OT) progress note dated 10/26/23, indicated R1's cognition was independent for decision making ability for routine activities and did not have any barriers likely to impact discharge. R1's OT progress note dated 10/27/23, indicated R1 sat on the edge of the bed unsupported with no loss of balance. R1 took off and put on upper extremity clothing with set-up and completed personal hygiene with moderate assist to wash his back. Completed transfer from bed to wheelchair with stand by assist. R1's OT progress note dated 10/30/23, indicated R1 was completing dressing task when OT entered the room and set-up assist. Physical therapy completed sit to stand, stand by assist and was ambulating R1 to the bathroom when he had a loss of balance and fell . Therapist had stepped away to grab a comb. R1 did hit his head and nursing was notified. Vitals were taken and all within normal limits. R1 stated slight pain in his head. R1 was assisted off the floor by two staff and R1 asked to walk with therapy; he walked in the hall 150 feet with no rest break. R1 then asked to lay down versus sit in his wheelchair. R1's Post Event Observation dated 10/30/23, identified R1 had a witnessed fall at 2:12 p.m. Vital signs post fall included blood pressure 113/50, heart rate 97, respirations 16, and temperature 98.2. R1's Neurological Check List dated 10/30/23 at 2:12 p.m. only included vital signs that had been obtained prior to the fall at 1:53 p.m. Sections of the checklist with no documentation recorded included Orientation, Level of Consciousness, Responses (to simple commands/verbalizes appropriately), Pain, and Extremities (movement and sensation) R1's progress note dated 10/30/23, at 11:42 p.m. indicated Situation, Background, Assessment, Recommendations, Response (SBAR)-Change of Condition=Situation; certified nursing assistant (CNA) reported that resident fall while walking in room with therapy, Background; [AGE] year-old with acute cystitis hematuria and chronic kidney disease stage 3A. Assessment/Appearance; Resident did not have an injury. Therapy stated, resident walking to the bathroom and fell . Resident is alert and oriented. Assessment: Blank, Recommendations: FYI [for your information], Response: Blank. R1's OT progress note dated 10/31/23, indicated R1 declined to get out of bed due to soreness from previous days fall. Bruising on left hip from where he landed during the fall. Vitals taken were blood pressure 123/57 and heart rate 98; nursing was notified. R1 was transferred from bed to wheelchair with walker and stand-by assist. R1 was observed with heavier breathing. Oxygen on RA [room air] 92-94%. In review of R1's medical record between 10/30/23 through 11/1/23, it was not evident bruising was monitored for worsening nor evident neurological assessments were completed to ensure R1 did not have symptoms of a brain bleed as a result of hitting his head. Additionally, not evident a respiratory assessment was completed after OT identified R1 had heavier breathing. R1's medication and treatment administration records (MAR/TAR) between 10/30/23 through 11/1/23, indicated every shift R1 had a 0/10 pain rating even though OT records identified R1 had soreness. R1's hospital emergency room records dated 11/1/23, indicated R1 presented to the ED for evaluation after a fall at skilled nursing facility (SNF). R1 described he was actively participating in physical therapy 2 days ago when he subsequently fell backwards and hit the left side of his head on a bed rail and landed on his left hip. Physical exams identified R1 had small hematoma over left parietal region of his head and tenderness to palpation of left lateral hip with small amount of ecchymosis (bruising). After the fall, R1 did not have loss of consciousness, numbness, tingling, focal weakness, or was incontinent. Associated symptoms include slight headache, while denying any fever, chills, vision changes neck pain, shortness of breath, chest pain, nausea, emesis, abdominal pain, or other complaints. R1 complained of left hip pain that had been constant and worsening since the fall; currently rating pain 7/10, with sharp aching quality while denying radiation. Computed Tomography (CT) (imaging test helps detect internal injuries and disease by providing cross-sectional images of bones, blood vessels and soft tissues.) of head, spine, left hip/pelvis x-ray, and labs were ordered. The CT scan identified a thin hyperdense subdural hemorrhage (brain bleed) measuring 2 millimeters that was not present on 12/17/22. CT of the hip identified reticulated soft tissue stranding left gluteal region, increased from 10/16/23 CT, comparable with soft tissue contusion. Labs identified R1's hemoglobin was 6.9 down from 8.0 (normal values for men 13.2 to 18.0) blood work remarkable for acute anemia down from 8. Given slight lightheadedness, headache, he will need [blood] transfusion. Given hip pain and fall, patient could have hematoma, but no obvious sign on examination. During an interview on 11/8/23, at 1:33 p.m. R1 stated he was working with the therapist on 10/30/23, when he was walking to the bathroom, had lost his balance and fell , hitting his head and landing on his left hip. R1 stated the nurse and therapist helped him up off the floor and took his vital signs. R1 stated he had quite a bit of bruising and lump on his head. R1 explained the day after the fall when he was working with therapy he knew his hemoglobin dropped because he could not breath when he stood up and told the therapist he could not breath. He laid in bed most of the day because he was too sore. R1 had been told by his previous doctor that if he ever had a fall, he needed to be seen right away because of his bleeding disorder. R1 stated he became afraid because he had a bleeding problem with a history of blood clots, he could not use his right light leg because of hematoma. He kept checking his own left leg to make sure it would move. R1 stated no staff ever came to check on him. The nurses had told him he wasn't bleeding so he was okay. R1 indicated he had requested to see the doctor, but it wasn't until three days later when he and a family member insisted on seeing a doctor. He was told by the facility staff the best way to do that was to go to the hospital. R1 had the facility call the non-emergent number and went to the emergency room (ER.) R1 stated he was very scared and felt unsafe at the facility and refused to return. During an interview on 11/8/23, at 10:53 a.m. occupational therapist registered and licensed (OTR/L) stated she worked with R1 on 10/30/23 the day of the fall. R1 had been walking beside OTR/L to assist him to the bathroom when R1's family member asked for a comb. OTR/L stated she stepped aside to get the comb when R1 lost his balance and fell backwards and hit his head and left hip. OTR/L indicated nursing came into the room with vital sign machine, R1 complained there was slight pain in the back of his head but nowhere else, so he was assisted by two staff to his chair. R1 was upset and wanted to continue to walk with therapy, so we completed a sit to stand transfer with contact guard assist and walked 150 feet with no rest breaks. After the walk he wanted to go to bed. Nurses had not completed any neurochecks while OTR/L was with him. On 10/31/23, OTR/L saw R1 via telehealth, he did not want to get out of bed. R1 had left hip bruising and had observed heavier breathing, however oxygen saturations were within normal limits. The nurse came into the room to get vital signs at which point R1 complained of soreness but was agreeable to complete exercises in bed. During an interview on 11/8/23 at 3:19 p.m. nursing assistant (NA)-A indicated she worked the overnight shift on 10/30/23. NA-A indicated she was not there when R1 fell , however was aware R1 had a fallen. NA-A indicated R1 had been pretty independent with activities of daily living. At the start of her shift he was in bed with his clothes still on. On her rounds she had asked R1 if she could help him get cleaned up and put pajamas on, however, R1 refused and told her he was good and remained in bed. During an interview on 11/8/23, at 4:26 p.m. licensed practical nurse (LPN)-A stated he was working on the day of R1's fall. LPN-A stated the therapist informed him of R1's fall in the room. LPN-A stated he and registered nurse (RN)-B helped R1 up at the end of his shift. R1 complained that his butt was hurting but pointed to the back of his head. R1 was alert and talking to staff the whole time. LPN-A stated he had not completed any assessments after R1 fell because it was the end of his shift and a RN had just started their shift. LPN-A thought RN-B had completed the neurological assessment. LPN-A did not identify R1 had a history of a bleeding disorder. LPN-A explained when someone falls and hits their head neurological status is supposed to be checked every 15 minutes for an hour then hourly for 4 hours, then every 4 hours-4 times, then every shift for total assessment period of 72 hours. The physician was also supposed to be notified by fax, but that recently changed to actually talk to the doctor During an interview on 11/8/23 at 2:39 p.m., registered nurse (RN)-B stated she worked the evening shift the day R1 fell from 2:00 p.m. to 10:30 p.m. and was not present at the time of R1's fall. R1 had told RN-B that he had a fall. RN-B stated she took R1's vital signs later in the shift and filled out the fall incident report. RN-B did not identify R1 had a history of a bleeding disorder. RN-B indicated R1 had not asked to see a doctor, voice concerns about bleeding, and he did not have complaints of pain. R1 only got up once during her shift to use the bathroom. RN-B indicated she had not completed monitoring or assessments for bleeding related to R1's history nor completed neurological checks, and did not inform the doctor of R1's fall. During an interview on 11/8/23 at 3:47 p.m., regional director of nursing (RDON) stated she was made aware of R1's fall on Wednesday 11/1/23. RDON stated on Thursday, 11/2/23 she looked in R1's medical records and found no fall assessment or after fall monitoring had been completed. R1 had not been on blood thinners and the bleeding disorder had not been identified in the care plan because he was a new resident. The facility's policy directs if a resident is on blood thinners, it is reflected in the care plan with interventions to monitor for bleeding. R1's hospital discharge summary did not direct R1 to be sent to the hospital immediately if there was a fall as R1 stated. RDON stated the expectation would be for a nurse to do a full body exam to check for injuries, complete range of motion, and do neuro checks because R1 hit his head. Everything should have been documented. RDOM stated the physician should be notified after all falls per the facility policy. During an interview on 11/8/23, at 3:27 p.m. nurse practitioner (NP) stated she was not notified of R1's fall and had not seen him during his stay at the facility. NP stated the facility is supposed to notify her of all resident falls. NP stated if she had known R1 had fallen and hit his head she would have wanted him sent to the hospital right away. During an interview on 11/8/23, at 4:40 p.m. medical director (MD) stated he was not aware of R1's fall in the facility. MD stated the NP is the primary medical provider in the facility and the facility should be notifying them timely of all falls. MD stated the facility nurse should be completing a total body assessment and doing a basic neurological exam with on-going monitoring if a resident hit his head. MD stated facility protocols and policies should be followed. Facility policy titled Change in Condition of the Resident, revised 9/20/22, identified the facility's policy was to inform the resident; consult with the resident's physician; and notify resident representatives when there is an accident involving the resident which results in injury and has the potential for requiring physician interventions. When a resident has a possible change of condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: the direction given is to 1. Assess the resident's need for immediate care/ medical attention. Provide emergency care as needed. 2. Assess/evaluate the resident by the following and a long list of descriptions are given. Documentation to include description of the change in condition noted and assessments or observations of findings, emergency care provided, notification of the provider, notification of responsible party and names and titles of employees involved with resident's care at that time.

Based on observation, interview, and document review the facility failed to ensure accuracy of comprehensive skin assessments and failed to follow physician orders for pressure ulcer management and treatment for 2 of 3 residents (R1 and R3). The facility's failures resulted in actual harm for R1 when ongoing wound mismanagement caused closed sacral surgical incision to deteriorate back to open stage 4 pressure ulcer, infection, and discontinuation of wound vac management. Findings include: Negative Pressure Wound Therapy (NWPT) also known as a wound vac helps to heal wounds by providing a moist environment, promote new tissue formation, and removing excess fluid and infection. The negative pressure or vacuum suction is provided by a pump that is connect to your wound. A foam dressing is placed in the wound and covered with an occlusive dressing. The fluid that is removed is collected in a canister on the pump. Stage 4 PU: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. R1's face sheet identified R1 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis of vertebra sacral and sacrococcygeal region (a rare spine infection that's often caused by bacteria), bone density disorder of multiple sites, and pressure ulcer of sacral region stage 4. A vulnerable adult maltreatment report submitted to the state agency (SA) on 7/12/23 at 5:18 p.m., indicated the facility incorrectly followed wound care orders which caused worsening of R1's stage 4 sacral (a bone located at the base of your spine) ulcer and an additional wound from the misplacement of the wound vac dressing. A second vulnerable adult maltreatment report submitted to the SA on 7/13/23 at 6:48 p.m., noted concerns regarding the facilities' ability to manage R1's stage 4 sacral ulcer and wound vac stating concerns of wound vac dressing not being changed after being placed on 6/28/23 till removed at the wound clinic on 7/12/23. R1's admission Minimum Data Set (MDS) dated [DATE], indicated staff assessed R1 to have moderate cognitive impairment; R1's activities of daily living assessment identified R1 required extensive assistance with bed mobility, transferring, dressing, toileting, personal hygiene and locomotion. R1 was occasionally incontinent of bladder and always continent of bowel. R1 was a risk for pressure ulcers and had a stage 4 pressure ulcer that indicated would be addressed in the care plan. R1's care plan dated 4/19/23, identified R1 had osteomyelitis of vertebra, sacral and sacrococcygeal region, interventions included administer medications as ordered, encourage resident to use good clean hygiene techniques to avoid cross contamination. Monitor for side effects from antibiotic therapy and report to physician if present. Monitor lab work as ordered and report results to physician. Additionally, the care plan identified R1 had stage 4 pressure area. Interventions included, report evidence of infection to MD as needed dated (dated 4/19/23) follow treatments per MD orders (dated 4/19/23), Obtain labs as ordered (dated 4/30/23), Specialty air mattress (dated 4/19/23 revised on 7/14/23), use pillows and or repositioning devices as needed (dated 4/30/23). R1's Weekly Pressure Injury Daily Trackers were reviewed in conjunction with the wound clinic's evaluations. The record identified facility skin assessments that had not been consistent with the wound clinic's assessment of the wound status. R1's medical record lacked a comprehensive skin assessment of the sacral incision upon admission on 4/19/23. R1's wound clinic office visit summary dated 4/26/23, identified R1's wound as a sacral incision with Prolene sutures (non-absorbable, sterile surgical sutures.) The sutures and wound was intact and incisional line was nonblanching (discoloration of the skin that does not turn white when pressed) periwound erythema (superficial skin redness), slough (a specific type of nonviable tissue that occurs as a byproduct of the inflammatory process) midline, no dehiscence (when a closed incision re-opens). R1's wound clinic office visit summary dated 5/2/23, identified R1's wound as sacral incision with Prolene sutures that were intact with minimal nonblanching periwound erythema, slough midline, no dehiscence, right gluteal Jackson Pratt (JP) drain (a closed suction device, meaning that the fluids are collected within a closed system, without the need for an outside suction machine) with minimal serosanguinous (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells). R1's record did not include a wound assessment for the sacral incision until 5/9/23. The Weekly Pressure Injury Tracker dated 5/09/23, identified the sacral wound. R1 had a wound flap procedure over a stage 4 pressure ulcer prior to admission and was on 2 intravenous (IV) antibiotics. R1 was followed by the wound clinic with an appointment today (5/9/23) for remaining suture removal. The sacral wound measurements included length 4.2 centimeters (c.m.) x width 1.4 c.m. x depth 0.0 c.m. Surface area area was between 4.1 cm and 8.0 cm2. The assessment indicated R1 did not have pain, periwound was bright red and/or blaches to touch, no inflammation or signs of infection. Further indicated the flap of skin was in place, red/pink in color with a small open area near top left, no drainage and surrounding tissue looked healthy. The assessment indicated the wound as improving despite documentation that identified the wound had a small open area. R1's wound clinic office visit summary dated 5/09/23. indicated R1's wound as a pressure injury that was down to muscle with some granulation, slough, and fibrinous material with circumferential undermining present (presence of undermining was not identified on the facility wound evaluation). Proximal and distal sutures intact with central area of dehiscence, central tissue parameters with new pressure injury to flaps, infected. Pre debridement measurements Length 9.0 cm, width 3.0 cm, depth 2.3 cm total 27 cm ^2 Post debridement measurements Length 9.0 cm, width 3.0 cm, depth 2.5 cm total 27 cm^2 New orders given . -perform the following twice a day: 1)carefully remove all prior wraps dressings 2) rinse sacral wound with saline 3) 2 or 3 inch Kling wet with Dakin's 1/4 strength twice daily 4) barrier cream 5) if dressing becomes soiled, saturated, or displaced, please remove the dressing and replace as above. 100% nonweightbearing to the sacrum Significant deterioration noted today during wound visit from pressure and loose stools, tissue culture obtained and increase protein intake Return to wound clinic in 1-2 weeks-plan for negative pressure wound therapy. R1's Weekly Pressure Injury Tracker dated 5/16/23, indicated wound measurements of : Length 4.1 c.m. x width 1.7 c.m. x depth 20 c.m. Further identified no tunneling and wound was unchanged. R1's wound clinic visit note dated, 5/23/23, indicated R1 had incisional dehiscence after sitting in stool for prolonged periods of time which led to flap necrosis along the incision and dehiscence down to the muscle fascia, R1 reported her dressings were not being changed consistently to wound clinic orders. The visit note indicated the wound had worsened. Pre debridement measurements Length 4.5 cm, width 2.0 cm, depth 2.5 cm total 9.0 cm ^2 Post debridement measurements Length 4.5cm, width 2.0 cm, depth 2.8 cm total 9.0 cm^2 R1's wound clinic visit note dated, 5/30/23, indicated R1 had concerns about her wound care, stated when she uses the restroom packing falls out and is not reapplied correctly, resident stated she was not receiving the Dakin's gauze and is often not getting packing at all or barrier cream. Wound description included pressure injury to muscle increased granulation, increased slough, intact proximal and distal incision, left lateral flap with stable subcutaneous necrosis, infected. Wound culture was taken. Pre debridement measurements Length 3.2 cm, width 2 cm, depth 2.5 cm total 6.4 cm ^2 Post debridement measurements Length 3.2cm, width 2 cm, depth 2.8 cm total 6.4 cm^2 R1's Weekly Pressure Injury Tracker dated 5/30/23, measurements were consistent with the wound clinic.Identified wound was unchanged. Assessment did not identify the wound was necrotic nor that it was infected. R1's Weekly Pressure Injury Tracker dated 6/5/23, describes wound as Measurements: Length 4.0 c.m. x width 2.0 c.m. x depth 2.4 c.m. The assessment indicated the wound did not have tunneling, periwound tissue was normal, and wound progress was unchanged. R1's wound clinic visit note dated 6/6/23, indicated R1's wound had a polymicrobial infection (Pseudomonas and Enterococcus Faecalis-bacteriums) and new orders for Cipro and Augmentin (antibiotics) were given. Pressure wound down to muscle with increased granulation, decreased slough, intact proximal and distal incision, periwound dermatitis, tunneling at 5:00 approximately 6.2cm (tunneling not identified on facility assessment). Identified the wound was overall slightly improved. Pre debridement measurements Length 4.0 cm, width 2 cm, depth 2.4 cm total 8.0 cm ^2 Post debridement measurements Length 4.0 cm, width 2 cm, depth 2.8 cm total 8.0 cm^2 Dressing change orders were changed to twice daily, acetic acid soaked gauze ensure packing to undermining, and application of Calmoseptine to periwound skin followed by nystatin powder. R1's Weekly Pressure Injury Tracker dated 6/13/23 and 6/20/23, included measurements, indicated no undermining or tunneling, no signs/symptoms of infection, and wound was unchanged. R1's Weekly Pressure Injury Tracker dated 6/26/23, described wound as Measurements: Length 3.8 c.m. x width 2.0 c.m. x depth 1.8 c.m. No tunneling, no undermining, no inflammation or infection. Wound was improving. R1's wound clinic visit note dated, 6/28/23, indicated residents dressings continued to not be changed as ordered and wound was not being packed and was often being left uncovered. Resident continues to be interested in wound vac therapy when she can safely use. Wound described as pressure injury sacrum down to muscle, periwound dermatitis, tunneling at 5:00 approximately 4.4 cm, increased granulation tissue, resolved malodor (unpleasant smell), minimal slough, overall slight improvement. Pre debridement measurements Length 3.8. cm, width 2 cm, depth 1.7 cm total 7.6 cm ^2 Post debridement measurements Length 3.8 cm, width 2 cm, depth 1.8 cm total 7.6 cm^2 The visit note included new orders for wound vac dressing change for three times a week. R1's June's 2023 treatment administration record (TAR) identified between 6/1/23 through 6/6/23, documentation identified a chart code of '9' indicating the dressing was not completed or the box was left blank on 5 of 12 occurrences where the dressing was supposed to be changed. Documentation between 6/7/23 through 6/29/23 identified the acetic acid packing at 5 o'clock position was left blank or a chart code of '9', for 10 of 22 possible changes. Physician order for sacral wound treatments with a start date of 6/30/23 (end date 7/23/23) included the following: 1) Remove old dressing. Rinse all open ares with saline 2) Aceitc acid 0.25% 2 or 3 inch kling gauze allow to soak for 10-15 minutes (in wound) and then rinse with saline 3) Black foam negative pressure wound therpay system at 125 mmHg continuous making sure to avoid any pressure points to the sacrum (use bridge dressing. change dressing if it becomes spoiled, saturated, or displaced.) Every Monday, Wednesday, and Friday. R1's June and July 2023 TAR included the physician order for wound vac dressing changes to be completed on Monday, Wednesday, and Friday. The TAR indicated on 6/30/23, 7/3/23, 7/5/23, 7/7/23, and 7/10/23 the sacral dressing was supposed to be changed however a chart code of '9' was recorded which indicated the dressing was not completed and directed to see progress notes. The box for 7/12/23 was left blank. Corresponding progress did not identify reason why dressing was not changed. Additionally, R1's care plan was not revised to include wound vac therapy, and R1's record did not include ongoing monitoring for signs/symptoms of infection, amount of drainage, R1's tolerance or associated pain related to wound vac, wound improvement/deterioration, and wound vac function and efficacy. R1's Weekly Pressure Injury Tracker dated 7/03/23, indicated a wound assessment had been completed even though the TAR identified the dressing was not changed. The assessment identified wound measurements of: Length 4.0 c.m. x width 2.0 c.m. x depth 2.5 c.m. Tissue described as 100% granulation tissue, moderate serosanguinous drainage, no tunneling or undermining, and no inflammation or infection. Wound was improving. R1's wound clinic visit note dated, 7/12/23, indicated when resident presented, she stated wound VAC had been left on from June 29th till July 6th. Patient also requested that the VAC be removed as it was painful and uncomfortable and stated she had requested it to be removed at the facility had not been acknowledged. Wound VAC was noted to be on healthy skin and not in the correct location or incorporating the wound. Resident indicated she was in much more discomfort than she had in the past even after undergoing surgery. Wound description: pressure injury sacrum down to muscle, new area of tissue breakdown to fat layer at 2:00 circumferential to periwound dermatitis, increased wound bed slough, malodor, deteriorated. Pre debridement measurements Length 3.2. cm, width 3.5 cm, depth 2.0 cm total 11.2 cm ^2 Post debridement measurements Length 3.2 cm, width 3.5 cm, depth 2.4 cm total 11.2 cm^2 Assessment/Plan: New wound orders obtained without wound VAC, R1 indicated significant wound care concerns and wound care orders not being followed. The current wound is a result of a surgical wound dehiscence that was healing postoperatively and resulted after patient was sitting in her own stool for hours. The wound VAC had been left on too long and resulted in significant wound deterioration. R1's Weekly Pressure Injury Tracker dated 7/13/23, described wound as Measurements: Length 3.5 c.m. x width 2.8 c.m. x depth 2.5 c.m. no tunneling or undermining, peri-wound skin is bright red and irritated about 1cm wide in circumferential redness/irritation. Resident describes pain and stated area has felt sore for a couple days. Wound is worsening. During an observation on 7/18/23, at 11:01 a.m. licensed practical nurse (LPN)-A entered R1's room to complete the coccyx dressing change. LPN-A obtained two towels, applied soap and water to one and left the other one dry. As she carried the towels over to R1, she dropped the dry towel on the floor twice and picked it back up. LPN-A then cleaned the wound with the soapy towel then used the towel that had been on the floor to dry the wound. LPN-A packed the gauze into the wound. LPN-A stated she had soaked the gauze in acetic acid before it was packed. During an interview on 7/17/23 at 4:41 p.m. R1 indicated she had admitted to the facility with a wound. During her weekly wound clinic appointments she had been informed the wound was not healing the way it should be and the dressing did not appear to be getting done correctly. R1 explained at the beginning of wound there had been discussion about a wound vac but had to wait until the infection in the wound cleared up. The wound vac was put on 6/29/23. R1 indicated after the wound vac was put on she had asked multiple nurses when it was supposed to be changed. Nobody was changing it, the nurses would put tape over it. Finally on July 9th R1 recalled the machine was beeping, one of the nurses came in, and applied tape over the dressing. The nurse did eventually change the dressing after I had informed her, I was seeing the wound doctor on 7/12/23. She had waited 11 days for the dressing to be changed. On 7/12/23, the wound clinic took it off and could tell the facility hadn't been changing it. During an interview on 7/18/23, at 10:41 a.m. LPN-A stated she had put on R1's wound vac but was unable to recall the date she had done so. LPN-A explained she was not comfortable with wound vacs because she had not had any training. LPN-A stated she did not tell anyone she was not competent or asked anyone questions. LPN-A stated she was going to change it one time but R1 had told her someone had changed it on the previous night. LPN-A documented R1 refused without further verifying with the record and/ or other nurses. During an interview on 7/18/23, at 12:49 registered nurse (RN)-B stated she had worked with R1 and thought she was reliable historian. RN-B stated she had not ever completed a wound vac change in the facility and stated R1 had told her the wound vac changes were being completed in the wound clinic. RN-B had not changed a wound vac since 2005 or 2006, had not had any wound vac education since, and would not feel comfortable changing it. RN-B stated if a 9 was marked on the TAR that meant the order/task was not completed; nurses were supposed to write a progress note explaining why it was not done. During an interview on 7/18/23 at 12:59 p.m. RN-A stated she had not taken care of R1's wound vac. RN-A reported she had worked for the facility for several years and never received any training related to wound vac dressings or cares. During an interview on 7/18/23 at 1:54 p.m. with clinical manager (CM)-A stated R1 is alert and oriented but can occasionally be forgetful. CM-A had not completed R1's dressing changes. CM-A indicated the findings of the facility's investigation identified floor nurses admitted to not changing R1's wound vac. CM-A explained no training on wound vacs had been offered at the facility and it was her belief the reason why it was not completed by nurses. During an interview on 7/18/23, at 1:24 p.m. wound clinic wound nurse (WN) stated, she had been following R1 since 4/26/23 after her surgery. WN stated R1 had sutures and a JP drain The plan was to keep pressure off the wound and bacitracin on suture line and Xeroform and Mepilex around the tube of the drain to prevent further injury. The wound clinic was monitoring it weekly. The end of April, beginning of May we had not seen R1, when we did see her the wound started opening and by 5/23/23, it had completely opened. We felt the biggest issues were that the dressings were not being done as ordered. The wound continued to worsen, and she ended up with another infection which caused the wound vac treatments to be pushed back. The wound vac was supposed to be started on 6/28/23. We did not receive any calls or questions at the wound clinic from the facility. When WN saw R1 on 7/12/23, the wound vac had been placed incorrectly and the wound appeared worse. The facility was contacted, and the orders were changed back to stop the wound vac because of the infection and improper placement. R1 had told us the facility had not changed the dressing since 6/29/23. During an interview on 7/18/2023 at 8:33 a.m. wound clinic doctor (MD)-A stated every visit R1 came in there were issues. R1 had reported to the wound clinic staff there were times she would sit in stool for hours before getting help. Her wound opened up. We found the facility was not completing the dressings as ordered. When R1 came into the clinic with the vac on, R1 reported the facility was not changing the vac dressing; we found the dressing had been applied wrong. The facility had put the sponge on normal viable skin which created a bigger problem of a new wound and no granulation tissue, the wound had deteriorated and became bigger. MD-A explained if a wound vac dressing was left on too long, it could cause infection, which happened to R1. We had to resect to the bone and put R1 back on antibiotics. MD-A further explained since the facility could not follow the basic dressings orders, it was decided to stop the wound vac. MD-A stated the wound should be healed already. MD reported no staff at the facility informed the clinic they didn't know how to manage the wound vac or called with questions. R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had moderate cognitive impairment; R3's activities of daily living assessment identified R3 required extensive assistance of two people with bed mobility, transferring, dressing, toileting, personal hygiene needed one person physical assistance and locomotion was supervision of one person. Walking had not occurred during assessment period. R3 was frequently incontinent of bladder and bowel. R3 was a risk for pressure ulcers and had a stage 2 pressure ulcer. R3's care plan dated 3/20/23, indicated, R3 had diagnoses that included, diabetes mellitus, diabetic neuropathy, and pressure ulcer stage 2. R3's skin care plan identified R3 had diabetic ulcers to toes left foot and pressure ulcer to ankle. Interventions included enhanced barrier precautions related to wound care (dated 11/22/22), Inspect skin during cares for redness, open areas and report (revised 7/5/22) and Treatments as ordered monitor for effectiveness. R3's physician orders signed included: Left malleolus (ankle) Cleanse ulcer base with normal saline or wound cleanser. Pat dry and then cover with gauze and secure in place with Kerlix.Change daily and as needed (ordered 6/2/23, started 6/3/23) Avoid wearing shoe until left malleous (ankle) is completely healed, document refusals every shift (11/2/22) During an observation on 7/17/23 at 12:23 p.m. R3 had a sign on his door that directed R3 required contact precautions (personal protective equipment). R3 had both shoes on his feet even though physician order directed to keep the left shoe off. R3 stated his dressings were not being done daily; R3's ankle dressing was not dated to show how long the dressing had been on. Nurse practitioner (NP) was prepping for R3's left ankle dressing change, NP did not have a gown on in accordance with the sign on R3's door. NP stated R3 was not supposed to have his left shoe on, it was supposed to be off till his wounds were completely healed. NP removed left ankle dressing with gloves on, then cleaned the wound without changing her gloves. After NP cleaned the wound she removed gloves and she washed her hands and put on new gloves. The NP applied Xeroform gauze over the wound, which was not consistent with the physician order dated 6/2/23. NP explained she had previously wrote the dressing change order directing Xeroform usage and was not sure when the order was changed that excluded the Xeroform. Physician order for left ankle with start date of 7/18/23, included xeroform cut to fit wound bed cover with soft gauze and secure with kerlix change daily and as needed (PRN) every day shift. During an observation on 7/18/23 at 9:33a.m. LPN-A was completing a dressing change on R3. LPN-A had gown and gloves on. LPN-A wet a towel and wash cloth in the bathroom. While walking back to R3 from the bathroom a towel dropped on the floor. LPN-A cleaned the wound and dried it with the towel that had dropped on the floor. LPN applied barrier cream to foot with same gloved hands and removed soiled gloves, washed hands and put on clean gloves. LPN-A cut the Xeroform and applied it to the whole malleolus going outside the wound edges (instead of fitting to wound bed according to physcian orders) and applied Mepilex. During an interview on 7/18/23, at 2:10 p.m. Regional Registered Nurse Consultant (RNC) stated she was notified on 7/13/23 with a call of concern from the wound clinic. The wound clinic stated the wound vac had only been changed once since 6/29/23 by LPN-A and LPN-B. RNC stated she had interviewed the nurses and LPN-A and LPN-C had indicated when they read the wound vac order they thought the dressing was only to be changed on Monday, Wednesday, and Friday if the dressing was soiled and needed to be changed. They both also mentioned they had not been comfortable changing a wound vac. RNC stated she had since checked all orders to make sure they have clear timelines and had separated PRN orders from scheduled orders. RNC stated training had been initiated on 7/13/23 and continued 7/14/23. Wound vac dressings and complicated dressings have been suspended until nurses can be trained. RNC also stated she had also talked to the floor nurse managers about holding floor nurses accountable for missed treatments and now missed treatments are now showing up first during the daily record reviews. Facility policy, Clean Dressing Change, Dated 7/20/22, indicated, the policy of the facility to provide wound care in a manor to decrease potential for infection and or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, interview, and document review, the facility failed to prevent pressure ulcers development or deterioration and promote healing by failing to follow physician ordered treatments, follow the care plan, and ensure comprehensive assessments and monitoring for 2 of 4 residents (R1 and R3) reviewed for pressure ulcers. The facility's failures resulted in actual harm for 2 of 4 residents (R1, R3) when new ulcers developed and/or worsened. The deficient practice has the potential to effect all residents in the facility that are at risk for pressure ulcers. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. The appearance will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin with a localized area of non-blanchable [CONDITION(S)] (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3 Pressure Ulcer: Full-thickness of the skin may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) are often present. At this stage, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface. R1's hospital discharge summary dated 3/1/22, indicated R1 had new [CONDITION(S)] in gluteal cleft associated with incontinence that developed on 2/18/22. R1's admission record identified an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderately impaired cognition, no behaviors or rejection of care, required supervision with eating, and extensive two-person assistance with all other activities of daily living (ADL's) and used a wheelchair for mobility. MDS identified R1 was frequently incontinent of bowel and bladder. The MDS also identified R1 was at risk for pressure ulcers and did not have pressure ulcers or other impaired skin integrity (the MDS did not identify R1's impaired skin integrity according to the record); associated interventions included pressure reducing device for chair and bed, application of nonsurgical dressings other than to feet, and applications of ointments/medications other than to feet. R1's admission physician note dated 3/4/22, indicated R1 was negative for any skin integrity conditions including wounds. On 3/10/22, physician note indicated R1 was negative for wounds R1's care plan dated 3/10/22, indicated urinary incontinence and bowel related to impaired mobility and will be free from skin breakdown and be maintained in as clean and dry, dignified state as possible. Care plan indicated R1 had actual skin integrity break and/or pressure sore(s) - see wound assessment pressure sore, skin tear - bilateral legs, elbows, underlying PVD, upper extremity fractures, and [CONDITION(S)]. On 3/23/22, revised interventions included: -Assess and measure all skin integrity areas per policy. -Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote health, and prevent complications. -Initiate skin monitoring forms per facility policy. -Initiate treatment per physician order. -Monitor and report any new open areas, draining, increased drainage or pain to nurse immediately. -Provide treatment to wound(s) per current treatment order. Assess wound(s) for signs and symptoms (s/s) of infection with each dressing change/treatment. Report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately. -Report wound progress or decline to medical doctor (MD) with any changes or lack of response to treatment per facility guidelines. R1's record was reviewed between 3/1/22 to 5/31/22. The record identified R1 was admitted to the facility with moisture associated skin damage and within two weeks of admission developed a stage 2 PU that continued to deteriorate to a stage 3. R1's record identified the physician had been following R1's wounds after notification and provided new treatment orders as the wound changed. However, in review of R1's treatment administration record and interviews, the treatments were not always completed per physician orders. The record also identified the facility was not completing comprehensive weekly skin assessments that would identify or determine potential causal factors and modifiable risk factors for appropriate care plan interventions that would reduce the risk of worsening and/or new pressure ulcer development. R1's progress note dated 3/6/22, indicated R1 had developed pressure areas on his coccyx and elbow. R1's record lacked a comprehensive assessment and physician notification. R1's progress note dated 3/9/22, indicated R1 now had a red open area on his coccyx and the physician was notified. A Non-pressure Weekly Tracker form was completed on 3/10/22, with wound measurements and description which included open area on sacrum which was pink and blanchable. The center has an open area that measures 1.4 cm x 1.1 cm x 0.1 cm. Skin is pink, no drainage, no odor, and no tunneling or undermining. R1's record lacked a comprehensive assessment for causal factors. R1's physician visit dated 3/15/22, identified open area at sacrum measuring 1.4 centimeters (cm) x 1.1 cm x 0.1 cm. Skin around area is pink. Wound continued to heal with pink skin area, no worsening open area or drainage. Nursing to continue to keep it clean and covered with a bordered foam dressing. Nursing was instructed to offload/turn resident at least three times daily to prevent further skin break. Nursing to continue monitoring skin with weekly skin check and update physician if worsening skin area. R1's wound tracker dated 3/17/22, included open area on sacrum measuring 1.4 cm x 0.7 cm x 0.1 cm and indicated wound was improving. R1's physician visit dated 3/23/22, indicated given the onset of coccygeal wound, he is getting closer to being appropriate for hospice. R1's Wound Tracker dated 3/24/22, indicated open area on sacrum measuring 1.7 cm x 1.0 cm x 0.5 cm and indicated wound was worsening and notified nurse practitioner on 3/22/22. R1's physician visit dated 3/30/22, indicated registered nurse (RN)-A reported coccyx is healing well without redness, drainage, or signs of infection. R1 enrolled with hospice on 3/30/22 per family consent R1's physician visit dated 4/1/22, indicated moisture associated open skin damage measuring 1.5 cm x 0.8 cm x 0.3 cm. R1's record included subsequent weekly Wound Trackers completed on 3/31/22, 4/7/22, 4/14/22, 4/21/22, 4/27/22. The wound trackers indicated the wound measurements remained relatively consistent in size and depth, however, continued to lack a comprehensive assessment to identify and remove potential causal factors. R1's physician visit dated 5/2/22, indicated R1's sacrum PU stage 3 and measured 1.5cm x 0.5 cm x 0.3 cm. R1's record identified weekly Wound Trackers were not completed after 4/27/22 through 5/19/22. R1's weekly Wound Tracker dated 5/19/22 included open area on sacrum measuring 1.5 cm x 0.6 cm x 0.4 cm. On 5/26/22, RN-A documented open area on sacrum measuring 2.2 cm x 1.0 cm x 0.4 cm and peri-wound tissue pink or normal for ethnic group; but indicated wound was worsening with larger open area measurements. When interviewed on 6/15/22, at 12:36 p.m. hospice registered nurse stated R1 was admitted to hospice on 3/31/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice RN stated she did not visualize the coccyx wound upon admission as facility LPN-B stated the wound was currently stable. Hospice nurse coordinated with LPN-B to be able to assess and change coccyx dressing on the second visit on 4/7/22; however, when hospice nurse called facility on 4/7/22, at 8:40 a.m. LPN-B stated she had already completed wound care for R1. LPN-B stated coccyx wound was stable, appeared smaller, and facility was continuing on with current treatment orders of acidic acid soaks and [MEDICATION(S)] dressing. On 4/28/22, hospice RN had a conversation with RN-A who stated the coccyx PU length and width were staying the same and the dimensions were getting shallower with acidic acid gauze. Hospice RN stated she was uncertain if facility was staging PU at this time. On 4/28/22, hospice nurse stated R1's coccyx wound was upgraded to a stage 2 PU with scant drainage and measured 1.6 cm x 0.5 cm x 0.4 cm with undermining and slough present and she completed dressing change and measurements with RN-A. On 4/29/22, hospice physician wound care orders were faxed to the facility for wound care coccyx pressure area: cleanse with wound cleanser (i.e. [MEDICATION(S)]) and gauze, allow to dry. Apply skin protectant (i.e. Sure-prep wipe) to intact peri-wound skin, let dry. Apply bordered gauze dressing. Perform wound care every three days and as needed for soiling and loosening. Routine wound care was to be performed by facility staff per these orders. Hospice nurse stated she faxed over the new wound care orders. Hospice nurse stated she then started noticing there was a pattern with R1 not being provided wound care per physician orders. There was a total of three to four visits made by the hospice RN when there was no dressing in place on R1's coccyx wound. Hospice nurse stated she brought this to the attention of RN-A; RN-A stated the facility had supply issues and there were no bordered dressings to cover the wound. Hospice RN stated it became pattern for facility to not have supplies for R1 so she brought supplies with her and gave facility supplies to use. On 5/24/22, hospice RN stated R1 was found with bowel incontinence in his brief and no dressing found on coccyx wound. Hospice RN stated wound was upgraded to stage 3 PU with undermining, surrounding skin tissue [CONDITION(S)], scant drainage, and measured 1.5 cm x 0.6 cm x 0.5 cm. Hospice RN was unable to locate RN-A at this time to notify her of worsening PU; but notified the floor nurse. On 5/26/22 at 12:10 p.m., hospice nurse called RN-A discussing her concerns with R1 repeatedly found without proper physician prescribed dressings in place for his coccyx PU. On 5/31/22, hospice nurse completed last visit with R1 prior to him discharging to hospice house. R1 was found in bed without coccyx dressing in place with a worsening Stage 3 Coccyx PU which then measured 2.0 cm x 1.2 cm x 0.5 cm with undermining and [CONDITION(S)] on surrounding skin. R1 was showing some signs of terminal decline, more swallowing decline, and hospice believed he was already transitioning at that time. R1's treatment administration record (TAR) identified physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/24/22, the order was changed to apply acetic acid solution-soaked gauze twice daily and as needed and cover with [MEDICATION(S)] dressing. Treatment was not completed on 3/26/22, 4/1/22, 4/9/22, 4/11/22, 4/15/22, 4/18/22, 4/20/22, 4/24/22, 4/25/22, 4/26/22, 4/27/22, and 4/29/22. On 5/3/22, order indicated to cleanse wound with wound cleanser and gauze and allow to dry. Apply skin protectant (i.e. Sure-prep wipe) to intact peri-wound skin, let dry. Apply bordered gauze dressing. Perform wound care every three days and as needed for soiling or loosening. Notify hospice if worsening, has increased drainage, size redness, warmth, pain. Treatment was not completed on 5/3/22 and 5/12/22. When interviewed on 6/15/22, at 3:28 p.m. nursing assistant (NA)-A stated R1 was incontinent of bowel frequently and required frequent checks and changes. NA-A stated aides would get floor nurse to change R1's coccyx dressing if soiled or if it fell off. NA-A stated R1 was repositioned every 2 hours and was unable to sit up in his wheelchair towards the end due to increased pain in coccyx area. When interviewed on 6/16/22, at 8:09 a.m. NA-B stated R1 had a stageable PU on his coccyx that was deep and worsened over time since his admission to facility. NA-B stated she found R1 without coccyx dressing in place usually in the mornings after night shift would say R1 was incontinent of bowel. NA-B stated aides were to notify nurses if dressing was soiled so a new one could be applied. NA-B stated R1 would grimace in pain if bowel movement in the wound and staff had to clean it out and when the nurses had to measure the depth of the wound. When interviewed on 6/16/22, at 11:35 a.m. RN-A stated a comprehensive head-to-toe assessment is completed on every resident upon admission, quarterly, and at change of condition which included: skin and bowel assessments. RN-A stated that weekly skin assessments are to be completed on bath days. Facility has bath sheets that the aide fills out and gives to the floor nurse to be signed and reviewed; then turned in to RN-A for final review. RN-A admitted these were not completed by floor nurses, RN-A had found them not signed and dated by floor nurses, so she was uncertain if the skin conditions had been addressed. RN-A stated she had fallen behind on completing these timely. RN-A stated weekly skin trackers are to be completed by her every seven days on residents with pressure and non-pressure related wounds. RN-A stated R1 developed a stage 1 PU on his coccyx after his admission to facility. RN-A stated she completed R1's admission comprehensive assessment; however, failed to complete a thorough skin assessment which included looking at R1's buttocks. RN-A stated she found R1's open area on coccyx and moisture associated skin damage (MASD) two weeks after admission to facility. RN-A stated she was aware R1 was found numerous times without proper wound care dressings to his PU and floor nurses would report to her that oh, I was just going to put that on now. RN-A stated R1 was frequently incontinent of stool and the coccyx dressing needed to be replaced; however, was not completed often because of some staff completely disregarded R1's need. RN-A stated the aides would get R1 cleaned up well but citric acid was not used by nursing staff to cleanse the inside of R1's wound during incontinence episodes as it should have been. RN-A stated R1 was on a turning and repositioning schedule every two hours; but thought this was not getting completed by aides timely. RN-A admitted she was not keeping up on weekly wound measurements and completing management duties as she was pulled to work the floor as a nurse. RN-A stated facility completes weekly interdisciplinary team (IDT) meetings on Wednesdays which included: Administrator, DON, RN unit manager, MDS nurse, and dietician. RN-A stated she was unable to go to these meetings in May as she was working as a floor nurse primarily. RN-A stated wounds and PUs were reviewed during their IDT meetings which included updating the plans of care and interventions for residents; however, was uncertain if these were getting completed timely as DON primarily updated care plans. During a returned call telephone interview on 6/21/22, at 1:17 p.m. NP stated R1 was admitted to facility without a PU. NP stated physician was notified approximately two weeks after admission that R1 developed an open area on his coccyx. NP expressed concern of not being able to find facility staff to assist with wound measurements and dressing changes when at facility which could have affected R1's care he received. NP stated she initiated a wound care protocol for DON to give her a list of all residents with current wounds every Friday at 9:00 a.m. for physician rounds so they were able to properly assess and measure all PUs and non-pressure ulcer wounds. R3's admission record identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarterly MDS assessment dated [DATE], indicated R3 was cognitively intact, displayed no behaviors or rejection of cares, required setup help for most ADL's, however required limited one-person assist for dressing and personal hygiene. The MDS identified R3 had occasional incontinence of bladder. R3's MDS indicated R3 was at risk for pressure ulcer development, did not have pressure ulcers, however, did have MASD, skin care interventions included pressure reducing device for chair and bed and application of ointments/medications other than to feet. R3's care plan dated 8/13/18, indicated R3 was at risk for bowel and bladder incontinence as evidenced by the resident needing some assistance with toileting as needed due to dementia, anxiety, weakness, and use of diuretic. Provide incontinence care/perineal care after each incontinent episode and use barrier cream each time. R3 was at risk for skin integrity related to dementia, weakness, [CONDITION(S)]/[CONDITION(S)], sleeps in recliner per resident choice, MASD to chest area/under breasts/groin/right buttocks with interventions that included: -Conduct pressure injury skin assessments (i.e. Braden scale) as indicated. -Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately. Head-to-toe assessment by licensed nurse performed weekly at minimum (revision date 2/11/22). -Administer medications per MD order. Resident refuses treatment at times. Encourage her to allow treatment (revision date 6/8/22). -Keep resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products. Encourage resident to allow staff to assist in cares. Resident has history of refusing due to wanting to remain as independent as possible (inconsistent with MDS dated [DATE]). Education given on risks of completing own cares as resident does struggle with thoroughness of task (revised on 6/16/22). R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Right buttock and left perineal area: apply [MEDICATION(S)] border to area and change every three days and as needed if soiled. Interdry to groin area. Change twice daily every morning and at bedtime (start date 4/19/22). -Nursing to check perineal area for proper wiping/cleaning/document refusal at bedtime (start date 4/22/22). -Nursing to check perineal area every shift and update provider if worsening skin area (start date 6/13/22). R3's record was reviewed between 3/31/22 to 6/16/22. Weekly Skin Reviews were reviewed in conjunction with non-pressure weekly trackers and physician notes. The record identified worsening skin integrity and the development of pressure ulcers after R3 had MASD. The record lacked ongoing weekly comprehensive skin assessments and treatments not completed according to physician orders. -Weekly non-pressure tracker dated 3/31/22, included facility acquired open area on right buttocks MASD increased in size measuring 1.0 cm x 0.5 cm x 0.1 cm was bright red and/or blanches to touch. Physician visit note dated 3/31/22, indicated facility requesting evaluation of right buttock open wound with redness that they have been dressing with border foam to cover. -Weekly non-pressure tracker dated 4/7/22, included an open area on right buttock measuring 0.5 cm x 0.3 cm x 0.1 cm and indicated wound was improving. A facility acquired open area on left perineal area MASD measuring 1.0 cm x 0.3 cm x 0.1 was pink or normal for ethnic group. Physician visit included dated 4/7/22, included nursing reported R3's periarea is very raw, red, and inflamed in periarea. She does refuse for personal cares to be done frequently. Today, NP assessed the MASD to right buttock area measuring 0.3 cm x 1cm and left perineal MASD measuring 0.57 cm x 0.3 cm x 0.1 cm. NP discussed new dressing and Nursing was instructed to continue monitoring skin with weekly skin check and update provider of worsening skin area. -Weekly non-pressure tracker dated 4/12/22, indicated an open area on right buttock measuring 0.4 cm x 0.3 cm x 0.1 cm was bright red and/or blanches to touch. Left perineal are MASD measuring 0.9 cm x 0.3 cm x 0.1 cm. -Weekly skin review dated 4/21/22 indicated R3 had a small open area on her perineum; no other information about the area was documented. -Weekly skin review dated 4/28/22 indicated R3 had a small open area on coccyx; no other information about the small open area was documented. R3's record did not include completed skin reviews and/or non-pressure weekly trackers between 4/29/22 and 5/18/22. R3's physician visit dated 5/6/22, indicated right buttock area MASD improving and groin rash has resolved per nursing. No further physician visits were provided that addressed R3's wounds. -Weekly skin review dated 5/19/22, indicated R3 had an area on left labia which is currently being treated. R3's record did not include completed skin reviews and/or non-pressure weekly trackers between 5/20/22 and 6/5/22. -R3's weekly skin review dated 6/6/22, included open excoriated areas on mons pubis and labia from scratching. Raw, reddened skin on right buttock measuring 4.5 cm x 6.0 cm with smaller open are in the middle measuring 1.5 cm x 1.0 cm. The corresponding non-pressure weekly tracker dated 6/6/22 was inconsistent with the weekly tracker; the non-pressure tracker only identified open area on right buttock measuring 1.5 cm x 1.0 cm x 0.1 cm. The next skin tracker that was completed on 6/16/22. The weekly skin review and the non-pressure tracker were inconsistent. The non-pressure weekly tracker dated 6/16/22, included an open area on right buttock measuring 0.9 cm x 0.5 cm x 0.1 cm. Whereas the weekly skin review dated 6/16/22 included, right and left buttock with open areas of concern to coccyx and right/left buttock. R3's record lacked comprehensive wound assessments for all the areas identified on the tracking forms. In addition, the record lacked identification of potential causal factors and/or modifiable risk factors contributing the deterioration of R3's that could otherwise be removed to ensure healing, reduce the risk of deterioration, and new ulcer development. Review of R3's TAR identified the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - Right buttock and left perineal area: Apply Medi-honey to right buttock and left perineal and cover with 2x2 foam dressing. Once daily and as needed. Update provider if worsening to be completed every dayshift. Not completed on the following dates: 4/9/22, 4/10/22, 4/15/22, 4/18/22, 4/19/22, and 5/2/22. -Right buttock and left perineal area: Apply [MEDICATION(S)] border to area and change every three days and as needed if soiled on dayshift. Not completed on the following dates: 4/20/22, 4/23/22, 4/26/22, 4/29/22, 5/2/22, 6/3/22, and 6/9/22. -Interdry to groin area. Change twice daily every morning and at bedtime. Not completed on 4/20/22, 5/19/22, 6/2/22, 6/6/22, 6/7/22, 6/8/22, and 6/9/22. -Nursing to check perineal area for proper wiping/cleaning at bedtime. Document refusal. Not completed on 6/3/22 and 6/9/22. During an interview on 6/14/22, at 2:19 p.m. NA-C stated R3 currently had multiple sores on her buttocks and thigh area that staff are cleaning twice a shift. NA-C stated there were no dressings ordered to be applied to open wounds. During an observation on 6/15/22, at 8:31 a.m. R3 observed sitting in grey recliner in corner of room with breakfast tray. Surveyor could smell stale, foul urine from the doorway of R3's room. During an observation and interview on 6/15/22, at 10:08 a.m. R3 laid in bed, RN-B at bedside to change R3's dressings. R3 did not have prescribed bordered foam dressing to open sores on right and left buttocks, bilateral mons pubis area, nor interdry in groin folds. RN-B indicated R3 had two open sores to right buttocks (one circular and the other a large, long rectangular shaped slit), one open sore to left buttocks, one open sore on left mons pubis perineal area, and one open sore on right mons pubis perineal area. RN-B stated the area was very reddened to almost darkened purplish colored and moist. RN-B stated she measured all wounds which included pressure and non-pressure sores; but was uncertain how often this task gets completed. RN-B applied one 4x4 [MEDICATION(S)] to two right buttocks stage 2 PUs and one mepliex applied to left stage 1 PU on left buttocks. RN-B stated facility did not apply dressing to open areas to mons pubis perineal area. RN-B stated R3 is very active during the day and transfers independently so is not on a repositioning schedule. During an observation and interview on 6/16/22, at 10:30 a.m. R3 observed walking with NA-B to go to third floor whirlpool tub for bath. NA-B assisted R3 to remove her clothing; physician ordered dressings were not in place on her buttocks nor interdry in her abdominal folds. Surveyor observed R3 with two open areas on right buttocks, one small open area on left buttocks, and bilateral openings on mons pubis perineal area. At 10:57 a.m. LPN-E completed dressing changes to R3's bottom. LPN-E indicated the small circular opening on left buttocks and right long rectangular shaped opening on right are new wounds since 6/10/22 when she had last worked. During an interview on 6/15/22, at 8:46 a.m. RN-B stated R3 has sores on her buttocks, lower extremities from [CONDITION(S)], redness in bilateral groin folds and abdominal folds that require interdry placed in folds. RN-B stated R3 was incontinent of bladder frequently and wore a brief. During an interview on 6/15/22, at 9:00 a.m. R3 stated she did not have any current open sores on her skin. R3 stated she used to have sores on her buttocks, but facility staff bandaged them up and they healed up right away. R3 stated she was continent of bowel and bladder and was independent with transfers and locomotion. R3 had some notable forgetfulness during interview as R3 was unsure why she wore an incontinence brief. During an interview on 6/15/22, at 4:20 p.m. NA-D stated R3 was alert, oriented, and independent with all cares. NA-D stated R3 wore an incontinence brief as she had some episodes of incontinence. NA-D stated R3 wanted to remain independent. During an interview on 6/15/22, at 4:05 p.m. RN-C stated R3 has had open areas on her buttocks and perineum, but they have since healed up and closed even though according to NAs R3 had open areas on 6/14/22 and the surveyor's observation earlier that day. RN-C stated NAs should be checking on R3 every two hours or as needed. RN-C stated if R3 refuses, aides should be redirecting resident or checking back with her shortly. RN-C stated R3 is incontinent of bladder at all times and R3's dementia is quite off sometimes and speaks about a past doctor who she takes recommendations from. During an interview on 6/16/22, at 8:09 a.m. NA-B stated R3 was alert, but often very forgetful due to her dementia. NA-B stated R3 listens to a MD from years past so they often redirect R3 informing her the MD is okay with cares. NA-B stated R3 has multiple open areas on buttocks and mons pubis perineal area and stated these were open on her shift on 6/12/22. NA-B stated R3 has reddened groin folds, underneath bilateral breasts, and on perineal area. NA-B stated these were very enflamed, swollen, sore, and painful for R3. NA-B stated aides are to be checking on R3's incontinence brief two to three times per shift and checking and changing as appropriate. NA-B stated she believed this was not part of the aide tasks on EHR; however, the information is passed along in verbal shift report. During an interview on 6/16/22, at 8:29 a.m. LPN-E stated R3 had an order to dress open areas on right and left buttocks with [MEDICATION(S)] every three days or as needed for soiling. LPN-E stated R3 will refuse; however she would respond easily with redirection or reapproach. LPN-E stated NA's should be alerting nurses if they need assistance for redirection. LPN-E stated there were only certain NAs who were aware of correct cares and completed them well. LPN-E stated R3 was incontinent of bladder all the time and wears an incontinence brief. During an interview on 6/16/22, at 11:35 a.m. RN-A stated R3's buttocks opened up in March. RN-A confirmed R3's skin wound measurements were not completed the weeks of 5/26/22 and 6/2/22. RN-A stated her concern would be failure to track and trend progression or healing of the wounds if there are no weekly skin measurements completed. RN-A stated R3 has dementia and is quite forgetful following a TBI. RN-A stated R3's dressing should be in place per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated she had fallen behind on completing these timely. RN-A stated weekly skin trackers are to be completed by her every seven days on residents with pressure and non-pressure related wounds. RN-A stated she was not keeping up on weekly wound measurements and completing management duties as she was pulled to work the floor as a nurse. RN-A stated wounds and PUs were reviewed during their IDT meetings which included updating the plans of care and interventions for residents; however, was uncertain if these were getting completed timely as DON primarily updated care plans. During an interview on 6/16/22, at 1:09 p.m. DON stated expectation for pressure and non-pressure wounds to be documented and measured weekly on all residents, turned and repositioned according to orders, and checked and changed as ordered, reminding and reapproaching residents on importance of repositioning, and following doctor prescribed wound care as ordered. DON indicated risk factors that may lead to worsening or new development of PUs which included, not repositioning timely, following physician orders, range of motion, and debility. DON stated an awareness of wound supply shortages. DON stated facility does IDT or weekly at risk (WAR) meetings every Wednesday to discuss new admissions, falls, skin concerns, new behaviors, service intensive families, new antibiotics in the past week, nutritional needs and weights, and any other concerns or issues identified with all residents. DON stated care plans and interventions were updated after IDT meetings by herself, MDS nurse, or RN-A. DON indicated if care plans were not updated; then residents were not receiving the best possible care and staff would not complete what needs to be done. During a returned telephone interview on 6/21/22 at 1:17 p.m. NP expressed concern of not being able to find facility staff to assist with wound measurements and dressing changes when at facility which could have affected R1's care he received. NP stated she initiated a wound care protocol for DON to give her a list of all residents with current wounds every Friday at 9:00 a.m. for physician rounds so they were able to properly assess and measure all PU's and non-pressure ulcer wounds. NP stated R3 has dementia with significant cognitive impairment. NP stated she thought R3's worsening skin conditions including MASD were related to R3 not receiving good perineal care following incontinence episodes. The facility policy titled Pressure and Non-pressure Injuries dated 8/2/21, indicated this center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in pl

Based on observation, interview and document review, the facility failed to ensure staff implemented infection control practices to prevent and/or minimize a facility wide outbreak of coronavirus 2019 (COVID 19) for 29 residents who resided at the facility. This systemic system failure resulted in an immediate jeopardy (IJ) and had the potential to affect all 59 residents and staff residing in the facility. The immediate jeopardy began on [DATE], when the facility failed to implement appropriate infection control practices to mitigate or reduce the spread of COVID-19 in the facility. Facility staff did not isolate and/or cohort COVID-19 positive residents appropriately who had shared rooms and bathrooms. Staff did not utilize N95 masks appropriately, did not doff personal protective equipment (PPE) or dispose of PPE after caring for residents who were COVID positive, also did not have a system in place for meal tray removal from Covid positive rooms to prevent cross contamination. In addition, staff were not demonstrating appropriate hand hygiene procedures, there was a lack of available hand sanitizer on all 3 units, and the medical records lacked daily monitoring of residents. The IJ was identified on [DATE], and the director of nursing (DON), director of clinical services DOCS and the infection preventionist (IP), were notified of the IJ at 12:42 p.m. on [DATE]. The immediate jeopardy was removed on [DATE], at 1:35 p.m. when the facility had implemented an acceptable removal plan. However, noncompliance remained at the lower scope and severity level of F, widespread scope, no actual harm with a potential for more than minimal harm that is not immediate jeopardy. Findings include: According to the resident line listing, between [DATE] and [DATE], 30 residents tested positive for COVID-19. The first positive test was identified on [DATE]. According to a staff listing, 11 staff members tested positive during the same period. The facility's resident line listing indicated COVID-19 first started on the second floor with one resident R8, on [DATE]. On [DATE], R9 tested positive. On [DATE], the line listing identified spread to the adjacent 2nd floor hallway with R6 and R10 testing positive. It had also spread on the 3rd floor where two residents tested positive, R11 and R12. On [DATE], 2 more residents tested positive on the second floor, R13 and R14. On [DATE], 6 more residents tested positive on the 2nd floor, these included R16, R17, R18, R19, R20, R21, and R22. On [DATE], 5 residents tested positive on the second floor these included, R23, R24, R25, R26 and R27. On [DATE], 5 additional residents tested positive on the second floor, these included R28, R29, R30, R31 and R32. One tested positive on the third floor R33. On [DATE], R34 from the second floor tested positive. On [DATE], R7 from second floor tested positive and R44 from third floor tested positive. On [DATE], R45 and R46 from second east floor tested positive. The facility's infection control program documentation in conjunction with resident records from [DATE] to [DATE]. Infection control records lacked evidence of ongoing prevention strategies such as audits to ensure infection control practices to prevent spread were completed, did not identify an increase for environmental services to clean and disinfect, did not include staff education on COVID-19 prevention strategies, no evidence to suggest intervention or alternative plan for neighboring resident rooms that had shared restrooms, and resident records lacked evidence of consistent monitoring prior to outbreak and lacked increased monitoring for symptoms or other modalities for early detection and testing for containment. Facility's delayed recognition of signs and symptoms of COVID and inappropriate implementation of transmission based precautions (TBP), monitoring for symptoms, implementation of prevention strategies and isolation/quarantine included: R29 shared a room with R23. R21 and R28 resided in the room next door, with a shared bathroom in between the two rooms. According to R29's progress note on [DATE], at 10:20 a.m. identified R29 had symptoms that included productive cough with clear yellowish sputum, sore throat, runny nose, raspy voice, head was stuffy, and he had diminished lung sounds. After R29's symptoms were identified, R29's record lacked consistent assessment and monitoring and lacked evidence TBP and isolation/quarantine were implemented. R23's record indicated he remained in the same room with R29 and lacked consistent monitoring for symptoms and later tested positive on [DATE]. R29 then tested positive on [DATE] (after testing negative on [DATE]) and died later that day ([DATE]). Resident records and the facility's infection control (IC) program did not identify implementation of prevention/containment strategies related to the shared bathroom. R21's record identified he tested positive on [DATE], and became symptomatic with a sore throat and runny nose. R21's progress note dated [DATE] at 10:55 p.m. R21 continued to reside in the same room as R28, record did not identify TBP were implemented, and lacked consistent monitoring for signs and symptoms after testing positive. R28's record identified he tested positive for COVID on [DATE]. R28's progress note dated [DATE] at 9:32 a.m. indicated R23 had symptoms of runny nose and fatigue. R28's record lacked ongoing consistent monitoring for signs and symptoms. During an interview on [DATE] at 8:27 a.m. IP indicated an unawareness of when R29 started having symptoms. IP stated that R29 had a false negative on [DATE] and later tested positive on [DATE]. IP stated the physician did not recommend moving R29 because he was symptomatic and further stated there was no rooms available to move R29 to. R15 and R26 shared a room. The facility line listing indicated R15 tested positive for COVID on [DATE]. R15's record did not identify R15 was positive for COVID until [DATE] at 2:41 a.m. Progress note dated [DATE] at 2:41 a.m. identified R15 was positive for COVID and R15 had watery diarrhea times four that shift. R15's record lacked consistent monitoring for symptoms prior and after being tested positive. In addition the record did not identify implementation TBP and isolation/quarantine on [DATE]. R15's progress note dated [DATE], progress note dated [DATE] indicated R15 was on and droplet precautions. R15's record did not identify R15 had a room change. The facility line listing was inconsistent with R15's medical record indicating R15 had a room change on [DATE]. R26's record identified inconsistent symptom monitoring. R26's progress notes dated [DATE] indicated R26 had tested positive for COVID, was in a private room, on droplet precautions, and had symptoms of cough, fatigue, and body aches. R26's progress notes and facility line listing indicated R26 remained in the same room. Based on available information between resident progress notes and facility records it could not be determined if or when R15 was moved out of the room. During interview on [DATE], at 12:07 p.m. IP indicated DON cohorted by removing the positive residents with roommates out of the rooms when they tested positive and left the other resident in place. At 12:32 p.m. the DON indicated an awareness R15 was not immediately moved to another room when she tested positive for COVID and indicated an unawareness of when R15 was moved to R9's room. The facility's line listing for staff indicated on [DATE] NA-D was the first to test positive for COVID-19. On [DATE], NA-I tested positive. On [DATE], NA-J tested positive. On [DATE], three staff tested positive, TMA-C, NA-K, and housekeeper (HSK)-B. On [DATE], two staff tested positive, LPN-F and NA-L. On [DATE] NA-M tested positive. On [DATE], NA-N tested positive. On [DATE] RN-F tested positive. Total of 11 staff tested positive from [DATE] to [DATE]. The facility vaccination list identified two unvaccinated staff with religious exemptions (HUC and NA-E) and a listing of staff who had been fit tested for N95's. The list of staff who were fit tested did not identify HUC and NA-E as having been fit tested for N95's. HUC and NA-E were observed working in COVID positive rooms during the survey. During observation on [DATE] at 6:38 a.m. on the second east floor, two of four hand sanitizer stations did not work or were empty. During observation on [DATE], at 6:58 a.m. on the third east floor, two of four hand sanitizer pump that hung on wall were empty. Nursing assistant (NA)-C verified they were both empty and was unsure who oversaw keeping the pumps filled. No individual bottles of sanitizer were observed anywhere on the unit. The nurse's station had open pop cans, used masks laying on the desk, and counters had dried wet marks on them. During observation and interview on [DATE], at 8:15 a.m. R36 was noted to be fully dressed lying in bed; R36's door was open. NA-C stated to surveyor be careful with R36, his roommate R33 just tested positive for COVID yesterday and we moved R33 to a private room down the hall. NA-C stated R36 needs to be on precautions for COVID because he was exposed. NA-C stated R36's room did not have precaution signage nor a PPE cart outside the room yet. During observation on [DATE], at 8:30 a.m., HUC delivered 2nd floor breakfast trays to COVID positive and COVID negative residents. Although she appropriately donned/doffed gown, gloves, and performed hand hygiene she wore an N95 mask that she was not fit tested for and did not change between tray deliveries. During an observation on [DATE], at 8:48 a.m. HSK-A was observed mopping floor on the third-floor hallway, HSK-A then entered R36's room with the mop; HSK-A entered with gloves, mask, and goggles on. HSK-A finished cleaning R36's room and exited without doffing any of the PPE and without performing hand hygiene HSK-A then entered R37's room who was not COVID positive. HSK-A stated an unawareness that R36 had been exposed to COVID. HSK-A stated if he had known he would sanitize those rooms last, and wear a gown and a face shield. During observation on [DATE], at 9:52 a.m., NA-A entered R22's room who was COVID positive with surgical mask on to gather food tray. Upon exiting R22's room, NA did not change face mask. NA-A walked down hallway and placed R22's food tray on a communal food cart that was not covered. NA-A did not perform hand hygiene NA-A then entered R32's room who was not COVID positive. During observation on [DATE], at 10:11 a.m. environmental Service Director (ESD) was delivered hand sanitizer refills to the second east hallway. ESD did not identify the batteries were dead in the hand sanitizer pump; the pump continued to not function. During observation on [DATE], at 10:12 a.m. NA-B had a surgical mask on. NA-B put on a gown entered R23's room who was COVID positive. Prior to leaving the room NA-B removed her gown, and without gloves on picked up R23's tray and water mug, walked out of the room and placed the the items on the dirty linen cart in the hallway. NA-B then picked up the tray, placed the tray in the communal tray cart, picked up the mug, picked up a water pitcher, went to the ice cooler by the nurse's station, filled it with ice and water, placed the mug on the water fountain to secure the lid. NA-B then obtained gloves from room [ROOM NUMBER], put the gloves on, and handed the water pitcher to R23 in the doorway of their room. NA-B then removed the gloves and threw them away in the waste receptacle attached to the treatment cart. At no time did NA-B disinfect the items she removed from R23's room nor perform hand hygiene. After giving R23 water pitcher NA-B then briefly talked to the nurse standing near by, then touched the handle of clean linen room, obtained clean hospital gowns and shut the door. NA-B then walked to the west linen closet, touched the handle, obtained another gown, placed it on the hallway outside room [ROOM NUMBER]. NA-B then sanitized her hands and entered the room. NA-B never changed the surgical mask throughout the observation. During observation on [DATE], at 8:31 a.m. NA-B came out of R23's (covid positive) room, removed surgical mask, placed the plate cover on the handrail, then picked it back up and placed it on the dirty linen cart. NA-B did not perform hand hygiene before putting a new mask on outside of R30's room who was COVID positive. After putting the mask on NA-B donned PPE outside of R30's room, entered the room and picked up the plate cover, NA-B removed PPE, performed hand hygiene, then took the plate cover to the steam cart and placed it on top of cart to go down to kitchen. During observation on [DATE], at 8:41 a.m. The PPE cart outside of R21 and R28's (COVID positive) room was empty. The PPE cart outside of R23's (COVID positive) was also empty. The cart outside of R24's (COVID positive) room cart was not stocked with N95's and the PPE cart outside of R34's (COVID positive) room was not stocked with surgical masks or N95's. During observation on [DATE], at 8:49 a.m. NA-D was observed in R35's room who was COVID positive, NA-D had full PPE that included a surgical mask. NA-D doffed inside R35's room however did not remove the surgical mask. NA-D sanitized hands, picked up R35's food tray and carried it down the hallway, and placed the tray on the communal food cart. NA-D was not observed to perform hand hygiene after putting the tray on the cart. During an observation on [DATE], at 8:56 a.m. An uncovered waste canister was outside R17's room, with used PPE. Trained medication assistant (TMA)-A was observed in R17's room who was COVID positive wearing an N95 mask, gloves, and gown on. TMA-A exited R17's room with the same N95 on, with gloves on, and without performing hand hygiene. TMA-A then walked to the medication cart and threw the gloves into the waste canister attached to the medication cart, sanitized her hands, doffed the N95 and put in waste basket, TMA-A did not perform hand hygiene after touching the N95 and replacing with surgical mask. TMA-A indicated education on infection control had not been provided since the COVID outbreak. On [DATE], at 9:17 a.m.NA-E was observed to be wearing a surgical mask while working the floor and was not fit-tested . During observation on [DATE], at 5:04 p.m. registered nurse (RN)-D was observed leaving R5's (covid positive) room with a surgical mask and not an N95, RN-D did not doff and change the surgical mask. During observation on [DATE], at 10:15 a.m. NA-D was observed in R10's room (COVID positive), was not wearing eye protection while in the resident's room. During observation on [DATE] at 10:20 a.m. RN-D observed family member (FM)-A walk into R34's (COVID) positive) room to visit wearing only a surgical mask, no other PPE worn. FM-A was observed to go in and out of R34's room twice. RN-D instructed FM-A to shut R34's room when visiting but did not ask FM-A to wear full PPE. During observation on [DATE], at 10:33 am breakfast trays from second floor east unit COVID positive rooms were still being delivered to communal food cart, to go back to kitchen. During an interview on [DATE], at 7:06 am, NA-C stated, I think more than half our staff in the whole building had covid. R29 passed away last night after he tested positive for covid yesterday, his roommate R23 was positive, I don't think they ever took R29 out of his room when R23 tested positive, and now R29 is dead. NA-C indicated an unawareness R29 had developed symptoms prior to testing positive. During an interview on [DATE], at 12:07 p.m. IP stated she started back at the facility on [DATE], and further stated the outbreak of COVID started on [DATE]. R8 was the first one who tested positive and was tested because she started having symptoms that day. R8 was someone who hardly ever left her room, we figured she may have gotten COVID when she left the facility for an appointment on [DATE]. When R8 tested positive we started facility wide testing. Our next positive case was NA-D, he tested positive on [DATE], after having symptoms that day. IP verified that NA-D had worked the whole weekend from [DATE], to [DATE], and had worked directly with R8 and worked all of the units. As more residents tested positive, we would remove the positive resident from the room to a private room. On [DATE], the DON had called, as there were an additional 8 residents who tested positive and had spread from the second floor to the third floor. We had talked about moving the positive cases to the first floor but were unable to due to staffing shortage. IP stated she had discussed to reach out to the Minnesota department of health (MDH) crisis staffing, but instead we reached out to our corporate office, and we obtained staffing from our sister facilities, we also increased bonuses for this facility in order to get shifts picked up. IP verified they did not open a COVID unit to cohort positive residents because of insufficient staffing. IP confirmed some residents who were COVID positive did have shared bathrooms with non-covid cases. During an interview on [DATE] at 12:32 pm DON stated that they ran out of hand sanitizer because the scheduler was responsible for ordering it and she had quit on [DATE], so it never got ordered. DON indicated the facility did not have a system in place to ensure supplies were ordered after the staff member left. DON stated she thought there were several bottles of hand sanitizer put out on all of the units. DON indicated the facility was still allowing visitation and visitors were instructed to wear full PPE when visiting COVID positive residents, then doff, and head straight out. During interview on [DATE], at 8:43 a.m. IP brought in a list of staff that were N95 fit tested , the list did not include the two unvaccinated staff who had religious exemptions (HUC and NA-E). The list had a total of 11 staff that had been fit tested . IP reviewed the list and confirmed the list was a complete staff list that the facility gave to her and verified the two unvaccinated staff were not fit tested . IP stated she was currently setting the HUC up today for medical evaluation. IP verified NA-E had been working the floor without being fit testing for N95 and indicated an unawareness HUC had been working on the floor. During interview on [DATE], at 8:45 a.m. licensed practical nurse (LPN)-B stated they have not been fit tested for N95's. LPN-B stated there had not been any education or audits completed in regard to COVID-19 since the outbreak. When asked about donning and doffing PPE in COVID positive rooms, LPN-B stated the facility did not provide N95 masks everyday, so they were not doffed after each resident encounter During interview on [DATE], at 9:02 a.m. NA-D stated he had worked here for 2 years, stated he knew nothing about fit testing N95 masks. During interview on [DATE], at 9:15 a.m. LPN-A stated she was not fit-tested and verified there was no formal education completed in regard to COVID outbreak. During interview on [DATE], at 11:02 a.m. RN-D stated no one told her that visitors needed full PPE when visiting COVID positive residents. Also stated they were not educated on food trays from positive rooms going on the communal cart. They educated about IC PPE, donning/doffing, leaving everything in the room, hand hygiene, and putting clean mask on as soon as you come out. On [DATE], at 12:13 p.m. The DON and nurse consulting team were notified of inappropriate ICP practices being followed by staff; IP stated she re-educated all staff the evening prior. IP stated she would re-educate staff on the spot. IP was observed to go and reeducate all staff in the building on the spot in regard to the above concerns. During observations and interviews on [DATE], at 12:13 p.m. across the units during the lunch hour, no PPE breeches were noted, and facility opted to use paper dining ware for COVID positive residents to avoid cross contamination. The IJ that was identified on [DATE], at 12:42 p.m. and was removed on [DATE], at 1:35 p.m. when it could be verified the facility had developed and implemented an acceptable removal plan including: Staff education was provided regarding appropriate use of PPE and hand hygiene with COVID positive residents and visitors, appropriate techniques for discarding contaminated supplies. These measures were verified by staff observation, interview, and review of facility documentation.

Based on observations, interviews, and record review, the facility failed to promptly identify and intervene for an acute change in condition for 1 out of 11 residents (R39), when R39 was exhibiting signs and symptoms of cardiopulmonary distress and was left unattended resulting an unwitnessed arrest and ultimate death. This resulted in an Immediate Jeopardy (IJ) for R39. The IJ began on [DATE] at 9:00 p.m.when the facility failed to provide ongoing assessment and monitoring of R39 who was having shortness of breath, chest discomfort, dizziness, which ultimately resulted in cardiac arrest. The vice president of operations (VPO), director of clinical services (DOCS), director of nursing (DON), and infection preventionist (IP) were notified of the IJ on [DATE] at 6:02 p.m. The IJ was removed on [DATE] at 1:35 p.m., but noncompliance remained at the lower scope and severity level of D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R39's Face Sheet dated [DATE], indicated R39 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's health history and physical exam dated [DATE], documented R39's fourth hospitalization for respiratory failure since late 2021 with symptoms of shortness of breath (SOB), tachypnea (rapid respiratory rate), and [CONDITION(S)] (rapid heart rate). R39's Minimum Data Set (MDS) dated [DATE], indicated R39 was cognitively intact, makes self-understood, exhibited no signs of [CONDITION(S)] (temporary mental state characterized by confusion and anxiety), and required limited assistance with bed mobility, transferring, walking in hallway corridors, locomotion, dressing, toileting, and personal hygiene. R39's MDS identified R39 did not use oxygen. R39's care plan dated [DATE], indicated R39 at risk for nutritional status related to [CONDITION(S)] and need for [CONDITION(S)] and ensure no significant weight changes, alteration in kidney function and to monitor for [CONDITION(S)] in extremities and report any increase to physician, activities of daily living (ADL's) self-care deficit, and had impaired cardiovascular status related to [CONDITION(S)] heart disease ([CONDITION(S)]), cardiac dysrhythmia's, CHF, and PVD which included: -assess breath sounds as necessary and report abnormalities. -assess productive/nonproductive cough, SOB/exertional dyspnea, dyspnea at rest, [CONDITION(S)] night dyspnea, or orthopnea. -listen to patient when verbalizing concerns over disease symptoms and address issues raised. -monitor oxygen saturation. -monitor weight and report significant changes. -observe and report headaches, flushing, nosebleeds, nausea, and SOB. -observe and report signs of chest pain, [CONDITION(S)], SOB, abnormal pedal pulse, restlessness, and fatigue. -observe for abnormal vital signs and report. -observe for changes in condition. -observe for sensory changes to extremities such as pain, warmth, and redness. R39's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Transfer to hospital and/or intensive care unit if indicated. All patients will receive comfort-focused treatments. On [DATE], orders indicated bi-pap on home settings ,d+[DATE] and to document refusal if needed. A progress note dated [DATE], at 4:23 p.m. registered dietician (RD) indicated R39 had a weight warning of +5.0% weight gain change over 30 days with a current weight of 186.6 pounds. RD indicated R39 triggered above weight gain which fluctuations may be expected related to [CONDITION(S)] status. RD indicated will continue to monitor and make recommendations as needed. A progress note dated [DATE], at 3:07 p.m. RD documented a weight warning of +5.0% change over 30 days with a current weight of 188.6 pounds and a current weight gain of +7.5% change. R39 triggered above weight gains which fluctuations may be expected related to [CONDITION(S)] status. RD indicated will continue to monitor and make recommendations as needed. R39's record lacked a comprehensive analysis of the weight gain and did not describe what type of monitoring was initiated and/or revision in the care plan after the weight gain was identified. A progress note dated [DATE], at 10:45 a.m. registered nurse (RN)-C documented it was reported to her R39 complained of sore throat and SOB on the evening shift. RN-C checked on R39 after getting report and asked her if she was having any COVID symptoms like chest pain, fever, and SOB but R39 declined. R39's temperature was 98.7 degrees Fahrenheit (F) and O2 saturation was 96% on room air. R39's record did not identify R39's symptoms on [DATE] and [DATE] as reported to the evening nurse, lacked evidence of assessment, monitoring, intervention, and physician notification. In addition, the record lacked evidence of ongoing comprehensive assessments and consistent monitoring of reported symptoms through [DATE]. R39 's electronic medical record (EMR) dated [DATE], at 3:47 a.m. identified 02 saturations were 96% on room air and temperature was 98.2 degrees F. R39's record lacked any further vital signs and comprehensive respiratory or cardiac assessment. The record did not identify why R39's oxygen saturation and temp was checked at that time. During an observation on [DATE], at 6:10 a.m. observed ambulance driving down the road with flashing lights on and it turned into facility parking lot and two emergency medical technicians (EMTs) went into side door of facility. At 6:20 a.m. observed ambulance chaser vehicle pull into facility parking lot and a third gentleman reported into facility. During an observation on [DATE], at 6:30 a.m. facility staff on 2nd floor notified surveyors that a code was happening down the hallway on 2 East. At 6:45 a.m. observed ambulance members packing up their equipment without taking a resident to the hospital. A progress note dated [DATE], at 7:30 a.m. RN-C documented nursing assistant (NA)-H called her at 5:40 am stating R39 needs help to use the bathroom but R39 was dizzy. RN-C went to R39's room and R39 confirmed she wanted to go to the bathroom. R39 and NA-H helped her back in bed. R39's O2 saturation was 88% on room air and respirations were 22. R39 complained of SOB, put on 2 Liters (L) of O2, O2 saturation was 93%, and blood pressure (BP) was ,d+[DATE]. At 5:45 a.m., RN-C went to call ambulance and called RN-E to help with printing paperwork needed to send R39 to hospital. Paramedics arrived, did CPR, and pronounced R39 dead at 6:40 a.m. At 7:20 a.m. RN-C called family to notify of death and discussed with them to call facility back to arrange for a funeral home of choice. During an observation and interview on [DATE], at 9:36 a.m. R39's room was observed cluttered with debris from the code that occurred earlier in morning with a white cotton bath blanket covering the entire bed of R39. R5 stated her roommate passed away unexpectedly after having chest pain for a while and needed to go to the hospital. When interviewed on [DATE], at 9:15 a.m. licensed practical nurse (LPN)-A stated she arrived for her day shift at 6:00 a.m. and noticed RN-C and RN-E at 2nd floor main nursing desk preparing paperwork. LPN-A stated she heard EMS yell for code help in the hallway just outside R39's room. LPN-A stated R39 was pulseless and not breathing upon her arrival to room and CPR was initiated already by EMS. LPN-A stated EMS asked facility staff to verify R39's code status, retrieve the crash cart and bag valve mask from the facility. When interviewed on [DATE], at 10:45 a.m. NA-C stated NA-A ran up to 3rd floor memory care unit on [DATE] at approximately 6:20 a.m. and asked where the facility kept an ambu bag. NA-F stated R39's death was unexpected as she fed R39 last evening for dinner and she appeared fine. When interviewed on [DATE], at 11:00 a.m. R5 stated her roommate, R39, was not feeling well the morning of [DATE]. R5 stated R39 was dizzy and had chest pain. R5 stated EMT's initiated CPR immediately upon arrival to their room on R39. R5 stated she was in the room the entire code so she overheard everything that occurred. During an interview on [DATE], at 1:43 p.m. RN-C indicated she went into R39's room on [DATE] at approximately 5:30 a.m. to 6:00 a.m. after a NA-H called her for assistance to help transfer R39 to the bathroom as she was unable to get there by herself with her walker. RN-C stated R39 was hypoxic(deprived of oxygen) and demonstrating signs and symptom of respiratory distress, tachypnea (increased breating rate), dizziness, and later become nauseous. RN-C indicated she had only obtained respirations which was 22 and 02 saturation was 88% on room air. RN-C grabbed portable O2 tank from the corridor and placed R39 on 2L nasal cannula (NC) and assisted R39 to lay down in bed and rechecked O2 saturation at 93%. RN-C stated she did not check R39's pulse at that time. RN-C left the room to prepare for ED transfer and did not instruct other staff to stay in the room and R39 was left alone. During that time, R39 coded and became pulseless and without respirations. RN-C stated she called RN-D from 3rd floor to come assist with gathering hospital transfer paperwork as RN-C said she had an emergency on 2nd floor East hallway. RN-C stated between the hours of 5:30 a.m. and 6:00 a.m. she went back to room to check on R39 with the last time having R39 attempt to sign bed hold paperwork for facility. R39 was unable to sign her signature at that time around 6:00 a.m. as R39 was too symptomatic and having cardiopulmonary distress. RN-C stated she was focused on getting the documents ready to send R39 out for hospital transfer. RN-C stated R39 was left unattended and alone and within 10 minutes R39 was deceased upon arrival of EMS. RN-C stated EMS had initiated CPR to R39 upon her arrival to R39's room. EMS asked facility staff for an ambu bag for respiratory resuscitation, more oxygen as the portable tank was empty, and to verify R39's code status. RN-C stated she left R39's hospital transfer paperwork at the nurses station so she had to run back to nurses station to find out if R39 was a full code or not. RN-C stated the ambu bag was not in the 2nd floor crash cart as NA-A eventually brought it to R39's room. RN-C stated CPR was continued until 6:40 a.m. when EMS pronounced R39 dead. RN-C stated R39 was not medically safe enough to be left completely alone. RN-C stated if she could re-do the events over again, she would have called a NA or nurse for assistance with calling EMS and doing paperwork while she stayed with her resident who was in distress. RN-C stated she was unaware how to document a medical emergency and death in the EMR other than writing a progress note. RN-C stated she has not received any Code Blue training since she started working for facility, but was CPR certified. RN-C stated Code Blue was never activated at facility on [DATE]. During interview on [DATE], between 10:00 p.m. and 11 p.m. RN-C stated R39's temperature and O2 saturation was checked and was 96% on room air; however, the medical record lacked documentation to support this finding. RN-C further indicated a comprehensive cardiopulmonary assessment was not completed. RN-C stated she received verbal report from RN-D who reported R39 had SOB and a sore throat. During an interview on [DATE], at 4:50 p.m. RN-D stated R39 called out to her in hallway on the evening shift of [DATE] to check O2 saturations because R39 felt shortness of breath. RN-D stated O2 was 96% on room air, but could not remember what her pulse was; however, R39 put her hand over her heart, stated she was not feeling right, and took a deep breath in. R39's medical record lacked documentation or vital signs. RN-D stated R39 was very fatigued that evening and requested to go to bed earlier than normal. RN-D stated R39 wore her bi-pap machine consistently every night and R39 placed it on herself as she was highly independent. RN-D stated R39 was independent with ambulation and her 4 wheeled walker. RN-D stated she reported the abnormal signs and symptoms R39 complained of to her night shift nurse RN-C. RN-D stated R39 had previous occurrences of shortness of breath as R39 had multiple hospitalization s recently for respiratory distress. RN-D indicated despite R39's symptoms and recurrent hospitalization s further assessment and physician notification was not completed. During an interview on [DATE], at 5:00 p.m. trained medication assistant (TMA)-B stated R39 was not feeling well the evening of [DATE] during her medication pass. TMA-B stated during verbal shift report from dayshift that she heard R39 was complaining of SOB and congestion which facility staff presumed may have been signs and symptoms of Covid-19; however, R39 was swabbed on [DATE] and was negative. During an interview on [DATE], at 9:05 a.m. R5 stated she was upset that her roommate (R39) had passed away on the morning of [DATE]. R5 stated facility staff did not do CPR as they left R39 alone. R5 stated R39 was speaking to her and then suddenly stopped after she stated, I need to get to the hospital. R5 stated RN-C was working on hospital transfer as she kept leaving the room. R5 stated when EMS arrived to room, R39 did not have a heart beat and she was not breathing. R5 stated EMS started CPR and yelled for a nurse. R5 stated she overheard everything because she was in the room the entire time and only the privacy curtain was closed when EMS arrived. R5 stated R39 had been complaining of pain in her chest the day prior and asked NA for something for pain; however, the nurse never came in to speak with R39. During an interview on [DATE], at 9:32 a.m. NA-A stated R39 had ambulance called for her on [DATE] due to breathing concerns. NA-A stated she heard EMS yell for a nurse from the hallway upon their arrival to R39's room. NA-A stated R39's skin on her body was yellowish-white and her face was bluish-purple upon her arrival to R39's room. NA-A stated EMS initiated CPR prior to facility staff arriving to R39's room. NA-A stated R39 was alone with her roommate, R5, when EMS showed up to facility. NA-A stated R39 normally did not have SOB, was on room air, and wore her bi-pap every night. During an interview on [DATE], at 3:49 p.m. Mayo Clinic Ambulance assistant supervisor stated a call was placed by facility on [DATE] at 6:03 a.m. as R39 needed to be transferred to hospital for breathing problems. Mayo Clinic Ambulance assistant supervisor stated ambulance was dispatched at 6:03 a.m. and enroute to facility at same time. Ambulance arrived to facility at 6:09 a.m. and patient time to R39's room at 6:11 a.m. He stated EMS's first assessment of R39 was pulseless and without respiration. During an interview on [DATE], at 4:15 p.m. emergency medical technician (EMT)-A stated facility called ambulance for a priority two transfer which means just a hospital transfer with no lights nor siren as R39 only had shortness of breath with no other symptoms. EMT-A was not aware R39 also demonstrated symptoms of dizziness, nausea, weakness, and lethargy. EMT-A stated upon arrival to R39's room, there were not staff in the room at the time nor to be found in the hallway at the time of arrival up to 2nd floor hallway. EMT-A stated R39 was unresponsive to sternal rub, lying supine on her back in bed, no pulse, not breathing; however, R39 was still warm to the touch upon first assessment. EMT-A stated since they thought they were transferring an alert and oriented patient to the hospital, they arrived to unit without advanced cardiac life support medications, advanced airway interventions for breathing support which included an oral airway. EMT-A immediately started chest compressions while EMT-B put on the automatic external defibrillator (AED) which indicated no shockable rhythm on monitor advised. EMT-A indicated life saving interventions were not successful and EMT-A stated a decision to call the death occurred at 6:40 a.m. During an interview on [DATE], at 4:30 p.m. R5 stated RN-C had been in and out of room the morning of [DATE] after her roommate, R39, said she was not feeling well. R5 stated the last time RN-C was with R39 was when R39 firmly stated, I want to go to the hospital when RN-C was completing the bed hold paperwork that R39 was unable to sign. R5 stated RN-C left R39 and never came back to room. R5 stated the next people who came into their room were the paramedics. R5 stated R39 was acting very unusual and knew R39 was very sick and wanted to go to the hospital immediately. During an interview on [DATE], at 4:34 p.m. director of nursing (DON) stated expectation of nurses to complete a full comprehensive cardiopulmonary assessment on any resident in distress which included: checking O2 saturations, respiratory rate if they have respiratory distress, listening to heart and lung sounds, applying O2 as needed, and notifying physician of change in condition and family as needed. DON confirmed a Code Blue was never called the morning of [DATE] for R39 as she would not expect her staff to call one if paramedics are in the building. DON confirmed EMT's initiated CPR on R39. DON stated if there was a medical emergency with any resident expectation for the nurse to not leave a resident by themselves. During an interview on [DATE], at 6:16 p.m. EMT-B stated they received a call for a hospital transfer due to R39 complaining of SOB, EMT-B indicated an unawareness R39 had displayed other symptoms. EMT-B stated they arrived to 2nd floor East wing and there were no facility staff present. EMT-B stated R39 was found in room alone with her roommate R5. EMT-B stated R39 was halfway lying out of bed upon arrival, pulseless, not breathing, and in cardiac arrest. EMT-B stated R39's O2 nasal cannula prongs were in her nares and portable oxygen tank set to 2L; however, the tank was completely empty and not administering any oxygen flow. EMT-B stated R39 skin was very warm to touch yet so she had clear clinical signs she had recently went into cardiac arrest. EMT-B stated he ran to hallway and yelled for help to get nursing staff to come to R39's room. EMT-B stated three facility staff arrived to R39's room at the same time. EMT-B stated he immediately gave them three things to find as soon as possible which included: a bag valve mask to resuscitate R39, verify code status, and find oxygen immediately. EMT-B stated facility staff brought in an oxygen concentrator instead of a portable oxygen tank which was unable to deliver high flow oxygen to R39. EMT-B stated they were unable to adequately ventilate R39 until their EMT supervisor showed up in the chase car. EMT-B stated they administered 1 milligram [MEDICATION(S)] and fluids, but R39 remained in a non-shockable rhythm per AED. R39 was pronounced dead at 6:40 a.m. EMT-B stated, there was no reason why this patient had to die the way she died without giving her a fighting chance; she died alone by herself. During an interview on [DATE], at 9:44 a.m. RN-E stated she was called by RN-C on [DATE] at approximately 5:55 a.m. to 6:10 a.m. to assist her with hospital transfer paperwork. RN-E stated she asked how R39 was doing and RN-C stated, she's stable and okay with her O2 saturation being 88%. RN-E stated RN-C communicated R39 was on O2 2L nasal cannula with O2 saturations at 93% after R39 laid back in bed. RN-E stated RN-C was at 2nd floor nurses station when she arrived to floor. RN-E stated she printed off R39's hospital transfer paperwork and returned to 3rd floor as the dayshift nurse, LPN-A, was already on shift. RN-E stated that RN-C confirmed R39 was fine at the time and she just wanted to send R39 to the hospital. RN-E stated if a resident were to have a change in condition, she would call for a NA for assistance or use the intercom system in the resident's room to ask facility staff for help. During an interview on [DATE], at 12:40 p.m. DON stated her concern regarding nurses not noticing a change in cardiopulmonary condition and staying with a resident who was in distress could result in rapid decline. DON confirmed there is a portable phone at the nurses desk for use. DON stated she could not remember or confirm if RN-C checked R39's pulse or count respirations. The IJ was removed on [DATE], at 1:35 p.m. when it could be verified the acceptable plan of correction was implemented which included: -Applicable policies were reviewed -Nursing staff were provided with re-education regarding identification of change in condition, cardiopulmonary assessments and signs/symptoms of distress, CPR, shift to shift monitoring of resident condition when change is identified, and direct supervision of residents when displaying significant signs and symptoms of decline in health that could result in a code event. -Like residents were identified and assessed by licensed nursing staff. -An auditing system developed and implemented. The facility policy titled Change of Condition of the Resident (Observing, Recording, and Reporting) dated [DATE], indicated to observe, record, and report any condition change to the physician so proper treatment can be implemented. -Change of condition refers to a deviation from the patient/resident's baseline in physical, cognitive, behavioral, or functional domains. This change can be negative or positive. The change of condition may be short lived or extend for a period of time and presents as a shift from the norm for that specific patient/resident. -An acute change of condition refers to a sudden, clinically important deviation from a patient/resident's baseline in physical, cognitive, behavioral, or functional domains. It is clinically important in that without intervention, the patient/resident may experience complications. -Assess the resident's need for immediate care/medical attention. (CNA'S to notify nurse, nurse to notify supervisor, etc.) Provide emergency care as needed. -Do not leave resident alone. Ensure resident's safety. -Assess the resident and notify the attending practitioner of the resident's condition. Compare the resident's condition. Compare the resident's current condition to his/her prior level of functioning. -Assessment, monitoring, and documentation include, but are not limited to the following: vital signs, oxygen saturation, blood glucose level, personality/behavioral/cognitive changes, alteration in level of consciousness/ability to respond, sensory weakness/change, generalized/localized weakness, gait/posture/balance change, dyspnea/irregular breathing. -Monitor resident's condition frequently until stable or transported to higher level of care, if needed. The facility policy titled Cardiopulmonary Resuscitation (CPR) dated [DATE], indicated to restore breathing and blood circulation to someone experiencing cardiac arrest. -CPR (Cardiopulmonary resuscitation) that is done improperly or on a resident whose heart is still beating can cause serious injury. The facility policy titled Charting and Documentation dated [DATE], indicated services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. -Incidents, accidents, or changes in the resident's condition must be recorded.

Based on observation, interview, and document review the facility failed to prevent pressure ulcers development or deterioration and promote healing by failing to follow physician ordered treatments, follow the care plan, and ensure comprehensive assessments and monitoring pressure for 7 of 7 residents (R3, R4, R11, R41, R43, R42, R5) reviewed for pressure ulcers. The facility's system failures resulted in actual harm for 5 of 7 residents (R3, R4, R11, R41, R43) when new ulcers developed and/or worsened. The deficient practice has the potential to effect all residents in the facility that are at risk for pressure ulcers. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. The appearance will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)] (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. R3's admission record identified an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that R3 had moderately impaired cognition, required supervision with eating and locomotion, extensive assist of one staff with all other activities of daily living (ADL)'s, and used a walker and wheelchair for mobility. Also noted to be frequently incontinent of bladder, and always incontinent of bowel. Section M indicated R3 was at risk for pressure ulcer development. No pressure ulcers identified, does note moisture associated skin damage (MASD). Pressure reducing device for chair and bed, nutrition/hydration intervention to manage skin problems. Also identified application of nonsurgical dressings other than to feet and applications of ointment/medications other than to feet. R3's care plan prior to 5/26/22, lacked a focus, goal and interventions pertaining to skin concerns. On 5/26/22, the care paln was updated to indicate R3 had actual skin integrity break and/or pressure sore, chronic non pressure wound on buttock, interventions to assess and measure all skin integrity areas per policy, monitor and report any new open areas, draining, or pain to nurse immediately, provide treatment to wound per current treatment order. Interventions do not include, repositioning or offloading pressure ulcers per current NP orders. R3's toileting care planned interventions included to toilet upon rising, before and after meals, at bedtime and as needed. R3's weekly skin review dated 4/3/22, and 4/9/22, indicated no concerns to skin on buttocks. On 4/16/22, indicated redness to bilateral butt cheeks. R3's progress note dated 4/17/22, indicated R3 was developing a new pressure ulcer at the coccyx region of her buttocks. R3's nurse practitioner (NP) progress noted dated 4/18/22, did not indicate any sacral redness. R3's progress note dated 4/20/22, indicated R3 had a moisture associated bilateral buttock injury. R3's Treatment Administration Record (TAR) dated April 2022, indicated an order on 4/30/22, to cleanse wound on buttocks with normal saline (NS) and pat dry. Apply hydrogel to open areas. Cover open areas with a border foam dressing after applying the cream. R3's weekly skin review dated 5/2/22, indicated redness and open moisture associated skin injury ([NAME]) to sacrum. R3's NP progress note dated 5/3/22, indicated R3 had an area to her sacral coccygeal (located near the tailbone) that was non-blanchable, nontender, [CONDITION(S)] (redness). This would be indicative of a stage 1 pressure ulcer (Intact skin with non- blanchable redness of a localized area usually over a bony prominence). Assessment and plan indicated, closely daily monitor wounds, looking for signs and symptoms of infection and to continue with current orders. R3's weekly skin review, dated 5/8/22, indicated redness and open area, the site and type of impairment was not assessed. R3's NP progress note dated 5/10/22, indicated skin excoriations noted on bilateral buttocks, no open [CONDITION(S)] present. New order: apply hydrogel to open areas on bilateral gluteal wounds, apply 3M barrier spray to surrounding skin, then cover with a foam border dressing. Change dressing daily and as needed if soiled. Encourage frequent repositioning when seated on the recliner or laying in bed. R3's TAR for May 2022, indicated a new order on 5/11/22: cleanse wound on buttocks with NS and pat dry. Apply hydrogel to open areas. Apply 3M barrier spray to surrounding skin, then cover open areas with a border foam dressing every dayshift for skin breakdown. R3's NP progress note dated 5/17/22, indicated R3's wounds to her buttocks have significantly improved, no signs and symptoms of infection noted today. Opened areas on right buttock have completely scabbed over, left buttock is healing gradually, will continue with current plan of care. Nursing to ensure that R3's buttocks are separated apart prior to applying foam dressing to minimize the chances of moisture buildup. R3's progress note dated 5/22/22, indicated when given a bath, a stage 1 pressure ulcer noted to coccyx. Review of R3's record identified there were no further weekly comprehensive skin assessments after 5/8/22 completed by facility registered nurses. Review of R3's record also did not identify root cause of the skin break down nor an assessment/evaluation of the effectiveness of the care plan interventions. During an observation and interview on 5/24/22, 6:47 a.m. R3 was noted to be walking independently down the hallway towards the dining area, with her red four-wheeled walker. During observation and interview on 5/26/22, at 11:20 a.m. R3 was seated in her recliner in her room. R3 was transferred to bed. RN-B changed the dressing on R3's coccyx with no complaints of pain. Left and right buttocks noted to be red with open areas, the left inner buttock middle area, measures 1.5 centimeters (cm) x 1.5 cm, distal to this is the second open area that measures 0.8 cm x 0.3 cm, and the top open area measures 0.2 cm x 0.9 cm. RN-B did not have any border foam available, she stated when their scheduler quit, she oversaw ordering the supplies and they had been out of border foam dressing for a while now. RN-B used a border gauze dressing instead. RN-B verified all 3 open areas are stage 2 pressure ulcers, and further verified she was not aware of them. RN-B stated, I would expect for dressing changes to be completed as ordered and for there to be comprehensive weekly skin assessments to include weekly measurements of wounds. Aides should be reporting skin concerns and when a residents dressing comes off. RN-B verified that R3's pressure ulcers had worsened. R4's admission record identified, an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly MDS assessment dated [DATE], indicated that R4 had severely impaired cognition, no walking, extensive assist of 2 with toilet use, total dependence of 1 with eating, hygiene and locomotion, total dependence of 2 with transfers and bed mobility, uses wheelchair for mobility. Also noted to be frequently incontinent of bowel and bladder. Section M indicated at risk for pressure ulcers, no skin concerns, has pressure reducing device for her chair and bed. Applications of ointments/medications other than to feet. R4's medical doctor (MD) orders indicated the following: 7/9/20, turn and reposition patient every 2-3 hours during the day and night. 5/11/22, cleanse wound on coccyx with NS, pat dry. Apply hydrogel to wound, 3M barrier spray around wound, let dry then cover with [MEDICATION(S)] border dressing and change every 2-3 days and as needed. Initial and date dressing. R4's care plan dated 1/11/19, indicated she was skin integrity risk related to impaired mobility, cognition, diabetes and incontinence. Interventions included barrier cream to buttocks as needed, encourage to reposition as needed, float heel s as able, observe skin condition with cares daily, pressure device on bed and chair, skin care routinely twice a day. Does not identify pressure ulcer. R4's Care Sheet lacks pressure ulcer interventions as MD ordered, to reposition every 2 hours and not lay R4 in supine position. R4's NP progress note dated 4/28/22, identified R4's pressure injury of sacral region stage 2 measurements were 1.2 cm x 0.7 cm. New order: cleanse wound with NS, pat dry entirely, apply hydrogel to wound, 3M barrier spray around wound, let dry then cover with [MEDICATION(S)] border dressing and change every 2-3 days and as needed. Ensure R3 was not resting in supine position, assist her to position from side to side. R4's progress note dated 5/7/22, identified that Trained Medication Aide (TMA) reported that there was an open area on R4's coccyx. Area cleansed, barrier cream applied and R4 was repositioned. No apparent discomfort noted. R4's NP progress note dated 5/9/22, identified R4 was evaluated for an open area to her coccyx. Wound on R4's coccyx seems superficial and is beefy red. Pressure injury of sacral region stage 2. Measurements are 2 cm x 0.5 cm. New order: cleanse wound with NS, pat dry entirely, cover with foam border dressing ([MEDICATION(S)] border), initial and date dressing, and change every 3 days and as needed. Ensure R3 was not resting in supine position, assist her to position from side to side. R4's TAR dated May 2022, indicated on 5/11/22, to cleanse coccyx wound with NS, pat dry entirely, apply hydrogel to wound, 3M barrier spray around wound, let dry then cover with [MEDICATION(S)] border dressing and change every day shift every 3 days. R4's weekly skin review, dated 4/1/22, 4/7/22, 4/14/22, 4/28/22, and 5/21/22, all indicated no skin impairments. R4's record did not include comprehensive skin assessments completed by licensed staff. Review of R3's record also did not identify root cause of the skin break During continuous observation on 5/24/22, at 6:55 a.m. R4 was seated up to the table in the dining room holding red tubular anticontracture cushion in both hands. At 8:22 a.m. the director of nursing (DON) started to assist feeding R4. At: 8:44 a.m. R4 was done eating and continued to be seated up to the table in the dining room. During observation and interview on 5/24/22, at 9:10 a.m. NA-C and NP-A assist R4 to bed with the sit to stand lift. R4's brief was wet and removed, border dressing on coccyx area was dated 5/20/22, NP-A removed the dressing. Coccyx open area was measured 0.7 cm x 0.7 cm. NP-A verified the pressure ulcer is a stage 2, stated the order for the dressing was to change every 3 days and will need to be changed to every other day with the same treatment order. RN-B began cleansing wound with NS, R4 began to have a bowel movement. RN-B left the room and asked NA-C to let her know when she was done. At 9:32 a.m. RN-B back in the room, was not observed to wash her hands, applied gloves, cleansed wound with NS, applied hydrogel with a Qtip, and sprayed skin protect around the wound, allowed to dry, and applied 6 x 6 border gauze. RN-B stated she would normally use border foam as ordered but stated they were out of border foam in the facility. During interview on 5/24/22, at 9:48 a.m. RN-B stated RN-A put in her notice a couple weeks ago, she used to be the third-floor unit manager. RN-B verified that R4's dressing was dated 5/20/22, and verified it should have been changed yesterday on 5/23/22, per MD orders. After RN-A left they have been super short staffed, and stated, I think the measurements for all the wounds up here have kind of fallen off the board. I think the last time her wound was measured was May 3rd, it started out with MASD and now has turned into a stage 2. Wound measurements should be done weekly to determine if the treatment plan is effective. During observation and interview on 5/26/22, at 10:10 a.m. R4 was transferred to the toilet with the EZ-stand, there was no dressing noted on her coccyx area. RN-B measured her wound which measured 1.2 cm x 0.5 cm. RN-B verified it is a stage 2 pressure ulcer. RN-B washed wound with NS, hydrogel to wound, and skin prep around wound applied, used a 6 x 6 border gauze as the facility is still out of the foam dressings. Stated she would normally use the 4 x 4 size. RN-B verified R4's wound had worsened. R11's admission record identified an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's PPS 5-day MDS assessment dated [DATE], indicated that R11 had severely impaired cognition, no walking, required supervision with eating and locomotion, extensive assist of one with locomotion and extensive assist of 2 with bed mobility, transfers, dressing, toilet use and hygiene, used wheelchair for mobility. Always incontinent of bowel and bladder. Identified that R11 is at risk for pressure ulcers, no current skin concerns. Pressure reducing device for bed and chair and application of ointment/medication other than to feet. R11's NP progress note dated 5/12/22, did not identify any skin issues to her buttocks. R11's NP progress note dated 5/16/22, follow up for incontinence associated [CONDITION(S)] (a type of MASD). R11 complained of pain/discomfort in her groin and intergluteal area, stated it was from her ongoing diarrhea. Nursing reported R11's bottom is raw or sore. Appearance appeared so raw and [CONDITION(S)] (red). Current plan, cleanse patient after each incontinence and apply barrier cream, apply hydrocortisone (corticosteroid) cream and [MEDICATION(S)] (antifungal cream) twice daily. R11's NP progress note dated 5/20/22, identified a visit for COVID infection, no new orders, diarrhea resolved 2 days ago, and skin was not assessed. Projected date of R11 coming out of isolation was 5/28/22. R11's NP progress note dated 5/23/22, identified a follow up visit for COVID infection, identified a pressure ulcer of sacral region measuring 2 cm x 0.5 cm, open area has good granulation tissue, new order for sacral dressing, cleanse with NS, pat dry entirely, apply hydrogel to wound, 3M barrier spray around wound, let dry then cover with [MEDICATION(S)] border dressing and change every day. Initial and date wound. R11's care plan prior to 5/26/22, lacked a focus, goal and interventions pertaining to skin concerns. On 5/26/22, indicated R3 has actual skin integrity break and/or pressure sore, chronic non pressure wound on buttock, interventions assess and measure all skin integrity areas per policy, monitor and report any new open areas, draining, or pain to nurse immediately, provide treatment to wound per current treatment order. Interventions do not include, repositioning or offloading pressure ulcers per current NP orders. Toileting assist was not addressed. R11's SBAR (situation, background, assessment, response) progress note dated 5/26/22, at 2:43 p.m. R11 noted to have an open area on her sacrum that measure 2.2 cm x 0.9 cm and an open area on her right buttock that measures 1.1 cm x 0.6 cm. These are both superficial open areas. Surrounding skin does look red and irritated. Areas cleaned with NS and foam and bordered gauze applied for protection. R11's medical record lacked weekly skin assessment nor include comprehensive skin assessments completed by licensed staff. Review of R3's record also did not identify root cause of the skin break down nor an assessment/evaluation of the effectiveness of the care plan interventions. R11's care sheet was requested and not provided. R11's TAR requested and not provided. During interview on 5/26/22, at 10:13 am NA-E was in R11's room and stated R11 had a bowel movement, so her dressing got soiled and it was thrown away. NA-E stated R41 does have a small crack in her butt crease. RN-B stated there were no current dressing orders for R11. During observation on 5/26/22 10:18 am. RN-B helped assist R11 to her left side while in her bed. RN-B cleaned gluteal cleft with NS. RN-B verified R11 has a stage 2 pressure ulcer on right side of buttock near fold that measures 1.1 cm x 0.6 cm, sacral wound is 2.2 cm x 0.9 cm, and small area of excoriation on left buttock. RN-B stated, I will put a gauze dressing on it for right now to cover the area and will call MD and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 5/26/22, 10:20 a.m. RN-B stated, I would expect to do doing dressing changes as ordered and for there to be weekly skin assessments. Aides should be reporting when dressings come off. RN-B verified the pressure ulcer had worsened. R41's admission record identified an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41' s admission MDS assessment dated [DATE], indicated that R41 had severely impaired cognitive impairment, physical and verbal behaviors occurred for 4 to 6 days and displayed other behavioral symptoms not directed towards others for 1 to 3 days. R41 did not walk, required extensive assist of 1 with hygiene, extensive assist of 2 with toilet use, dressing, transfers and bed mobility and total dependence of 1 with locomotion and eating. R36 was always incontinent of bladder and bowel and no pressure ulcers identified. At risk for pressure ulcers, pressure reducing device for bed and wheelchair, application of nonsurgical dressing and ointment/medications other than to feet. R41's MD progress note dated 5/4/22, identified that R41 had slept the night in his Geri chair (a large, padded chair that is cushioned and can recline, that is designed to help seniors with limited mobility). R41's progress note dated 5/9/22, indicated R41 had V-shaped redness to his buttocks, no measurement identified, barrier cream and [MEDICATION(S)] powder applied and covered with a [MEDICATION(S)] dressing. R41's NP progress note dated 5/10/22, identified that R41's wife had concerns about R41 getting pressure ulcers due to all the time spent in his Geri chair. Pressure ulcer stage 1 of sacral region was noted with a picture. Did not identify a measurement. New order to apply 3M barrier spray to skin, air dry and cover with a [MEDICATION(S)] border. Change dressing every 3 days and as needed if soiled. Initiate frequent positioning, at least every 2 hours. Ensure to lay down after breakfast and lunch to offload pressure. R41's care plan dated 5/16/22, identified R41 at risk for skin integrity condition or pressure ulcers, related to impaired mobility, incontinence of bowel and bladder, and nutritional deficit-malnutrition. Interventions included: frequent repositioning, pressure reduction chair cushion and pressure reduction mattress, avoid friction/shearing while repositioning and keep resident clean and dry use barrier cream after good peri-care, also apply proper incontinent products as indicated. apply dressing to area as needed. Further identified R41 to be dependent on staff for toileting and to offer toileting upon rising, before and after meals, activities and at bedtime. R41's progress note dated 5/21/22, at 6:24 a.m. indicated R41 slept all night in his Geri chair. R41's progress note, SBAR dated 5/26/22, at 2:11 p.m. indicated R41 had his dressing changed to his buttocks and a superficial open area measuring 1.8 cm x 0.7 cm just to the left of his sacrum. Skin surrounding the open area was red but was blanchable. Area cleansed with NS, foam dressing and bordered gauze applied, please assess and determine if new orders need to be initiated for this new finding. R41's weekly skin review assessments were completed on 5/4/22, 5/18/25 and 5/24/22, and indicated no skin concerns. Review of R3's record also did not identify root cause of the skin break down nor an assessment/evaluation of the effectiveness of the care plan interventions. During continuous observation on 5/24/22, 6:55 a.m. R44 was noted to be well groomed and dressed seated up to the table for breakfast. At 7:52 a.m. R41 remained seated in his Geri chair in the dining room near the window. At 8:22 a.m. the DON noted to be assisting R41 with eating. At 8:44 a.m. R41 continued to be seated up to the table in the dining room overlooking the window. At 9:45 a.m. R41 remained seated in the same spot looking out the window. At 10:33 a.m. R41 remained in the dining room in his Geri chair, no one had offered to reposition or toilet R41. Toileting and repositioning record indicate he was toileted and repositioned on 5/24/22, at 5:59 a.m. and again at 12:17 p.m. 6 hours without being offered toileting or repositioning. During interview on 5/24/22, at 7:06 a.m. NA-C stated, We are severely short staffed, I don't get to reposition the residents or potty them timely. For example, R41 came here about three weeks ago, by Monday he already had a sore on his bottom that opened up, he literally sits in that chair all the time. During observation on 5/26/22, at 8:54 a.m. R41 was noted to be seated in his Geri chair in the dining room with his breakfast tray in front of him. During observation and interview on 5/26/22, at 11:08 a.m. NA-E and NA-J assisted R41 to the toilet via ez-stand, RN-B assessed R41's buttocks and noted an open area measuring 1.8 cm x 0.7 cm just to the left of his sacrum. RN-B verified this was a stage 2 pressure ulcer. Skin surrounding the open area was red but blanchable. Area cleansed with NS, foam dressing and bordered gauze applied. RN-B stated she would contact the doctor for dressing order, stated she was not aware he had a pressure ulcer and verified the last mention of his wound to buttocks was reddened on 5/9/2,2 and verified his wound had worsened. During interview on 5/26/22, at 11:20 a.m. NA-J verified R41 had not been offered toileting or repositioning since he got up in his chair at 5:39 a.m. R43's admission record identified an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's quarterly MDS assessment dated [DATE], indicated that R43 had moderately impaired cognition, no walking, supervision with eating, extensive assist of 1 with locomotion and extensive assist of 2 with toilet use, hygiene, dressing, transfer and bed mobility, uses wheelchair for mobility. Also noted to be frequently incontinent of bowel and bladder and no pressure ulcers identified. At risk for pressure ulcers, pressure reducing device for bed and wheelchair, application of nonsurgical dressing and ointment/medications other than to feet. R43's MD orders dated 5/7/22, indicated to apply [MEDICATION(S)] to coccyx area every day to prevent skin break down. Offload from chair every 3 hours document refusal. R43's MD notes were asked for and not provided. R43's care plan dated 6/21/17, identified R43 is at risk for skin integrity break related to impaired mobility, and bowel and bladder incontinence. Interventions included to lay resident down in bed after meals to offload buttocks, provide treatment to wound per current treatment order, assess and observe wounds for signs and symptoms of infection with each dressing change, report negative findings to the physician. For toileting provide incontinence care/perineal care after each incontinent episode. Use barrier cream each time. April 2022 skin assessments were completed weekly and identified no skin concerns R43's weekly skin assessments dated 5/3/22, identified a pink coccyx-barrier cream applied. On 5/10/22, assessment showed reddened coccyx applied barrier cream, 5/17/22 and 5/25/22 skin assessments do not identify any skin concerns. R43's TAR dated 5/10/22, indicated an order to apply [MEDICATION(S)] to coccyx area every day to prevent skin break down every evening shift every 3 days. Offload from chair every 3 hours document refusal. R43's toileting and repositioning documentation was reviewed for 5/24/22, and was noted to have assist at 5:59 a.m. 1:59 p.m. and 9:58 p.m. During observation on 5/24/22, at 6:47 a.m. R43 was noted to be seated up to the table in the dining room. At 10:33 a.m. remained seated in the dining room was not offered toileting or repositioning during this period of time. During interview on 5/24/22, at 7:06 a.m. NA-C stated, We are severely short staffed, I don't get to reposition the residents or potty them timely. For example, we have lots of pressure ulcers on this unit within the last few weeks that just happened because we have been running such short staffed. There are four residents that I can think of [R3, R4, R41 and R42]. It is from not enough staff so we can't reposition them, toilet timely, several are two person transfers, and they are all incontinent. During observation on 5/26/22, at 10:41 am. R43 was transferred to the toilet with an ez-stand, a bordered foam dressing dated 5/14/22, was found on her lower back, underneath dressing skin was clean and intact on lower back. RN-B was not sure why the dressing was there and verified there were no orders for it. RN-B assessed buttocks and found a stage 2 pressure ulcer that measured 0.4 cm x 0.2 cm, verified it is stage 2 pressure ulcer and stated, I will put some zinc cream on it and write up an sbar for the doctor so we can get a dressing ordered. During interview on 5/26/22, at 4:01 p.m. DON was asked when R41's first skin issue was and DON was not aware of one. When told DON that R41 had a 1.8 cm x 0.7 cm, stage 2 pressure ulcer to left upper buttock that RN-B verified and measured. DON stated, Our company says we are not allowed to stage a pressure ulcer, we are to notify the provider and they are the ones that will diagnose it. DON could not find any pressure ulcer in the medical record, when asked about R3, R4, R11, R42 and R43, stated she will have to check. DON was notified that there were continuous observations done on 5/24/22, for R4, R41, and R42 and they were not moved out of their wheelchairs for almost 4 hours, not offloaded, toileted, or repositioned. DON stated her expectation is to offer toileting, repositioned and offloaded per the care plan, especially when they are at risk for pressure ulcers. DON stated they have been short staffed since RN-A abruptly quit. When asked who took over the unit manager for 3rd floor, DON stated, well me and RN-B are trying to. During interview on 5/27/22, at 11:08 a.m. DON indicated the facility has been severely short staffed. DON stated when RN-A (who was the third-floor unit manager) quit on 5/6/22, was when the staffing got bad. DON stated, We have no maintenance staff, no social worker, no unit manager for third floor, no scheduler, and our MDS coordinator is out with COVID, so I am having to fill it all. DON verified they have not hired a replacement for third floor manager and verified no one has been doing the third-floor managers job which includes the RN assessments, falls, wound assessments, and care plan updating. R42's admission record identified, an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's quarterly MDS assessment dated [DATE], indicated that R42 had severely impaired cognition, no walking, extensive assist of one staff with dressing, extensive assist of 2 staff with bed mobility, total dependence of 1 staff with locomotion, hygiene and eating, total dependence of 2 with transfers, uses wheelchair for mobility. R42 was frequently incontinent of bladder and bowel and no pressure ulcers identified. At risk for pressure ulcers, pressure reducing device for bed and wheelchair, application of nonsurgical dressing and ointment/medications other than to feet. R42's NP progress note dated 5/6/22, identified new wound measurements from 4/29/22, were 0.7 cm x 0.5 cm x 0.1 cm to intergluteal cleft. Current measurements are 2.1 cm x 1 cm x 1 cm and distal pinpoint 0.3 cm 0.3cm open area. New order Intergluteal Cleft, cleanse with normal saline or wound cleanser. Pat dry and apply Hydrogel to open areas and then 3 M barrier spray to surrounding skin, then cover with foam border dressing. Initial and date dressing. Change every other day and PRN when soiled. Ensure skin is always dry. Ensure patient is repositioned every 2 hours to offload pressure. R42's NP progress note dated 5/13/22, identified wound measurements 2.1 cm x 1 cm x 1 cm and distal pinpoint 0.3 cm 0.3cm open area. New order Intergluteal Cleft, cleanse with normal saline or wound cleanser. Pat dry and apply Hydrogel to open areas and then 3 M barrier spray to surrounding skin, then cover with foam border dressing. Initial and date dressing. Change every other day and PRN when soiled. Ensure skin is always dry. Ensure patient is repositioned every 2 hours to offload pressure. R42's MD Orders dated 5/13/22, indicated, Intergluteal Cleft, cleanse with normal saline or wound cleanser. Pat dry and apply Hydrogel to open areas and then 3 M barrier spray to surrounding skin, then cover with foam border dressing. Initial and date dressing. Change every other day and PRN when soiled. Ensure skin is always dry. R42's NP progress note dated 5/23/22, identified wound measurements from 4/29/22 were 0.7 cm x 0.5 cm x 0.1 cm to intergluteal cleft and 2.1 cm x 1 cm x 1 cm and distal pinpoint 0.3 cm 0.3cm open area. Continue with current orders and will follow up in 1 week on 6/1/22. R42's care plan reviewed and indicated the potential for developing skin alterations due to resistance with bathing and cares from caregivers, often refuses baths and will refuse am and pm cares, interventions included Inform the resident/family/caregivers of any new area of skin breakdown, monitor dressing to ensure it is intact and adhering. Report lose dressing to Treatment nurse, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. For toileting the intervention is to check resident before and after meals and prn for incontinent episodes. R42's Care sheet identified R42 needed mechanical assist of 2 with transfers and did not identify repositioning and pressure ulcers. Toileting should be offered every am and hs and before and after meals. During observation on 5/24/22, at 6:47 a.m. R42 was noted to be seated up to the table in the dining room. During observation on 5/26/22, at 8:06 a.m. R42 was seated in her Broda chair up to the table in the dining room. During observation on 5/26/22, at 8:54 a.m. R42 was seated in her Broda chair dressed in blue, has a blanket on her lap, with mask on and her eyes closed, she is seated up to the table. During observation and interview on 5/26/22, at 9:33 a.m. R42 is transferred to the toilet with EZ-stand, R42 is noted to not have a dressing on her buttocks. RN-B measures the wound 0.3 [TRUNCATED]

Based on observation, interview, and document review the facility failed to provide sufficient nursing staff to provide care and services to assure resident safety and attain or maintain the highest practicable well-being in accordance with resident's comprehensive assessment, individualized care plan, and facility assessment. As a result, systemic system failures were identified in deficient practices in infection control prevention and practices that resulted in an Immediate Jeopardy (IJ), deficient practices in pressure ulcer prevention and care which resulted in harm for 5 of 7 residents (R3, R4, R11, R41, R43), and deficient practices related to bowel and bladder care for (R5, R41, R11, R42). Furthermore inadequate staffing also resulted in supply ordering for resident medication(s), wound supplies, and hand sanitizer. The facility's failures had the potential to effect all current residents that resided in the facility. Findings include: SEE F686 The facility failed to prevent pressure ulcers development or deterioration and promote healing by failing to follow physician ordered treatments, follow the care plan, and ensure comprehensive assessments and monitoring pressure for 7 of 7 residents (R3, R4, R11, R41, R43, R42, R5) reviewed for pressure ulcers. The facility's system failures resulted in actual harm for 5 of 7 residents (R3, R4, R11, R41, R43) when new ulcers developed and/or worsened. The deficient practice has the potential to effect all residents in the facility that are at risk for pressure ulcers. SEE F689 The facility failed to ensure fall program protocols were implemented resulting in system failure. The system failures included, failing to ensure completed comprehensive assessments, identification of causal factors and probable root cause, and development and implementation of interventions that would prevent and/or mitigate the risk of re-current falls and injury. In addition, the facility failed to complete post-fall neurological assessments in accordance with the facility's policy and failed to ensure interdisciplinary involvement process for 6 of 6 residents (R33, R36, R3, R1, R24, R41) reviewed for falls. This had the potential to affect all residents who are at risk for falls residing in the facility. SEE F690 The facility failed to complete comprehensive bowel/bladder assessments, failed to develop individualized toileting schedule/program, failed to follow the care plan for toileting to improve, maintain, or reduce the risk for worsening bowel/bladder function for R5. In addition, failed to provide timely incontinence cares to R41, R42 and R43. SEE F755 The facility failed to provide routine medications and have them available for R5. SEE F880 The facility failed to ensure staff implemented infection control practices to prevent and/or minimize a facility wide outbreak of coronavirus 2019 (COVID 19) for 29 residents who resided at the facility. This systemic system failure resulted in an immediate jeopardy (IJ) and had the potential to affect all 59 residents and staff residing in the facility. Resident observations and interviews: During on an observation on 5/24/22, at 7:22 a.m. room [ROOM NUMBER] on the second floor was noted to have a call light on and not answered for thirty-two (32) minutes. During on an observation on 5/24/22, at 7:27 a.m. room [ROOM NUMBER] on the second floor was noted to have a call light on and not answered for sixteen (16) minutes. During on an observation on 5/24/22, at 7:32 a.m. room [ROOM NUMBER] on the second floor was noted to have a call light on and not answered for forty-two (42) minutes. During on an observation on 5/24/22, at 10:20 a.m. room [ROOM NUMBER] on the second floor was noted to have a call light on and not answered for sixteen (16) minutes. During this time period R45 could be heard yelling, can anyone help me please? Please, please please. During an interview on 5/24/22, at 7:58 a.m. R7,an alert and oriented resident, stated staffing was a concern, on a good day there were 4 aides on second floor, recently it has been mediocre with 3 aides. During on an observation on 5/24/22, at 8:37 a.m. room [ROOM NUMBER] on the second floor was noted to have a call light on and not answered for thirty-nine(39) minutes. During an interview on 5/24/22, at 10:13 a.m. R47, an alert and oriented resident, stated facility was short staffed, and it took up to 30 minutes to get the call light answered. R47 indicated he was admitted the beginning of March for a left knee surgery and stated, I fell on [DATE], trying to get to the bathroom and ended up with a subdermal hematoma which has extended my stay. Staff claimed they heard the fall and responded right away. The staff have told me they are short staffed. When I look out into the hallway, I don't see any staff around. During an interview on 5/26/22, at 9:05 a.m. R5, an alert and oriented resident, stated she put her call light on at 7:40 a.m., said she needed help to be boosted up in bed and has had to lay in the same position until staff responded at 9:00 a.m. R5 stated with the long call light wait times it makes her legs sore and further stated the staff do not check and change her or reposition her every 2 hours like they are supposed to. R5 stated she lays in wet depends for extended periods of time, and indicated the short staffing started before COVID hit the building and it has gotten worse since. We do have agency staff, but they don't seem to care, you might just put your light on to get some water, but no one answers it. R5 stated the long call light wait times have not been addressed. Staffing schedule: On 5/25/22, at 10:30 a.m. it was requested for the business office manager (BOM) to print timecards for nursing staff that worked each day. After review of facility documents, Daily Nursing Staffing schedules were not reflective of who worked the floor. Through staff interviews, review of schedule, and the facility assessment the expectation was to have two aides staffed to each unit during the day and evening shifts and to have a nurse or TMA assigned to each unit. For night shift one nurse for second and third floor and two aides on second floor and one aide on 3rd floor. The following days and shifts identified staff shortages: 5/1/22 for day shift, 1 of 4 aides scheduled worked the second floor. For evening shift, 2 of 4 aides scheduled worked the second floor. 5/2/22: for day shift, 2 of 4 aides scheduled worked the second floor and 1 of 2 aides scheduled worked the third floor. 5/3/22: For night shift, 1 of 2 aides scheduled worked the second floor. 5/5/22: for evening shift, 3 of 4 aides scheduled worked second floor and 1 of 2 aides scheduled worked third floor. 5/6/22: for day shift, 2 of 4 aides scheduled worked the second floor. For evening shift, 3 of 4 aides scheduled worked the second floor, and 1 of 2 aides scheduled worked the third floor. 5/7/22: for day shift, 3of 4 aides scheduled worked the second floor. For evening shift, 3 of 4 aides scheduled, worked the second floor. 5/8/22: for evening shift, 3 of 4 aides scheduled worked the second floor, and 1 of 2 aides scheduled worked the third floor. 5/13/22: for evening shift, 3 of 4 aides scheduled, worked the second floor, and 1 of 2 aides scheduled worked the third floor. 5/14/22: for evening shift, 3 of 4 aides scheduled, worked the second floor, and 1 of 2 aides scheduled worked the second floor. 5/15/22: for day shift, 3 of 4 aides scheduled, worked the second floor. 1 of 2 aides scheduled worked the third floor. For evening shift, 2 of 4 aides scheduled worked the second floor. 5/21/22: for day shift, 3 of 4 aides scheduled worked the second floor. For evening shift, 3 of 4 aides scheduled worked the second floor. 5/22/22: for day shift, 1 of 4 aides scheduled worked the second floor. For evening shift, 3 of 4 aides scheduled worked the second floor. Staff concerns: During an observation and interview on 5/24/22, 6:47 a.m., R3 walked independently down the hallway towards the dining area, with her red four-wheeled walker. While ambulating R3 was hunched over, and her gait was not steady. nursing assistant (NA)-C stated that R3 fell and fractured her hip awhile back, after that she needed more assist. NA-C verified R3 was to be stand by assist with the use of a gait belt when ambulating. NA-C stated, we just don't have enough staff to do that with her, as you can see, she just gets up and goes wherever she wants, we just don't have the staff, and she has fallen several times since her surgery. During interview on 5/24/22, at 7:06 a.m. NA-C stated, we are severely short staffed, I don't get to reposition the residents or potty them timely. For example, R41 came here about 3 weeks ago, by Monday he already had a sore on his bottom that opened, he literally sits in that chair all the time. During interview on 5/24/22, at 7:48 a.m. NA-B stated on second floor they should always have 4 aides on, we usually only have 1 aide on each side of second floor and then we usually have a (trained medication assistant) TMA on one side and 1 nurse that must run the whole second floor. Most of the time we don't have time to get the showers done and people are not getting turned and repositioned timely. During an interview on 5/24/22, at 9:06 a.m. licensed practical nurse (LPN)-A stated, staffing has really been a challenge, I am the only full-time nurse here, it turns into being mandated at times, usually once a week. During an interview on 5/24/22, at 9:15 a.m. NA-B stated due to staffing shortage we don't get to call lights on time, or turning and repositioning timely, we also only have 1 EZ-stand lift and 1 Hoyer lift for the whole second floor that functions correctly. We also need more staff at mealtimes. 5/24/22, at 9:24 a.m. when asked about staffing, NA-A stated, the residents extra wants are more than we can attend to right now. During an interview on 5/24/22, at 9:49 a.m. LPN-B stated, we are short staffed, we have 1 nurse to 23 residents who need their meds, skin checks after showers and wound care. There should be a nurse to each wing and that does not always happen, a year ago they had 3 nurses assigned to the second floor. The extra nurse did all the wound and dressing changes. Morning med passes are not getting completed until after 11 a.m. We also need more aides in the morning for (activity of daily living) ADL cares such as showers, oral care, and general grooming are not getting done. During interview on 5/24/22, at 9:48 a.m. registered nurse (RN)-B stated, RN-A put in her notice a couple weeks ago, she used to be the third-floor unit manager. RN-B verified that R4's dressing was dated 5/20/22, and further verified it should have been changed yesterday on 5/23/22, per MD orders. After RN-A left we have been super short staffed, I think the measurements for all the wounds up here have kind of fallen off the board. I think the last time R4's wound was measured was 5/3/22, it started out with MASD and now has turned into a stage 2. Wound measurements should be done weekly to determine if the treatment plan is effective. During an interview on 5/24/22, at 12:07 p.m. infection preventionist (IP) stated she started back at the facility on 5/1/22, and further stated the outbreak of COVID started on 5/13/22. On 5/19/22, the DON had called, as there were an additional 8 residents who tested positive and had spread from the second floor to the third floor. We had talked about moving the positive cases to the first floor but were unable to due to staffing shortage. IP stated she had discussed to reach out to the Minnesota department of health (MDH) crisis staffing, but instead we reached out to our corporate office, and we obtained staffing from our sister facilities, we also increased bonuses for this facility to get shifts picked up. IP verified they did not open a COVID unit to cohort positive residents because of insufficient staffing. IP confirmed some residents who were COVID positive did have shared bathrooms with non-covid cases. During an interview on 5/24/22 at 12:32 p.m. the DON stated that they ran out of hand sanitizer because the scheduler was responsible for ordering it and she had quit on 5/17/22, so it never got re-ordered. DON indicated the facility did not have a system in place to ensure supplies were ordered after the staff member left. DON stated she thought there were several bottles of hand sanitizer put out on all of the units. During observation and interview on 5/26/22, at 11:20 a.m. R3 was seated in her recliner in her room. Registered nurse (RN)-B changed the dressing on R3's coccyx .RN-B did not have any border foam available, she stated when their scheduler quit, she oversaw ordering the supplies and they had been out of border foam dressing for a while now. RN-B used a border gauze dressing instead. RN-B verified all 3 open areas are stage 2 pressure ulcers, and further verified she was not aware of them. During interview on 5/27/22, at 11:08 a.m. director of nursing (DON) indicated the facility has been severely short staffed. DON stated when RN-A (who was the third-floor unit manager) quit on 5/6/22, was when the staffing got bad. DON stated, we have no maintenance staff, no social worker, no unit manager for third floor, no scheduler, and our MDS coordinator is out with COVID, so I am having to fill it all. DON verified they have not hired a replacement for third floor manager and verified no one has been doing the third-floor managers job which includes the RN assessments, falls, wound assessments, and care plan updating. Since RN-A has left, all residents that have had falls on the third floor, their care plans have not been updated with new interventions, and their falls have not been root caused. At 12: 24 p.m. DON admitted that due to the staffing shortage and the loss of the staffing coordinator, she is managing the staffing schedule and does not have time to get into each resident's chart to update the care plan. The IDT discusses fall prevention interventions, they are just not entered into the resident's chart in a timely fashion. At 12:40 p.m. DON stated her expectation would be to have the call lights answered within 10 minutes. DON further stated that the staffing since COVID has been horrible and has been working on staffing since the scheduler up and quit. DON showed surveyor the staffing sheets which indicated there were 36 open shifts for nurses from 5/16/22 to 5/31/22 and 36 open shifts for aides between 5/18/22 to 5/31/22. DON stated, so, we have had the social worker, scheduler, maintenance, and nursing educator all quit. We used to have 3 nurse managers and receptionist, and DON verified they only have 1 nurse manager now. Call light logs were requested and not received. A document titled, Facility Assessment Tool, dated 11/2021, indicated, the purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The intent is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services that residents require. Under Resident Profile, the assessment indicated the facility is licensed to provide care for 111 residents: first floor has a maximum capacity of 17, second floor has maximum capacity of 64 and memory care has a maximum capacity of 30 residents. Part 2: Services and care we offer based on our resident's needs. Activities of daily living, mobility and fall/fall with injury prevention, bowel/bladder/toileting programs, skin integrity, medications, management of medical conditions to include early identification of problems/deterioration and identification, containment, and prevention of infections. Section 3.2 indicated the staffing plan will require for licensed nurses (LN) -1 DON full time days, -MDS RN full time days, part time days, -1 ADON/unit managers full time days, and 1 LN for each shift. Day shift short term rehab unit: 1: 17 residents, Day shift days and evening long term care/mixed units 1:22, and LN ratio night shift 1:40, the assessment does not identify the ratio for the memory care unit. For direct care staff: Day shift short term rehab unit: 1: 7 residents, days and evenings, 1:10 might shift, second floor mixed unit 1:10 ratio for days and evenings, 1:19 ratio for night shift. Third floor memory care unit 1:8 ratio for days and evenings and 1:14 ratio for night shift. Other departments heads that are required are: 1 fulltime director of clinical education, 1 full time maintenance staff, 1 full time social services staff, medical supplies that would be available include gloves, gowns, hand sanitizer, gait belts, infection control products and oxygen. Does not identify wound products. Section 3.11 identified the infection control [programs review new state recommendations, participates in quality network ([NAME]) and follows CDC guidelines to ensure the most current practices are in place as it relates to infection control. A line listing for resident infections and a separate line listing for facility staff and others is maintained, reviewed, and analyzed monthly to identify any trends or educational needs or gaps in processes as it relates to infection control. and 1 full time scheduler/central supply specialist.

Based on observation, interview and document review, the facility failed to comprehensively assess, revise care plan interventions following MD ordered interventions, and did not communicate timely with the medical doctor (MD) that a pressure ulcer (PU) was necrotic (tissue death). Facility staff waited two days after discovering the necrotic wound to request the MD come to the facility and assess resident. This resulted in an immediate Jeopardy (IJ) for R1 who was hospitilized and required three surgeries to treat the PU. The IJ began on 2/15/22, when the facility failed to timely intervene with medical services after discovering R1 had necrotic tissue. This had the possibility of further wound necrosis and increased pain. The director of nursing was notified of the IJ on 3/8/22, at 5:45 p.m. and the immediacy was removed on 3/9/22, at 1:45 p.m. when the facility's approved removal plan was verified onsite by the state agency but the noncompliance remained at the lower scope and severity level of D - no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission minimum data set (MDS) assessment dated [DATE], documented R1's Brief Interview of Mental Status (BIMS) assessment as R1 was moderately cognitively intact; R1's activities of daily living assessment identified R1 required extensive assistance with bed mobility, transferring, dressing, toileting and personal hygiene, and total dependence with locomotion; and skin assessment documented R1 did not have skin issues or a pressure ulcer upon admission. Review of R1's care plan copied 3/7/22, identified R1 at risk for skin integrity condition or pressure sores related to impaired mobility and incontinence. The goal of the intervention was to assess skin for redness or pressure related changes with each care encounter and report any changes immediately. Review of R1's Braden Scale for Predicting Pressure Sore Risk Scale dated 12/03/21, indicated R1 was at moderate risk of developing a pressure ulcer. Review of R1's Non-Pressure Weekly Tracker assessment dated [DATE], documented R1 had a facility acquired wound to his left buttocks. Review of the Weekly Pressure Wound Evaluations: 1/18/22 Measurements: Length 3.6 c.m. x width 1.8 c.m. x depth 0.1 c.m. 1/25/22 Measurements: Length 3.2 c.m. x width 1.5 c.m. x depth 0.1 c.m. 2/1/22 Measurements: Length 3.0 c.m. x width 1.0 c.m. x depth 0.1 c.m. 2/8/22 Measurements: Length 3.0 c.m. x width 1.1 c.m. x depth 0.1 c.m. Review of NP-A encounter visit summary dated 1/7/22, at 3:40 p.m. documented R1's sacral wound assessment. Documentation included, PU of right buttock Stage 1 measuring 2.5 x 1.0 cm, skin remains intact, non-blanchable, and facility staff to assess skin underneath dressing daily, and notify provider if skin breakdown is observed. PU of sacral region Stage 3, more on the left side, measures approximately 3.5 x 2 cm., and wound bed is covered with slough/fatty tissue. NP-A ordered to cleanse the right buttock and apply foam board dressing, and sacral region to apply [MEDICATION(S)], change dressing daily, and cover with foam border dressing. Review of medical doctor (MD)-A encounter visit summary dated 1/11/22, unknown time of encounter, documented PU of sacral region Stage 3, measures approximately 3.5 x 2.0 cm., wound bed is covered with slough, cleanse the wound with normal saline or wound cleanser, pat dry, apply [MEDICATION(S)], cover with foam border dressing, change dressing daily and as needed and to reposition resident every two hours to offload pressure. Review of NP-A encounter visit summary dated 2/7/22, 10:00 a.m. documented R1's sacral pressure ulcer is getting worse, updated wound measurements of 3.0 x 1.1 x 0.1 cm., and continue with previous treatment orders. No new pressure ulcer prevention interventions were added to R1 provider order. Review of medical and treatment records lacked evidence pressure ulcer interventions were included or added following the MD orders and that even though the PU was worsening, interventions were updated on the care plan since 12/7/21. Review of NP-A's Progress Note dated 2/7/22, at 10:00 a.m. directed to change to a air altering mattress, dietician to evaluate and treat (needs protein supplementation to help with wound healing), continue to work with physical therapy and occupational therapy, encourage R1 to frequently reposition himself every 1.5- 2 hours, and avoid forty-five degree angle in supine position except when eating. Review of Situation, Background, Assessment, Recommendation (SBAR) dated 2/15/22, at 2:29 p.m. created by registered nurse (RN)-A documented R1 has had a change in condition regarding the sacral wound that is currently being treated and has had significant changes over the last week. Resident's sacral area now has an open area of 2.3 x 1.0 x 0.6 c.m. and the area around the wound measures 7.0 x 6.2 c.m. of dark brown/black skin. There is odor coming from this area and it is notable when entering the resident's room. RN-A indicated R1 was to be followed up with nurse practitioner (NP)-A the following week, but with the significant changes this week, R1 should be seen sooner. On 3/8/22, at 8:48 a.m. R1's significant other (SO) stated R1 has had three surgeries since being admitted to the hospital on 2/17/22, to treat the tunneling PU and he is currently receiving intravenous antibiotics due to the massive infection. SO stated they were in the emergency department (ED) for approximately forty minutes when they were informed R1 would be going to emergency surgery to remove dead tissue from his coccyx. SO stated R1 was in so much pain at the facility and questioned why he was not sent to the ED sooner. SO stated R1 is not expected to live. On 3/08/22, at 12:09 p.m. RN-A stated, when the provider needs to be contacted the procedure is to create an SBAR in PointClickCare (PCC) electronic medical record, print the document, and then fax it to clinic (C)-A. RN-A stated she keeps a paper copy of the SBAR and fax so she can track the request and make sure it is followed up by the provider. RN-A stated residents are usually seen in one to two days after faxing. If it is emergent or an emergency, then the facility will fax and call the provider. RN-A stated R1's PU change in condition and odor was not emergent or an emergency so waiting two days was acceptable. RN-A stated there were no new wound care interventions created after discovering the odor coming from R1's wound. RN-A stated the facility did not change R1 to an air mattress because that needs a provider order and they continued to use the standard facility mattress, even though NP-A had ordered an air altering mattress on 2/7/22. RN-A stated she faxed the change in condition to C-A regarding R1 on 2/15/22. RN-A documented in PCC that the wound had been changing and now it smelled like it was infected. RN-A stated she could smell the bad odor as soon as she entered R1's room and indicated she thought it was dead tissue. RN-A confirmed she faxed the SBAR on 2/15/22, but MD-A did not assess R1 until 2/17/22. RN-A stated there was no investigation of the reason why it took two days for a provider to see R1, even though R1 and R1's room smelled like dead tissue. RN-A stated she followed the facility process for notifying the provider. RN-A stated she has not had any formal training in wound assessments, but she observed the corporate clinical nurse (CCN)-A for a day to complete wound trackers (wound/skin assessments). The observation included how to measure wounds. After the observations, RN-A started completing weekly skin/wound assessment checks independently. On 3/08/22, at 12:18 p.m. director of nursing (DON) stated there was not an investigation or follow up of why R1 was not seen for two days after the SBAR was faxed to C-A. DON indicated with possible necrotic tissue, an SBAR fax should have been submitted with an immediate telephone call to the provider. DON stated MD-A wanted to complete a virtual exam, but she informed MD-A that due to the necrosis, he needed to exam R1 face-to-face. Upon examination, MD-A discussed the seriousness of the wound and that R1 needed to be transported to the ED. On 3/08/22, at 5:41 p.m. MD-A indicated he was not at a computer and would not be able to share any medical information without looking at R1's chart. MD-A would not state what his expectations would be if he was informed that a resident had possible necrotic tissue, other than someone should assess it. Review of the facility policy, Pressure and Non-Pressure Injuries, original effective date 8/2/21, identified a Stage 4 Pressure Injury as tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer and tunneling often occurs. Tunneling is described as a passageway of tissue destruction under the skin surface. The policy directs the provider be consulted to remove slough or eschar so a Stage 4 PU will be revealed. The immediate jeopardy that began on 2/15/22, was removed on 3/9/22, when the facility assessed all in-house residents skin to ensure there were no unidentified concerns, verified the care plan was up to date, and all findings were reviewed by the interdisciplinary team (IDT); all on-duty staff and all oncoming staff were reeducated on the skin policy; RN-A was assigned further training in Relias Learning Management System on wound and skin assessment and will have education completed by 3/9/22; LPN's were educated by DON starting 3/8/22, regarding RN completing weekly skin assessments, and consistent nurse completing measurements and wound and skin documentation process; LPN staff were reeducated by DON starting 3/8/22, on skin policy including, identifying risks for skin break down, ensuring air mattress as needed and incorporated appropriate interventions and ensuring skin preventions measures in place and care planned; the DON, executive director (ED) and unit managers were educated by DCC that residents with skin impairment are to be assessed for skin impairment risk and interventions to be implemented and care planned based on assessment; skin audits were implemented by DON on wound process, including care plan reviewed and up to date and new interventions put in to place as needed based, IDT review, and includes timely notification of physician and responsible party starting 3/10/22; and the quality assurance/process improvements (QA/PI) committee (composed of ED, DON, unit managers and MD-A) met ad-hoc to review the incident, discuss above action items and audits related to skin integrity and wound care on 3/9/22. A formal QA/PI meeting is to be held and all items and information will be reviewed and follow up on as needed., but the noncompliance remained at the lower scope and severity level of D- no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview and document review, the facility failed to comprehensively assess, monitor and implement interventions including completion of dressing changes and administer ordered antibiotic treatment for 1 of 3 residents (R43) with non-pressure related wounds. In addition, the facility failed to ensure elevation of swollen legs and utilization of compression wraps. This deficient practice resulted in actual harm for R43, who acquired an additional wound on the left lower leg and the medial and lateral wounds increased by 3-4 centimeters each in size. In addition, the facility failed to ensure treatment orders were provided as ordered for 1 of 3 resident (R4) reviewed for wound care who was at risk for non-pressure related wounds, Findings include: R43 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R43 as having a brief interview for mental status (BIMS) score of 12 indicating the resident had minor impairment in cognition. The MDS indicated R43 required extensive assistance with activities of daily living (ADL's). The MDS indicated R43 had 2 non-pressure related ulcers. The MDS identified interventions including non-surgical dressing to feet as well as ointments. R43's discharge MDS assessment dated [DATE], identified R43 as having a BIMS score of 12 indicating the resident had only minor impairment in cognition. The MDS indicated R43 required extensive assistance with ADL's. The MDS indicated R43 had a non-pressure related ulcer on the lower left leg. R43's current care plan dated 6/9/21 identified R43 as having impairment in skin integrity related to a venous ulcer (see wound assessment) . Interventions listed: provide treatment as ordered, monitor for redness, warmth, swelling and drainage, report progress or decline to provider and assess and measure all skin integrity areas per policy. The care plan identified R43 as having impairment ADL's due to a self-care deficit that included [CONDITION(S)], congestive heart failure (CHF) (when the heart does not pump blood like it should) and chronic obstructive pulmonary disease ([CONDITION(S)]) (inflammation in the lungs that causes obstruction of airflow). Although the care plan directed to see the wound assessment for R43's lower leg ulcer, there was no wound assessment in the medical record. In addition, it was noted in R43's history to have swollen legs as well as orders for compression wraps, this was not included in the plan of care nor were interventions. Review of a discharge hospital progress note dated 9/21/21, indicated R43 was hospitalized from 9/12//21 to 9/21/21, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (protein in the blood that carries oxygen to the body). The note dictated by medical doctor (MD)-A indicated R43 had chronic venous status ulcers to the lower left leg (medial and lateral). Wound care treatments were recommended for a few days to stabilize her healing prior to discharge. Physical therapy with advanced wound therapy was recommended on an out patient basis after discharge. The discharge notes did not include R43's wound progress or measurements while in the hospital. Recommendations included follow up with outpatient wound care for R43. Review of a facility re-admission skin assessment dated [DATE], identified R43 as having a vascular skin concern on the front lower left leg. The assessment did not include a description of the skin concern. There were no other skin assessments completed since the re-admission assessment on 9/21/21, of which only indicated R43 had a vascular skin concern. There was no documentation describing the condition of the wound. On 10/18/21, at 2:40 p.m. R43 was observed to have several fluid filled blisters on her left lower leg. R43's left lower leg was shiny, swollen and pinkish in color. There was a Kerlix wrap on the left lower leg, but the dressing was partially off exposing the blisters. R43 was sitting in her wheelchair with her legs down. R43 indicated she was unsure if the wounds were worsening or getting better, but that they were still painful. R43 indicated that her wound dressings often would fall down her leg, exposing the wounds. R43 further indicated that staff do not always replace the dressing when this happens. On 10/20/21, at 12:30 p.m R43 was observed sitting in a wheelchair with her legs down. R43's left leg remained pinkish, swollen and shiny. There was a dressing on the leg that was coming off, exposing several fluid filled blisters. R43 stated she had [CONDITION(S)] in her legs. R43 indicated she had blisters that would come and go, but was unsure if she had any other open areas. Ace wraps were on the lower leg, but were falling down as well. On 10/21/21, at 12:30 p.m. registered nurse (RN)-A was observed to change R43's lower left leg dressing. R43 had a 9.0 cm by 8.0 cm open area on the lower front part of the left leg. A 7.0 cm by 6.0 cm open area on the outer part of the lower left leg and a 6.0 cm by 6.0 cm open area on the outer back of the left leg. The dressings were noted to have yellowish colored drainage on the gauze when removed. The center of the wounds were pinkish in color with maceration (skin broken down by moisture) on the edges of each ulcer. There were several fluid filled blisters surrounding the ulcers. Interview with RN-A indicated she did not routinely measure or document the description of R43's lower leg wounds, because she thought that was only done with PU's. RN-A stated the lateral wound on the lower left leg was new and did not have when the resident returned from the hospital. RN-A indicated she observed R43's wound daily and had last observed on 10/20/21. RN-A stated R43 continues to get fluid filled blisters that form and then heal, as well as swelling in the legs RN-A also confirmed there were no discharge notes from the hospital stay, that included measurements or the description of the lower left leg wounds. RN-A also confirmed there were no measurements or description of the wound after returning from the hospital, or when the new ulcer on the lateral left leg had been identified. R43 complained of pain during the dressing change, but had received pain medication prior. R43's current physicians orders dated 10/1/21 to 10/31/21, included a dressing change to the lower left extremity ulcer. The order included to cleanse the lower left leg wound with saline and apply a [MEDICATION(S)] (antimicrobial agent to treat infections) compress. Apply silicone barrier cream (skin protectant) to wound perimeter and cover with a wet [MEDICATION(S)] Ag (antimicrobial dressing) followed by a ABD pad (absorbent dressing). Change daily and as needed. The orders also included to assess the wound daily. The physicians orders also included an order dated 10/8/21, for [MEDICATION(S)] 500 milligrams (mg) twice daily (BID) for 10 days and [MEDICATION(S)] V 250 mg four times a day (QID) for 10 days. Review of a progress note by doctor of podiatry medicine (PDM)-A dated 9/30/21, indicated R43 was seen to re-evaluate the lower left leg medial and lateral ulcerations. R43 was also seen for debridement of the lower left leg ulcers. The progress note identified the medial and lateral ulcers of the lower left leg to have slough tissue in the wound bed. Wound measurements were done before debridement and after debridement and listed below: Medial ulcer of the left lower leg Pre-debridement- 3.8 cm length by 3.9 cm width and 0.4 cm depth Post-debridement- 3.8 cm length by 3.9 cm width and 0.4 cm depth Lateral ulcer of the left lower leg Pre-debridement- 7.7 cm length by 4.0 cm width and 0.3 cm depth Post-debridement- 7.7 cm length by 4.0 cm width and 0.3 cm depth Review of a progress note by PDM-A dated 10/7/21, identified R43 as having ulcerations of the medial and lateral aspects of the lower left extremity. The progress note indicated there was increased redness of R43's left lower extremity and worsening of the skin of the periwound. A culture was completed which was positive for pseudomonas and enterococcus (bacteria). The progress note also indicated R43 was to have compressive wraps on, but did not during the appointment. The progress note identified the medial ulceration on the lower left leg having no slough tissue present and no new epithelial tissue present. The ulceration on the lateral aspect of the lower left leg identified the ulcer to have no slough tissue or epithelial tissue in the wound. The note indicated there was increased [CONDITION(S)] and skin breakdown of the periwound which appears to be drainage from the wound bed. [CONDITION(S)] present of the left lower extremity. The note further indicated R43 had been seen previously at the advanced would healing clinic (AWHC) on 9/30/21, and had increased redness of her left lower extremity and worsening skin of the periwound. The ulcerations of the lower left extremity are unchanged since last visit, although measurement were not included with this visit. R43 has numerous comorbidities which are making it difficult for the ulcerations to heal. In addition to the progress note, there was a notation included under special considerations indicating a volunteer at the facility relates R43 had not been receiving as much help with dressing changes. The volunteer added this was due to lack of staff available. R43's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Both antibiotics were ordered by the provider on 10/8/21, in the afternoon. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R43 had missed 9 doses of [MEDICATION(S)] and 18 doses of [MEDICATION(S)] V. R43's treatment administration record (TAR) dated 10/1/21-10/31/21, showed no documentation on 10/4 or 10/21, that the treatment to R43's wounds had been done. Although R43 had an outpatient visit from the PDM on 10/7/21, to evaluate R32's lower left leg ulcers there were no measurements completed to monitor healing. The only measurements that had been completed since the residents hospital stay on 9/21/21 were on 10/21/21, when the surveyor requested RN-A to measure and assess the resident's wounds. A voice message was left for PDM-A on 10/21/21, at 1:30 p.m. to inquire on R43's lower leg wounds, with no response. A phone conversation with PDM-A's clinic nurse on 11/9/21, at 3:00 p.m. to have provider return a call when available. There was no response. Interview with RN-A on 10/21/21, at 12:30 p.m. verified R43's left leg ulcers had not been assessed to appropriately monitor the healing of the wounds. RN-A also confirmed there had been no documentation by the facility related to the description of the wounds when returning from the hospital on 9/21/21. RN-A further stated there were times that she was responsible for over 40 residents and and did not always get to R43's dressing changes, but confirmed she had signed them off on the treatment administrative record (TAR), due to the current staffing shortage (1 licensed nurse for 43 residents). Interview on 10/21/21, at 1:00 p.m. the director of nursing (DON) indicated it was not required for the staff to measure/document on non-pressure related wounds. The DON indicated only PU were measured , described and documented. RN-A further stated staff were to monitor healing with observations, when changing the dressing. RN-A indicated she was not aware that the dressing were not always getting done. DON stated that the staff are not required to measure skin wounds unless it is caused by a pressure ulcer and that they just monitor by observations. The DON confirmed she was unable to find any weekly skin documentation for R43 in the past couple of months. Interview on 11/5/21, at 2:00 p.m. the DON confirmed the ordered [MEDICATION(S)] and [MEDICATION(S)] V had not been started until 10/13/21, missing several doses of both medications. The DON stated the medications were missed from 10/8 -10/12, because the order did not get transcribed to the MAR, so the nursing staff didn't see the order. Although the facility was aware of R43's lower left leg wounds, skin breakdown risk and [CONDITION(S)], the staff did not comprehensively assess, monitor or implement all interventions to prevent further skin breakdown, to determine if wounds were improving or needing further interventions to promote healing. Interventions that had not been implemented included: administering antibiotics per order (causing a delay in treatment), elevating edematous legs, applying compression wraps and changing dressings to the lower left leg wounds, as ordered. This failure occurred from 9/21/21 to 10/20/21, (after return from hospital) and resulted in a new skin breakdown on the back of the left lower leg, and worsening of the wounds on the medial and lateral left leg. The medial wound increased by 5.2 cm in length and 4.1 cm in width. The lateral wound increased by 2.0 cm in width. The new breakdown on the back of the leg measured 6.0 cm in length by 6.0 cm in width. Review of the facility policy Pressure and Non-Pressure Injuries dated 8/2/21, indicated upon admission/re-admission a head to toe evaluation will be completed on every resident and will be documented on the evaluation form. If skin is compromised initiate a injury tracker form (1 per wound) and assess weekly. Initiate a comprehensive skin integrity care plan based on the residents history, risk factors and current skin assessment conditions. Report any changes to the physician. R4 R4's facesheet printed 10/21/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 declined to complete a brief interview for mental status, did not exhibit any behaviors - including rejection of care, had adequate hearing and vision, clear speech, was able to make self understood and could understand others. R4 did not walk and required extensive assistance of two staff for bed mobility, transfers and toileting. R4 was frequently incontinent of urine and always incontinent of stool. R4 had an infection of her foot requiring a dressing. Physician orders included: 3/23/21: Wash feet with soap and water every evening. 10/8/21: Use skin marker, mark area of redness and notify provider if worsening. Assess every shift. 10/15/21: Right lower extremity and right dorsum (top) foot and right lower abdominal panniculus (a sheet of fat tissue in the lower abdominal area): [MEDICATION(S)] soaks two times a day for 7 days. R4's plan of care dated 1/21/20, indicated R4 had actual skin integrity break related to mobility and incontinence at that time, and a goal indicated skin would show signs of progressive healing without signs of infection. The care plan did not identify current skin infection and treatments ordered to enhance healing and reduce infection. In addition, the care plan indicated R4 displayed signs of mood and behavior possibly related to paranoid personality disorder and a goal indicated R4 would not refuse cares important to her health. Interventions included education on the importance of receiving cares and R4's refusals would be monitored. Record review indicated R4 was seen by a physician or nurse practitioner on 9/29, 10/4, 10/8, 10/11, and 10/14. The 9/29, note reiterated importance of R4 wrapping her legs due to [CONDITION(S)]; but there were ongoing refusals by R4 to wrap them. The 10/4, note indicated R4 was being seen following communication from nursing that when R4's shoes were removed at bedtime, maggots were noted crawling out of her right shoe and in between her toes. R4 had open areas to the right foot: one at the dorsum and the other at the lower part of the shin, both laterally. The 10/8, note indicated R4 was being seen regarding worsening pain, redness, and warmth of lower right extremity, and worsening [CONDITION(S)]. An antibiotic was started. The 10/11, note indicated follow-up of right lower extremity [CONDITION(S)], with the redness subsiding. The 10/14, note indicated R4 had no resolution of right lower leg [CONDITION(S)] and another antibiotic was started. During an interview and observation on 10/18/21, at 3:51 p.m., R4 was in a hospital gown, and was sitting on the side of her bed, facing the door with her legs over the side of the bed. R4's bare feet rested directly on the tile floor. Significant [CONDITION(S)] was noted to both lower legs and feet. The right lower leg and foot were reddened, and areas of skin on dorsum of the right foot were peeling. R4 had a panniculus which hung over the outer aspect of her right thigh and over the side of the bed. The right side of the panniculus was slightly reddened as compared to the left side. No obvious open areas during a quick observation when R4 lifted her gown to show her panniculus. During an interview on 10/19/21, at 2:56 p.m., when asked if staff had recently been soaking her right foot and panniculus with a special solution, R4 stated her foot had been soaked maybe twice since arriving to the facility a year and a half ago. No soaking supplies observed in room except for a white plastic basin, upside down on the floor between her bed and wall, toward the top of the bed. R4 stated no one had been washing her feet either. No signs of black marker markings on reddened area of skin on right leg or right foot, as ordered, to indicate improved or worsening redness. During an interview on 10/20/21, at 8:17 a.m., when asked what kinds of skin treatments R4 had, licensed practical nurse (LPN)-A stated, If she would let me do anything with her wounds -- she refuses. LPN-A opened the TAR (treatment administration record), and stated, See the 2's? Those are refusals. When asked about soaks for foot and panniculus with [MEDICATION(S)], LPN-A stated, I don't know anything about that. LPN-A was asked to look at the order, but could not find it until it was pointed out, then she read it. LPN-A confirmed the order was added on 10/15/21, and admitted she was unaware this order existed and therefore had not performed the treatment. When pointed out that R4 had multiple wound care orders, LPN-A was asked how many wounds R4 had and she stated she didn't know. LPN-A was unaware of the physician order dated 10/8, to mark R4's areas of redness with a skin marker either, stating she never saw that order, and shrugged her shoulders when asked how she knew if the wound was worsening or improving. It was noted on the MAR (medication administration record) that LPN-A had signed off marking the areas of redness on 10/11, 10/13, 10/14, 10/17, and 10/20. During an interview on 10/20/21, at 11:44 a.m., when asked if R4 had foot and panniculus soaks, the director of nursing (DON) looked at the physician orders in the electronic medical record (EMR) and stated not at this time, adding that R4 was very non-compliant and that the provider was aware of her non-compliance. The order for the [MEDICATION(S)] soak dated 10/15/21, was pointed out and the DON stated Oh, that started on the 15th. When asked if it were being done, the DON looked at the TAR and stated the evening shift had been doing it consistently and identified the two nurses who had documented performing the treatment. The DON also stated that LPN-A had signed off that she performed it on 10/17. The DON was informed that when the [MEDICATION(S)] soaks were pointed out to LPN-A, she did not know anything about it. When asked if it were possible LPN-A signed off as performing the treatment when she had not, the DON stated, I can't say. Requested to look at R4's skin with the both the DON and LPN-A. During an observation and interview on 10/20/21, at 1:59 p.m. in R4's room with LPN-A and DON, R4's skin and [MEDICATION(S)] soak treatment were observed. R4's panniculus had generalized, slight redness; skin was smooth and intact except for one dime size scab noted. The center of R4's abdomen had a healed vertical scar with a small scab at the proximal end. Right lower leg, middle section had closed, blistered skin. Dorsum of right foot had peeling skin. No open wounds noted. LPN-A was asked how the [CONDITION(S)] of R4's right lower leg and foot looked to her and she stated slightly better. LPN-A stated to the DON, I didn't know about this [order for [MEDICATION(S)] soaks] till she [surveyor] asked me about it this morning. After the treatment was over, again asked LPN-A and DON if LPN-A had been doing this treatment prior to today and LPN-A stated she would have to go back and look at the R4's record. During a telephone interview on 10/21/21, at 9:02 a.m., registered nurse (RN)-A was asked if she was aware of a new treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated she was not aware. When brought to her attention that she initialed performing the treatment twice on 10/18, RN-A stated, I might have signed off on it at the end of the shift and not done it. RN-A further stated, I didn't know about this order and we are constantly rushed; we can't do everything. Everyone is frustrated; I get done what I can. When asked if she washed R4's feet with soap and water, RN-A replied no. When informed she initialed that she did soak R4's feet several times this month, RN-A replied, Okay. RN-A had not told the DON or administrator how she felt about her workload. During a telephone interview on 10/21/21, at 9:06 a.m., (RN)-C was asked if she was aware of a new treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Asked again if she was aware of a new order for [MEDICATION(S)] soak, RN-C stated, no, she had not seen the order, then stated she offered the [MEDICATION(S)] soak to R4 and R4 refused. RN-C stated she had filled out an SBAR (situation, background, assessment, recommendation) documentation to the physician about the refusal and that it should be in R4's record. RN-C stated she also sent a copy of the SBAR to the DON. According to an interview with the DON on 10/21, at 1:57 p.m., there was no SBAR documented about this in R4's EMR, nor did she receive a copy of an SBAR. During an interview on 10/21/21, at 10:21 a.m., when informed staff say she refused care a lot of the time, R4 stated how can I refuse if they don't asked me! Stated they aren't asking her things that she is allegedly refusing. During an interview on 10/21/21, at 1:57 p.m. with the DON and the corporate director of clinical services (DCS)-C, both confirmed it was the expectation that nurses carry out physician orders unless a resident refused. The DON stated R4 often refused care and treatment. The DON stated the physician had been been informed of R4's refusals and that multiple SBAR's regarding refusals has been sent to the physician. This documentation was requested. The DON admitted there was no SBAR in R4's record from 10/20, nor did she receive communication from an RN about a refusal. The DON and DCS-C were informed three nurses were unaware of the 10/15, order for [MEDICATION(S)] soaks yet they documented they performed the treatment. In addition, the nurses admitted they were not washing R4's feet, nor were they marking the area of redness on her skin, yet documenting these treatments had been performed. The DCS-C stated the process for nurses being aware of new physician orders needed to be improved, that she expected nurses to complete orders as directed, and expected nurses to be truthful in their documentation. During an interview on 10/21/21, at 3:48 p.m., based upon the request for SBAR documentation to physicians pertaining to R4's refusals of care, the DCS-C provided three pieces of documentation: 1) SBAR dated 10/2/21, for change of condition, 2) Nursing home orders dated 10/4/21, and 3) History and physical note dated 9/29/21. None were SBAR's indicating refusal of care. Only the history and physical note dated 9/29/21, read: R4's plan of care calls for daily application of Solaris Velcro ready wraps to control lower extremity [CONDITION(S)], but not currently being used due to non-compliance. The DCS-C admitted these documents did not address the refusals that the staff and the DON had been reporting to the surveyor, and added we need to fix that. A facility policy for carrying out physician orders was requested, and a policy titled Medication Orders was received which did not address carrying out physician orders.

Based on observation, interview and document review, the facility failed to follow manufacturer's guidelines for proper use of slings for eight residents (R2, R11, R18, R13, R8, R10, R12, R9) of 14 residents who utilized full body lifts. This deficient practice resulted in an immediate jeopardy (IJ) for R1, who fell from the full body lift and had the potential for injury for R2, R11, R18, R13, R8, R10, R12, R9 as a result of not following the manufacturer's guidance for proper use. Furthermore, the facility failed to assess and evaluate causal factors for falls, and failed to ensure adequate supervision and interventions were implemented to reduce falls for 2 of 2 resident (R3 and R4) reviewed who sustained multiple falls. The IJ began on 7/18/21, at 11:00 p.m. when licensed practical nurse (LPN)-A and nursing assistant (NA)-A were transferring R1 with a full body lift and R1 fell out of the sling to the floor. The administrator and director of nursing (DON) were notified of the IJ on 7/26/21, at 7:04 p.m. The IJ was removed on 7/28/21, at 3:30 p.m. however, noncompliance remained at the lower scope and severity level of E, pattern, no actual harm, but potential for more than minimal harm. Findings include: R1's facesheet printed on 7/19/21, listed diagnoses which included amyothrophic [CONDITION(S)] (ALS) (nerve cells break down, reducing functionality in the muscles they supply), dysphasia (language disorder that affects a person's ability to communicate), anxiety,and [CONDITION(S)] (paralysis of all four limbs). R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact, had adequate hearing and vision, unclear speech, was sometimes able to make self understood and could usually understand. R1 required extensive assistance or was dependent upon two staff and/or the use of a full body lift for bed mobility, transfers, dressing, toileting, and moving about in a wheelchair. R1's plan of care initiated on 5/14/21, indicated: a) self-care deficit as evidenced by increased dependence on others to complete activities of daily living related to disease progress and newly diagnosed ALS, and would require transfer with a mechanical lift and assistance of two. b) impaired functional mobility as evidenced by diagnosis of ALS. Nursing would provide assistance as needed for transfers via total mechanical lift and two staff. R1's care plan did not indicate the type of sling nor size of sling to be used with the full body lift. R1's progress note dated 7/19/21, at 4:15 a.m. by LPN-A indicated: R1 fell from Hoyer (mechanical lift used for a full body lift) approximately three feet from floor while transferring to commode. R1 hit her head and back on the leg of hoyer. No apparent injury but R1 transferred to local hospital via ambulance. Unsure how fall from hoyer occurred. R1's progress note dated 7/19/21, at 4:30 a.m., by LPN-A indicated: R1 was admitted to the hospital with three rib fractures on the right side and would probably be in the hospital for two days. During a telephone interview on 7/26/21, at 10:02 a.m., family member (FM)-D stated he received a call on 7/18/21, that R1 was being sent to the hospital. FM-D was told R1 had been in the mechanical lift and something happened causing her to fall three feet hitting her head and lower back on the ground; but they didn't know how it happened. FM-D stated R1 did not like using the full body lift; it scared her and she didn't trust certain staff using it, but no one would listen to R1 and ask her why she was afraid. If they did it the right way every time, she wouldn't be afraid. FM-D stated R1 was still in the hospital and was uncertain if R1 would return to facility due to her fear of being moved with the mechanical lift. During an interview on 7/26/21, at 11:10 a.m., (NA)-B stated there were three Invacare brand full body lifts -- one on each floor, and there were two different manufacturer slings being used with the lifts: Invacare and MedCare, adding MedCare slings were not made for the Invacare lifts but we use them. During document review, the Invacare User Manual dated 10/18/18, indicated the following warning: Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system. During an interview and observation on 7/26/21, at 12:40 p.m. with NA-B, R2 was sitting in a wheelchair in the dining room on a MedCare sling, color navy with gold trim. Per NA-B, R2 was not on [CONDITION(S)], but she ended up on a MedCare sling. During an interview on 7/26/21, at 12:45 p.m., (NA)-C stated the facility used more than one brand of sling for the mechanical lift, but didn't know the brand names. Stated staff always crisscrossed the legs on the sling, adding that was how she was trained. NA-C was aware of R1's fall from a lift and stated she had recent retraining after the incident, and the training included to use an Invacare sling with an Invacare lift. Stated prior to recent training, did not know a sling specified by the lift manufacturer should be used. During a telephone interview on 7/26/21, at 1:10 p.m. LPN-A verified she was involved in the 7/18 incident in which R1 fell from the full body lift. LPN-A stated they were moving R1 from bed to the commode. LPN-A was guiding R1's feet and looking at the commode to see how close they were when suddenly R1 fell out of the sling to the floor. LPN-A stated R1's head hit the ground and her back was over the leg of the lift. LPN-A recalled the sling being royal blue in color, but didn't remember the trim color or the brand name. LPN-A was certain the legs of the sling were crisscrossed around R1's legs. I have no idea how she fell out; we have done this many times before and nothing was out of the ordinary. During an interview on 7/26/21, at 1:14 p.m. corporate director of clinical services (DCS)-C stated she knew residents should be using slings specified by the mechanical lift manufacturer. It was not until the incident with R1 on 7/18, that she became aware the facility had been using more than one brand of sling. DCS-C stated once she became aware of this, more Invacare slings were ordered, but had not arrived yet. Of the 14 residents who used the full body lift, eight were still using MedCare brand slings: R2, R11, R18, R13, R8, R10, R12, R9. DCS-C stated the correct sling had been used for R1 at the time of her fall, a large Invacare sling. After the fall DCS-C inspected the sling and there were no abnormalities, tears or frays. During an observation on 7/26/21, at 1:20 p.m. observed NA-B and (LPN)-B transfer R2 from wheelchair to bed using the Invacare lift with a MedCare sling. During an interview on 7/26/21, at 1:46 p.m. the administrator acknowledged he was unaware until R1's incident that only slings specified by the lift manufacturer could be used with a lift. As a result of the facility investigation of the fall, he had approved the purchase of additional Invacare slings to ensure all residents who used the lift had the proper sling. Furthermore, the administrator was aware that non-Invacare slings continued to be used with the Invacare lift for R2, R11, R18, R13, R8, R10, R12, R9 until additional Invacare slings arrived. During an interview on 7/26/21, at 2:55 p.m., the director of nursing (DON) stated the MedCare slings were acquired from the local hospital who wanted [CONDITION(S)] residents on this sling. Over time the facility acquired more of the slings and they were being used on non-[CONDITION(S)] residents and with the Invacare full body lift. The DON stated it was after R1's fall that she became aware of lift manufacturer specifications to use only slings designed for their mechanical lift. The DON was aware that non-Invacare slings continued to be used with the Invacare lift for R2, R11, R18, R13, R8, R10, R12, R9 until additional Invacare slings arrived. During a telephone interview on 7/26/21, at 3:07 p.m. with the Invacare representative (IR)-E, was asked if it were possible when a split leg sling was crisscrossed under and over a person's leg, and if the legs were sticking out rigid, could a person fall out of the sling. IR-E stated if the sling was too big, it's plausible, but very unlikely. IR-E stated the most likely cause would be that it wasn't attached to the hanger bar properly. One of two reasons a resident falls from a lift: usually not hooked up to lift properly -- the loop on the sling isn't secure in the hook on the lift and one end falls off the hook. Or they didn't crisscross the sling at the legs. Someone of that size wouldn't likely fall through the middle if the sling was attached properly. IR-E added, at 163 pounds (weight of R1), a person would use a large sling, adding even if an extra large sling were used, it would be highly unlikely a person would fall out. IR-E stated we're very strict with use of our slings with our equipment. We can't test anyone else's slings. Our stance is clear: we can't guarantee someone else's sling will work properly in our lifts and vice versa. IR-E was unaware of this incident as the facility had not informed him. During an interview on 7/28/21, at 10:10 a.m. the DON stated the Invacare representative had not been contacted to inform him of a fall from their company's lift, or to utilize his expertise for problem solving or for staff education; we hadn't thought of that. Training records were reviewed for the two staff involved in R1's fall from lift on 7/18. According to DCS-C, NA-A and LPN-A's training included a Relias online learning module titled: Safe Use of Mechanical Lifts. DCS-C provided a 19 page document dated 2017, which outlined the content of the training and listed .the safe and proper use of mechanical lifts was illustrated with an emphasis on abiding by the manufacturer's guidelines for operation, and the most important part of an individual's responsibility in using mechanical lift devices was complying with both the manufacturers instructions and the organizations policies and procedures. And also included You must abide by all of the manufacturer's specific instructions for the lift you are using. Never assume that because you used one practice or piece of equipment for one mechanical lift that you can use it for another type of lift. Doing so may result in equipment failure or even injury, or worse, death. - NA-A's training transcript listed the lift training had been completed on 7/14/19, and competency testing for mechanical lift was validated on 9/20/19. -LPN-A's transcript which included dates from 2018 to 2020, did not indicate completion of the Relias's online learning module titled Safe Use of Mechanical Lifts. The facility was not able to provide evidence that LPN-A completed training on safe use of mechanical lifts. Facility policy titled Safe Lifting and Movement of Residents with revised date of 8/19/2020, indicated: In order to protect staff and residents, the facility would use appropriate techniques and devices to lift and move residents. Staff would receive training and complete a competency for use of the mechanical lifts prior to providing direct care. Residents who required the use of a mechanical lift would be assessed for the appropriate lift type and size using the Lift Mobility Status UDA. Registered nursing staff would assess residents upon admission, with significant change, and on an ongoing basis for need for transfer assistance. This information would be documented in the care plan and kardexes. Sufficient slings in sizes required by residents would be available at all times, and maintenance would perform routine checks and maintenance of equipment used for lifting consistent with the manufacturers guidance. The immediate jeopardy that began on 7/18/21, was removed on 7/28/21, when the facility's DON reviewed the Lift Mobility Status Assessment for residents who utilized full body lifts, care plans and kardexes were updated with size and type of sling for each resident. The facility initiated the use of the previously ordered Invacare slings for all residents on 7/27/21. The facility developed a color-coded list for sling sizes were laminated and attached to each Invacare Reliant 450 Lift as well as laminated instructions for each type of sling to provide a quick, easily accessible reference for staff who completed training. The DON educated staff on the Lift Mobility Assessment to ensure the assessment was completed in full and specified vendor specific lift sling for type of lift and proper style. The facility nursing staff were re-educated on the use of full body lift and specifically regarding the use of Invacare slings, selection and sizing and use of these slings was provided. The DON or designee performed audits to ensure staff demonstrated understanding of sling types, size and proper application for full body mechanical lifts However the noncompliance remained at the lower scope and severity level of E, pattern, no actual harm, but potential for more than minimal harm. Falls R3 R3's facesheet printed on 7/28/21, indicated diagnoses of orthopedic aftercare following surgical amputation of great toe, muscle weakness, chronic [CONDITION(S)] (inflammation of bone caused by infection) of right foot and ankle, [CONDITION(S)] (serious mental disorder in which people interpret reality abnormally), and diabetes. R3's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R3 was cognitively intact, had adequate hearing and vision, clear speech, was able to make self understood and could understand others. R3 required extensive assistance of two staff for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and hygiene. R3 did not walk. R3's care area assessment (CAA) for falls dated 5/24/21, indicated R3 would return to group home when he was back to his baseline, was working with therapy following amputation of right great toe. Used a wheelchair and walker. R3 had a fall prior to hospitalization due to weakness and illness. R3's admission fall risk assessment, dated 5/19/21, and completed by licensed practical nurse (LPN)-D, indicated R3 was at risk for falls; had a history of one to two falls in the past 30 days, including a fracture related to falls in the past 6 month prior to admission. He had fall risk factors related to medications and exhibited gait or balance problems. R3's plan of care initiated on 5/27/21, indicated R3 was at risk for falls due to recent amputation of right great toe and history of falls. Interventions included: --Have commonly used articles within easy reach. --Medications as ordered. --Provide assistance to transfer and ambulate as needed. --Reinforce need to call for assistance. --Reinforce wheelchair safety as needed such as locking breaks. --Therapy evaluation and treat as ordered. All of the above interventions were initiated on 5/27/21. No new interventions were added to the care plan after falls on 6/2/21, 6/3/21, 7/17/21, and 7/18/21. Four fall incident reports for R3 indicated the following: --6/2/21: At 2:50 a.m., R3 was found sitting on the floor next to the bed. According to an unnamed NA in the room, R3 had been sitting in his wheelchair while she changed his bedding. R3 leaned forward and the NA assisted him to slide from the wheelchair to the floor. No injury sustained. --6/3/21: At 11:04 p.m., R3 was found sitting on the floor next to the bed with wheelchair behind his back. R3 told RN-C that he was trying to stand up and lost his balance. No injury sustained. --7/17/21: At 5:57 p.m., R3 attempted to transfer self from bed to wheelchair. Staff were present and assisted him to the floor between the wheelchair and bed. R3 stated he was trying to get in the chair but slipped. No injury sustained. --7/18/21: At 2:50 p.m., R3 was found in the hallway with his knees, hands and forehead on the floor and his wheelchair behind him. Another resident informed staff he saw R3 leaning forward in his wheelchair and assisted him to the floor. R3 was sent to the hospital for evaluation and returned to the facility on [DATE]. R4 R4's facesheet printed on 7/28/21, indicated diagnoses of traumatic subarachnoid (fluid filled space around the brain) hemorrhage with loss of consciousness, muscle weakness, abnormalities of gait and mobility, dementia, depression, age-related cognitive decline, and bilateral [CONDITION(S)] (clouding of the lens of the eye). R4's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R4 was cognitively intact, had moderate difficulty hearing, adequate vision, clear speech, was able to make self understood and could understand others. R3 required extensive assistance of one staff for bed mobility, transfers, walking in room, locomotion on and off the unit, dressing, toileting, and hygiene. R4's admission fall risk assessment, dated 5/18/21, and completed by licensed practical nurse (LPN)-D, indicated R4 was at risk for falls; had a history of one to two falls in both the past 30 and 60 days. R4 had fall risk factors related to medications and exhibited gait or balance problems. R4's plan of care initiated on 5/18/21, indicated R4 was at risk for falls/injury due to history of falls and cognitive impairment. Interventions included: --Have commonly used articled within easy reach. --Medications as ordered. --Provide assistance to transfer and ambulate as needed. --Reinforce need to call for assistance. --Reinforce wheelchair safety as needed such as locking breaks. --Therapy evaluation and treat as ordered. All of the above interventions were initiated on 5/27/21. No new interventions were added to the care plan after falls on 5/19, 5/29 and 5/30/21. In addition, R4's fall interventions were identical to R3's fall interventions. Three fall incident reports for R4 indicated the following: --5/19/21: At 5:15 a.m., R4 was found sitting on the floor in his room. No injury. R4 stated he was going to the bathroom and didn't know what happened. --5/29/21: At 4:15 p.m., R4 was found crawling on the floor by his bed, and told staff he slipped out of bed. No injury. --5/30/21: At 4:26 a.m., R4 was found on floor in his room. No injury. During an interview on 7/28/21, at 10:10 a.m., NA-F did not recall R4, however did recall R3, and that R3 was tall and a riser had been placed on his toilet to prevent him from having to get up and down from a low position. When asked what other kind of fall interventions were used for R3, NA-F stated they removed clutter from his room and floors, made sure his call light was within reach, and put signs in the room to remind him to use the call light. When asked how she was made aware of fall interventions for a resident, NA-F stated after a fall, management updated residents care plan with interventions. Use of a toilet riser was not an intervention on R3's care plan. NA-F confirmed recent training on slings and lifts, including brand of sling must match the lift manufacturer. During an interview on 7/28/21, at 11:12 a.m., when the DON was asked how resident falls were addressed, specifically determining causal factors and adding or modifying existing fall risk interventions. The DON presented three documents titled War Meeting Key Indicators and stated falls were discussed at this meeting. The documents provided the following information: One document dated 6/8/21, had two handwritten entries for R3 under a section titled falls which indicated: a) Date 6/2, R3's name and the word self. When asked what that meant, the DON stated R3 fell while self transferring. The DON admitted no new interventions had been identified or put into place after that fall. b) Date 6/3, R3's name and call don't fall was written. When asked what that meant, the DON stated they added a sign to R3's room that read call, don't fall. c) There was no documentation for falls on 7/17 and 7/18. One document dated 5/25/21, had an entry for R4 under a section titled falls which indicated: a) Date 5/19, R4's name and call don't fall. When asked what that meant, the DON stated they added a sign to R4's room that read call don't fall. Asked if a sign was the most effective intervention for someone with a brain injury, the DON didn't reply. Another documented dated 6/3/21, had an entry for R4 under a section titled falls which indicated: a) Date 5/29, R4's name and crawl on floor said slid from bed - mattress. When asked what that meant, the DON stated R4 slid off his bed and thought R4 was given a new mattress to prevent further falls, but did not know what kind of mattress, adding that the maintenance supervisor would know but he was on vacation. b) Date 5/30, R4's name and slid out of chair - therapy evaluate chair. Physical therapy notes from May through June were reviewed and did not include an evaluation of R4's wheelchair. During the same interview, when asked how new fall interventions are communicated to the nursing staff, the DON stated it was done at shift report. When asked what new fall interventions were identified for R3 after his four falls, the DON admitted on ly the sign had been identified after the 6/3 fall, but had not been added to R3's care plan. The DON verified that no new interventions had been discussed or identified after R3's falls on 6/2, 7/17 and 7/18. During the same interview, when asked what new fall interventions were discussed and identified for R4 after his three falls, the DON stated the sign had been identified, as well as new mattress. However the DON could not verify what type of mattress as the resident was no longer in the facility. In addition, therapy was to evaluate chair, but unable to determine if that was done. The DON verified these interventions had not been added to R4's care plan after his falls. The DON admitted if the fall interventions were not on the care plan, nursing staff would not be aware of them. During an interview on 7/28/21, at 1:42 p.m., when asked for post-fall assessments for R3 and R4, DCS-C stated I wish I could give them to you, but they don't exist, they weren't done. When pointed out the facility fall prevention and management guidelines indicated they must be completed, DCS-C stated she was aware of that and could not explain why they were not done; the expectation was they were done after each fall. During an interview on 7/28/21, at 2:10 p.m., when asked what occurred after a resident fall to prevent further falls, NA-G stated NA's inform a nurse that a resident fell and the nurse informs the DON, and the DON and therapy decided any new interventions. When asked how NA's learned about new fall interventions, NA-G stated through the nursing channel. Usually verbal; someone tells us. NA-G added that if the therapy department determined an intervention, staff were required to sign off on it. NA-G was aware of R1's fall and confirmed re-training on lifts and slings, including sling to match the lift manufacturer. During an interview on 7/28/21, at 2:20 p.m. when asked what her responsibility was after a resident fell , RN-B stated she assessed the resident and obtained vital signs, notified the provider, completed a risk management report and informed the DON and family. RN-B stated she can recommend fall interventions, for example moving the bed against a wall or adding a fall mat. When asked how her recommendation would get passed onto other staff, RN-B stated it was passed on during the 24 hour report. RN-B stated there were no new fall interventions in R3's care plan that she was aware of and according to RN-B, when we see R3 leaning forward in his wheelchair, we have to lay him down to prevent a fall. That had been passed on in report on 7/18/21. RN-B stated apparently R3 had been leaning forward for most of the day on 7/18/21, and fell out of his wheelchair at the beginning of her evening shift at 2:50 p.m. RN-B sent R3 to the hospital for evaluation (he returned on 7/26/21). RN-B did not recall R4 and his falls and/or fall interventions. RN-B verified recent training on slings and mechanical lift after a resident fell from the lift. During an interview on 7/28/21, at 2:50 p.m., TMA-A stated after a resident fell , they figured out a way so it doesn't happen again, adding that the nurse and the DON would get back to them and tell them what to do for fall interventions. If therapy was involved, they required nursing to sign off on any new interventions. Sometimes new interventions get added to the care plan but not always. TMA-A was not able to state specific fall interventions for either R3 or R4, only general interventions such as call light within reach, a sign in the room reminding a resident to use call light and floor mats. TMA-A verified she had recent training on use of lifts and slings and specifically slings and lifts brands needed to match. During an interview on 7/28/21, at 3:57 p.m. the administrator stated falls were discussed at the weekly WAR (weekly at risk) meeting where at-risk residents were discussed. The leadership team also reviewed the 24 hour report (generated by nursing staff on each shift) each morning and discussed everything from falls to behaviors, and from there nursing identified fall prevention tactics and communicated them to the staff. The administrator assumed interventions were being added to resident care plans, but could not speak to that. The administrator was aware the workload for nurse leaders had been challenging due to recent resignations of nurse managers. The facility Fall Prevention and Management Guidelines with revised date of 3/10/21, defined a fall as an episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself. Facility policy titled Fall Prevention and Management Guidelines with revised date of 3/10/21, indicated the facility would implement a fall program for residents determined to be at risk for falls. A fall referred to unintentionally coming to rest on the ground. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, was considered a fall. Specific interventions would be developed based on the results of the fall assessment. An individualized plan of care would be developed and communicated with staff. An investigation and comprehensive fall risk assessment would be completed. After review, investigation, and assessment, a nurse would update the care plan with new interventions and remove interventions no longer appropriate. Each fall was reviewed at the interdisciplinary team meeting (IDT), which may include the review of the investigation and potential root cause for the fall, review of updates and revisions to the plan of care, and education to the staff of any care plan revisions. If after IDT review, it was determined that existing interventions in the care plan were appropriate, the rationale was to be documented and any additional actions taken was to be included. All staff were to receive in-services on falls upon orientation, semiannually, and after a fall as necessary.

Based on interview and document review, the facility failed to ensure residents received care and services in accordance with their individual needs. R1 suffered neglect of care when the facility failed to ensure she was provided care and services in accordance with professional standards of practice for repositioning and incontinence care. R1 was actively dying, and was left for long periods of time in a feces soiled brief without being changed, or repositioned. This resulted in actual harm for R1 who developed open areas on her skin. Findings include: R1 had a significant change Minimum Data Set (MDS) assessment dated [DATE], completed following hospitalization and admission to hospice services. The MDS indicated R1 had adequate hearing and vision, clear speech, was able to make herself understood and could usually understand others. R1's BIMS score (brief interview for mental status) was identified as 99, indicating R1 could not complete the interview. Further, the MDS indicated R1 was dependent upon two staff for bed mobility (including repositioning), transferring in and out of bed, toileting, hygiene and bathing. R1 could not walk, and was assessed to have an indwelling urinary catheter (tube in bladder draining urine into a bag) and was always incontinent of bowel. R1 was able to eat with assistance of one staff. A corresponding care area assessment (CAA) for pressure ulcers and pressure injury indicated R1 had the potential for alteration in skin integrity related to ongoing need for assistance with mobility, bowel incontinence, urinary catheter, and multiple medical issues with readmission to the facility on hospice services. The CAA indicated R1 had no skin issues noted at that time (2/17/21). The CAA indicated staff would continue to provide assistance to meet R1's needs related to oral intake, bowel elimination, urinary catheter care, assistance with activities of daily living, including mobility, and monitoring R1's overall skin status every shift and as needed when providing care. The CAA indicated interventions would remain ongoing per the care plan to assist with prevention of future skin issues. R1's plan of care printed 3/24/21, indicated special instructions at the top of the first page with included: assist with repositioning every two hours and prn (as needed). In addition, R1's care plan indicated R1 was at risk for pressure injury and a goal was for R1's skin to remain intact and the risk of developing a pressure ulcer would be minimized. Interventions to prevent pressure injury included weekly skin inspection, and for staff to assist with positioning and repositioning when in sitting position every two hours and as needed. R1's care plan had not been updated following R1's recent hospitalization and admission to hospice services in mid-February 2021. Interventions for prevention of pressure injuries were dated 2017 and 2018. The same care plan indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A goal was for R1 to have a formed bowel movement at least every three days. Interventions included: bedside commode, monitor use and effectiveness of bowel medications, call bell within reach, encourage fluids, monitor bowel frequency, and use briefs/pads for incontinence protection. Interventions for alteration in elimination of bowel were dated 2018 and 2019. The care plan for bladder incontinence indicated R1 had an indwelling urinary catheter due to terminal condition. A goal, dated 3/5/21, indicated R1 would have no acute complications of urinary catheter use and would receive catheter care. The care plan also indicated R1 had a self-care deficit related to physical limitations, dementia and mood. A goal was for R1 to receive assistance necessary to meet activity of daily living needs to ensure R1 would be clean, dressed and well-groomed daily to promote dignity and psychosocial well being. Interventions included daily hygiene, grooming, dressing, and oral care. The care plan indicated R1 was on hospice/palliative care due to end of life, with a goal dated 2/21/21, indicating R1 would be made comfortable with assistance of staff from a hospice agency. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] --Admit to hospice agency. Order date 2/12/21. --Daily catheter (urinary) care; empty bag each shift. Start date 2/12/21. --Weekly bathing and skin review. Start date 2/13/21. --Three PRN (as needed) medications for bowel elimination. None administered in March 2021. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 3/24/21, at 1:28 p.m., family member (FM)-C reported the following concerns about R1's care: FM-C stated that for the most part, R1's care had been very good until the last week of her life, which FM-C found to be very disturbing. FM-C stated R1's condition declined significantly between 3/13 and 3/16/21, adding R1 could no longer get out of bed. FM-C stated she was there every day from 3/16 to 3/21/21, and took for granted R1 was being turned. FM-C stated, I had been there multiple days, for long periods - and never saw her turned. FM-C stated, On 3/19/21, I arrived at the facility at approximately 8:30 a.m. and left at approximately 9:30 a.m. When I returned at approximately 2:30 p.m., [R1] was in the exact same position as when I left at 9:30 a.m. FM-C further stated she was certain of this because she always tucked R1's gown in between her legs, and placed a teddy bear in R1's hands in a certain way, with R1's hands wrapped around the neck of the teddy bear, and these two things were unchanged. FM-C also stated on 3/19/21, RN (registered nurse)-A arrived to R1's room at approximately 6:30 p.m. RN-A asked FM-C when R1 had last been repositioned and since FM-C stated she didn't know, they two decided to reposition R1. FM-C stated when they pulled R1's sheet back, they were hit with a strong smell of urine. To investigate further, they removed R1's pants and they discovered R1's brief was soaking wet. FM-C stated it could not have held another drop. FM-C stated R1's brief was wet despite R1 having an indwelling urinary catheter because R1 had bladder spasms and sometimes leaked urine. FM-C stated R1's pants and draw sheet under her were wet. RN-A asked an unidentified nursing assistant (NA) to help asking her to bring supplies (basin, washcloths, brief and clean sheets). FM-C said RN-A asked the NA when the last time R1 had been changed and the NA stated she didn't know. FM-C stated the NA got the supplies, but added we took over and she [the NA] helped by holding [R1's] leg. We told the [NA] that [R1] was completely soaked, but she didn't say anything. As we looked further, we could see [R1] had dried stool in her brief, on her butt cheeks and on the inside of her closed butt cheeks. The nursing assistant watched us wash [R1]. We were assertive in taking over and cleaning her, and the nursing assistant could see we were not happy. FM-C stated R1's skin was starting to break down in her vaginal area, stating we spread her labia apart and the edges were raw, red and looked so tender. FM-C stated R1 grimaced and moaned when they cleaned her. When FM-C and RN-A turned R1 to change the linen, they saw solid red crease lines on her back from her shirt, including a deep red crease at the bottom of R1's right shoulder blade that looked like it could open up. In addition, FM-C described an area on R1's right butt check as a black blister about the size of a man's thumb nail. FM-C stated R1 had not had pressure ulcers before that. FM-C stated, [RN-A] and I were dumbfounded about [R1] not being changed and repositioned. In order to verify whether R1's brief was being changed, we placed an X on the back of the incontinent brief. When [RN-A] and I returned to the facility the next day (3/20/21) at 8:30 a.m., [R1] was still wearing the brief with the X on it. After being at the facility on the morning of 3/20/21 at 8:30 a.m., FM-C said she'd left and came back in the afternoon, staying with R1 until about 11:45 p.m. FM-C stated staff rarely came into R1's room. FM-C stated she repositioned R1 by herself at about 2 p.m. At about 8 p.m., RN-B came into the room and asked if the NA's had repositioned R1 yet. FM-C said she'd told RN-B no, the staff had not been coming into R1's room. FM-C said RN-B told her it was important for R1 to be repositioned and she would talk to the NA's. Following that conversation, two NA's came in and gave R1 a bed bath, changed her brief, applied lotion and repositioned her, all in about four minutes, it was like [NAME] bam. FM-C stated they cleaned one side of R1's leg, but not the back side. FM-C then stated, If they did that when I was here, what are they doing when family isn't here? FM-C stated even though she was there with R1 until about 11:45 p.m., no one came back to reposition R1. In all the times I've been here, she was only repositioned once or twice at shift change - it wasn't every two hours. FM-C stated that when she left that night, she marked R1's brief again with a fine line on the tabs of the brief so she could tell if the brief had been checked or changed. FM-C said, When I returned on 3/21/21, the lines I'd put on her brief still lined up, indicating the brief had not been checked or changed. FM-C also reported staff did not consistently know where to position pillows under R1's feet to keep her heels off the bed. FM-C stated, [R1's] heels elbows were red, but had no pressure ulcers yet. Her oral care was disgusting .I don't think it was being done. The oral mucous membranes were dry, and there were never toothettes in [R1's] room until I asked for them. She would have thick mucous in her mouth that was hard to remove, but I never noticed any sores in her mouth. RN-A was interviewed by telephone on 3/24/21, at 3:35 p.m. RN-A stated she was R1's hospice case manager and saw her at the facility two times per week starting 2/12/21. RN-A stated initially her visits with R1 were not very long and sometimes R1 was sitting up in a wheelchair. RN-A stated she sometimes had to change R1's brief but didn't think anything of it. RN-A stated when she got to the facility, she usually asked the staff how R1 had been doing, then would check R1's vital signs and do a brief assessment. RN-A stated due to R1's declining condition, she had started daily visits on 3/17/21. RN-A stated, during the 3/19/21, hospice visit at 6:30 p.m., FM-C was there too. RN-A stated staff didn't know when R1 had been repositioned last, so RN-A and FM-C decided to reposition her. RN-A stated when FM-C pulled back the sheets, they caught a whiff of something really strong, even with with their masks on. RN-A stated they looked further and found R1's brief saturated beyond belief .it shocked me. RN-A stated they obtained supplies to clean R1 and when they turned her onto her side, they found dried stool on her buttock at the gluteal fold, adding it had been there a long time as it was dried to her skin. RN-A stated they had to get wash cloths to soak the stool before they would wipe it off, adding it left an imprint on the skin because it had been there so long. RN-A stated they found R1 had a blood blister on her left upper buttocks, near the gluteal fold which had not been there before. RN-A stated she'd last looked at R1's bottom when she changed her urinary catheter on 3/10/21, adding that's when she would inspect R1's genitalia and buttocks. In addition to the blood blister on the buttocks, RN-A stated on 3/19/21, she'd observed new pressure areas to both elbows, mid back, lower back and right heel, adding they were not there previously, they developed in that short time. RN-A stated she didn't tell anyone because it was a Friday night and administrative staff were gone. After R1 was cleaned and her brief changed, RN-A confirmed she and FM-C had marked the back of R1's brief with an X to verify whether the brief was changed when they returned the next day. RN-A stated, I wanted to see if they were taking care of her. When I came back the next day at 8:30 a.m. with [FM-C], R1 was wearing the same brief with the X, and the brief was soiled with stool. We found [R1] pretty much in the same position and in the same same clothing. Before leaving the facility on 3/20/21, RN-A said she'd communicated to RN-C to make sure someone was going into R1's room to reposition her, change her and provide incontinence care. RN-A added, I have honestly never seen anything this bad before. A hospice visit note documented by RN-A dated 3/17/21, indicated: R1's lung sounds were diminished and she had 5-10 second periods of apnea (cessation of breathing) and her breathing was labored. R1's lower extremities were bluish and indicated poor oxygenation. R1 was moaning and had facial grimacing. The hospice physician was notified of change in status and new pain medication orders were issued. Urinary catheter was noted as being patent and draining amber colored urine. A hospice visit note documented by RN-A dated 3/19/21, indicated: R1 was lying in bed; some restlessness was noted with facial grimacing. R1 had shallow respirations with 10 second periods of apnea. FM-C was present. When repositioning R1, FM-C verbalized what is that smell? R1's brief was heavily soiled with dark amber colored urine with a pungent odor and dried BM (bowel movement) to buttocks. Incontinence care was performed extensively. Noted new pressure areas to bilateral elbows, mid back, lower back, right heel and a 2 cm (centimeter) x 3 cm blood blister to left buttock. A hospice visit note documented by RN-A dated 3/20/21, indicated: R1 had labored breathing, with 15-20 second periods of apnea. Scant amount of amber colored urine in catheter tubing. RN-A and FM-C turned and repositioned R1, and performed extensive incontinence care as the same brief that RN-A and FM-C put on last night at 6:30 p.m. was still present as evidenced by the marking of a X with pen on the outer side of the brief. Further, the note indicated RN-A had coordinated care with facility staff RN, encouraged pain medications, and encouraged the staff RN to make sure facility staff were turning, repositioning and providing incontinence care. On 3/21/21, at 12:35 p.m , R1 passed away. During an interview on 3/25/21, at 8:38 a.m. director of clinical services (DCS)-A stated she became aware of FM-C's concerns about the care of R1 on 3/22/21, at 11:00 a.m. from the administrator. DCS-A stated, This was immediately self-reported to the State Agency. DCS-A said she'd reviewed R1's medical record and completed several staff interviews. DCS-A stated, I told [FM-C] I was sorry if that was your perception of the care. DCS-A further stated staff who were interviewed stated the urinary catheter wasn't leaking and that R1 had a strong urine smell due to decreased urine output from not drinking. DCS-A was aware FM-C changed R1's brief and marked it, but stated staff had changed the brief and had repositioned R1. During a phone interview on 3/25/21 at 9:06 a.m., (RN)-B stated she worked with R1 for the first time on 3/20/21. RN-B stated she had checked R1's brief and looked at her skin when she turned her and did not see anything unusual, adding she did not see any skin discolorations. RN-B stated she told the NA's they needed to go into the room to reposition R1 and check her brief, even if a family member was in there. RN-B stated, We needed to show that we cared. According to a weekly skin review document from the electronic medical record, RN-B completed R1's weekly skin assessment 3/20/21 in the evening, and indicated the skin was intact with no redness or blisters, despite RN-A documenting on 3/19/21, that R1 had new pressure areas to bilateral elbows, mid back, lower back, right heel and a 2 cm x 3 cm blood blister to left buttock. During an interview on 3/25/21, at 9:19 a.m., nursing assistant (NA)-A stated she worked with R1 on 3/19/21, when RN-A and FM-C were there. NA-A stated she helped clean R1 and reposition her, but didn't notice if R1's brief was wet or if there was stool in it, I really couldn't see that part. NA-A couldn't recall when R1's brief was changed or whether she'd been repositioned prior to that, but stated they usually checked her brief and repositioned her every two hours. NA-A stated, the staff didn't always document when they toileted or repositioned the resident. NA-A stated she did not recall seeing any skin problems, other than red lines on R1's back from wrinkles in the sheets. NA-A stated she didn't report that to the nurse because those marks are common on residents who remain in bed. NA-A stated she did not see any marks on R1's buttocks, but confirmed she really couldn't see R1's buttocks closely. NA-A stated she didn't go into R1's room a lot because her family was there, and she wanted to respect their privacy. During an interview on 3/25/21, at 9:33 a.m., NA-B stated the nursing assistants don't document if they check a residents brief and it is dry, and clarified they would document repositioning at the end of the shift not right after it was done. NA-B stated the status of a resident's brief and repositioning were communicated to the next shift. NA-B stated she had cared for R1, and stated, Toward the end of her life, we checked her brief every hour. She had a urinary catheter, and at no time was she wet or soiled. NA-B also stated R1 had no pressure injuries or skin discoloration. However, NA-B verified she had not worked with R1 the weekend of 3/19 through 3/21/21. During an interview on 3/25/21 at 9:47 a.m., RN-C acknowledged working with R1 the weekend she passed away. RN-C stated R1 was actively dying, adding that she seemed comfortable and was getting scheduled [MEDICATION(S)]. RN-C stated hospice was working with R1 and requested frequent dosing of R1's PRN (as needed) pain medications. RN-C said was not aware if R1 had pressure injuries, adding the NA's didn't report it. RN-C didn't know whether the nurses had oversight over the nursing assistants regarding them repositioning, or checking and changing their briefs, but added it was hit or miss if they wrote those things down. RN-C stated, I don't think we provided the best care to [R1] at the end of her life. There wasn't enough time or staff to ensure proper care was provided all of the time. I apologized to [R1's] daughter for that. During an interview on 3/25/21, at 10:24 a.m., (NA)-C showed the surveyor the assignment sheets the nursing assistants carried. The sheet had six columns that included: room number/name, code status, diet, blood sugar, bath day, and a column titled additional information. NA-C acknowledged the sheet did not identify those residents who required repositioning or checking/changing briefs. NA-C stated they would find out that information from the nurses and nursing assistants from the previous shift. NA-C's assignment sheet did not include any hand-written notes about repositioning, toileting or checking and changing briefs. When asked how she remembered which residents required repositioning or having their brief checked and changed, NA-C stated We just remember. During an interview on 3/25/21 at 10:28 a.m., RN-D stated she had cared for R1 the week prior to her passing and R1 did not have any pressure injuries that she was aware of. RN-D stated the nurses were responsible to remind nursing assistants to reposition residents and to check and change them. During an interview on 3/25/21 at 11:49 a.m., DCS-A stated the facility was not able to validate FM-C's concerns. DCS-A was aware that FM-C put an X on R1's brief, but stated R1 may not have had a bowel movement on 3/19 or 3/20/21, and therefore the brief would not need to be changed, adding documentation showed R1 did not have a bowel movement from 3/18 through 3/21/21. When asked if staff would have to undo the brief to determine if it was wet or soiled, DCS-A stated not always. DCS-A also stated R1 could not have had a urine-saturated brief because she had a urinary catheter in place. DCS-A stated documentation from 3/17 to 3/21/21, did not indicate any urinary incontinence episodes related to R1's urinary catheter except for on 3/18/21. DCS-A also stated NA's documented repositioning under bed mobility in the medical record but were only required to document that once per shift. DCS-A stated, I can't validate if [R1] was repositioned or not on 3/19 and 3/20/21, nor can I validate whether or not there was something on [R1's] skin that weekend. During interview on 3/25/21, at 12:07 p.m., the administrator stated he'd spoken to FM-C on 3/22/21, and took the information she provided, adding it seemed the concerns arose the week before R1 passed away. The administrator stated, [FM-C] was very complementary of the care [R1] received prior to this. The administrator stated having shared the family's concerns with the director of nursing who along with a social worker, submitted the report to the State Agency. The administrator further stated their director of nursing (DON) had a family emergency so was out of work, and DCS-A was investigating the concerns. The administrator stated he did not know if FM-C's concerns were valid, but acknowledged they were taking the concerns seriously and looking into it. During a telephone interview on 3/25/21, at 1:47 p.m., FM-C stated she'd taken photos of R1's pressure injuries. The facility's 6/1/17 policy titled, Residents Receiving Hospice Services, indicated: 1. The hospice and the nursing home agree upon a coordinated plan of care which reflects the hospice philosophy and based on an assessment of the individual's needs 2. The plan of care must include directives for managing pain and other uncomfortable symptons and revised and updated as necessary to reflect the individuals current status. The facility and the hospice are responsible for performing each of their respective functions that have been agreed upon and included in the plan of care. The facility's October 2010 policy titled, Incontinence Care indicated: 1. Purpose: to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. 2. Review the residents care plan for special needs. Incontinent residents need to be checked on a regular basis and provided incontinence care with every change of brief. 3. After continence care is provided, the following was to be recorded in the residents medical record: date and time perineal care given, any problems noted at the catheter-urethral junction. The facility's 2/22/21 policy, Indwelling Catheter Care, indicated: 1. Purpose: to prevent infection and reduce irritation. 2. Procedural steps were listed. 3. Inspect meatus (opening leading to the interior of the body) for redness, irritation, and drainage. 4. Check the catheter where it enters the meatus for encrusted material and drainage. 5. Clean the meatus with soap and water during daily bathing. 6. Be sure tubing is not kinked, twisted, obstructed, or caught on bed parts. The facility's June 2017 policy, Positioning the Resident, indicated: 1. Purpose: to relieve pressure and prevent skin breakdown, to relieve pain. 2. Procedural steps were listed. 3. Document date, time, body position; frequency of positioning, condition of skin. 4. Care plan guidelines: identify the appropriate problem under which to list appropriate positioning procedures. The facility's 12/17 policy, Skin Management System, indicated: 1. A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter and documented on the Weekly Skin Integrity Review form or electronic medical record. 2. Routine weekly checks will be completed on every resident. 3. NA's will note any alteration in skin integrity during routine care and report it to the charge nurse. 4. Braden Scale (used to predict pressure sore risk) will be completed upon admission, readmission, weekly for three weeks, change of condition, then quarterly thereafter. 5. Facility DON's are responsible to establish a system to monitor and assure skin management system compliance.

Based on observation, interview and document review, the facility failed to ensure 4 of 14 residents (R218, R25, R14, & R9) reviewed for diabetic management were provided adequate diabetic care in accordance with current standards of practice and physician orders. This practice, including inacurrate recording of diabetic blood sugar readings, inaccurate insulin adminstration, and inadequate monitoring and notification of the physician, resulted in an immediate jeopardy situation. In addition, the facility failed to ensure appropriate monitoring of oxygen therapy 2 of 2 residents (R8 & R62) reviewed who utilized continuous supplemental oxygen to maintain safe blood oxygen levels. Also failed to notify the doctor of a decline of health timely for 1 of 1 resident (R9) reviewed for death. The immediate jeopardy began on [DATE], when R218 required emergent care due to [MEDICAL CONDITION] (high blood glucose level) due to a failure of the staff to montior and assess the resident's diabetic status. On [DATE] at 5:03 p.m., the administrator, regional administrator, director of nursing (DON), certified nurse practitioner (CNP), and clinical nurse consultants were notified of the immediate jeopardy. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of G, a pattern with actual harm but is not immediate jeopardy. Findings include: R218's face sheet indicated R218 was her own person, who had been admitted on [DATE] at 4:00 p.m. following a two day hospitalization after a fall at home. The face sheet indicated R218 had [DIAGNOSES REDACTED]. R218's admission Minimum Data Set (MDS) assessment dated [DATE], identified R218 as cognitively intact. R218's baseline care plan dated [DATE], included a problem area of safety, and identified R218 as diabetic. However, there were no documented interventions. R218's electronic medical record (EMR) care plan also indicated R218 had diabetes, but did not indicate resident specific interventions for diabetic management. R218's post hospital medication reconciliation document authored by nurse practitioner (NP)-B on [DATE] at 5:10 p.m. included: She (R218) is concerned that her medications (insulin) are not correct. The document also included, She (R218) does admit she vomited this morning after she had a few bites of breakfast stating her blood sugar was over 500. NP-B further documented having asked staff about R218's blood sugar and they'd reported her blood sugar was 296 this morning and 409 at bedtime last night. The note indicated R218 had reported to NP-B she had not received her Tresiba (insulin) that morning. The NP documented plan for R218 included: She will continue with Tresiba, changed to administer in the morning. She has not received her dose today and therefore this will be given at dinner time instead of bedtime then start tomorrow morning. (R218) will continue with [MEDICATION NAME] sliding scale which was given to the nursing home staff per telephone order. The documentation further indicated R218's [MEDICATION NAME] sliding scale insulin was based on carb counting previously, however the staff at the nursing home do not follow this sliding scale. Her blood sugars have been quite elevated although I am not sure she got the correct dose of her insulin on the 28th ([DATE]). Staff will continue to monitor her glucose level 4 times a day. A nursing home progress note dated [DATE] at 1:37 p.m. included, (R218) also reports that she has been counting her carbs for years and will continue to do so. R218's order summary report, dated and signed by the medical doctor on [DATE], included the following orders: -[MEDICATION NAME](fast acting) 100 unit/ml (millimeters) (Insulin [MEDICATION NAME]), inject as per sliding scale: if BS ,[DATE] give 1 unit; ,[DATE] = 2; ,[DATE] = 3; ,[DATE] = 4; ,[DATE] = 5; ,[DATE] = 6; ,[DATE] = 8;,[DATE] = 9; 400+ = 10 greater than 400 give 8 units and notify provider, insulin to be given subcutaneously before meals, for diabetes call MD if blood sugar reading less than 70 or greater than 450. -Tresiba Flex Touch Solution Pen-Injector 100 unit/ml (short acting insulin) inject 7 units subcutaneously at bedtime for Diabetes, Call MD if blood sugar less than 70 or greater than 450. A nursing progress note following R218's transfer to the emergency room (ER) on [DATE] at 5:45 p.m., indicated the ER physician had called to inform staff R218 would be staying at the hospital under observation overnight. The note also indicated the ER physician had indicated he would be sending R218 back wiith an order to self-administration of insulin. The note indicated the ER physician had reported that R218 had been able to keep her blood sugars very stable and had been competent to manage her sugars and insulin for the last [AGE] years. R218's [DATE] ER discharge instructions, indicated her discharge [DIAGNOSES REDACTED]. It is a dangerous and serious condition that can develop very quickly, sometimes within the space of 24 hours)(typical cause is lack of insulin to use blood sugar for cell fuel). R218's medication self-administration of medication assessment form dated [DATE], indicated R218 had managed her blood sugars and insulin for the last [AGE] years, was able to demonstrate proper procedure and that the resident may self-administer medications unsupervised. During interview on [DATE], at 7:01 p.m. R218 expressed to the surveyor she was concerned she was not getting her insulin dose on time and reported her blood sugars have been over 500. R218 reported when her blood sugar went over 500 she had requested staff to give her insulin now and had requested to go to the emergency department because she felt strongly there was something wrong regarding her insulin/blood sugar control and was afraid she was possibly going into ketoacidosis. R218 stated this had happened on [DATE] before breakfast. When asked what the staff had done for her when she asked for her insulin now R218 said she had not received the insulin right away, but had to wait for some time. At that time, the MAR was reviewed and reflected documentation of R218's insulin having been given at 8:00 a.m. However, the resident indicated the insulin had not been administered until 9:49 a.m. R218 said the staff did not think it was a serious matter and had not sent her to the ER for evaluation even when she had requested it. R218's nursing home discharge coordination note authored by NP-B on [DATE], included: (R218) was seen for a follow up appointment and had not felt well and was sent to the emergency room . (R218) had a blood sugar over 500 at ER. (R218) then received fluids and insulin (at the hospital). She (R218) does admit to me (NP-B) that her insulin was not given correctly at the care facility after she was discharged from the hospital previously ([DATE]). R218's (MONTH) (YEAR), medication administration record (MAR), indicated blood sugar checks were conducted before meals at 7:30 a.m., 11:00 a.m. and 4:00 p.m. with bedtime checks at 8:00 p.m. and 9:00 p.m. Insulin administration times were documented on the MAR are as: 7:00 a.m., 11:00 a.m., 5:00 p.m. and 8:00 p.m. During interview on [DATE], at 4:51 p.m. the administrator and Director of Clinical Services (D[NAME]S)-A were given an update of concerns regarding insulin administrations including insulin be administered outside times ordered. During interview on [DATE], at 7:42 a.m. the D[NAME]S-A provided documentation titled Performance Improvement Plan for diabetic management, which identified actions including: identify diabetic residents who have orders for insulin, review blood glucose monitoring results for identified residents, review administration of insulin for identified residents, educate nurses using Insulin Tips Sheet for each nurse. Maintenance to attach Insulin Tip Sheet to each medication cart, consult with medical providers regarding scheduling blood glucose monitoring to concur with insulin administration times, review protocol for identifying and responding to hypo/[MEDICAL CONDITION] with nurses, review signs of hypo/[MEDICAL CONDITION] with certified nursing assistants (CNAs), educate nurses on obtaining Accucheck just before administration of insulin and following Insulin Tip Sheet guidelines for administration, Review insulin protocol with resident who often requests insulin early and explain why insulin must be given closer to meal intake and monitor compliance with professional standards five times weekly for four weeks then weekly for twelve weeks. The document also indicated diabetic education had been provided, with staff sign in signatures dated [DATE], and [DATE]. During a follow up interview with R218 on [DATE], at 8:15 a.m. she verified she had requested to go to the emergency room (ER) the first day admitted to the facility ([DATE]) and stated she yelled a lot the next morning to get her insulin and her blood sugar test completed in a timely manner. When asked about staff having informed her that she did not need to be seen in the ER after requesting it on [DATE], R218 identified the licensed nurse as licensed practical nurse (LPN)-E. R218 then stated the second time the high blood sugar reading had happened, she'd gone to a follow up appointment on [DATE], with a medical provider and was not feeling good. At that time, the provider had sent R218 to the ER, where they found [MEDICATION NAME] in her urine, and they kept her overnight for treatment and observation. R218 said after the ER visit and overnight hospital stay, she hasn't had any high readings because she started checking her own blood sugars with her personal glucometer. During further interview with RN-D on [DATE] at 8:30 a.m., RN-D verified the staff nurse working during the day on [DATE], when R218 had reported having a high blood sugar levels and wanted to go to the ER, was LPN-E a staff nurse from an outside staffing agency. During interview on [DATE], at 8:40 a.m. LPN-A stated he didn't recall the blood sugar readings for R218 on [DATE], but verified each resident has their own glucometer (device used to check blood sugar) and stated the glucometers are kept on the nurse's cart. R218's glucometer blood sugar history was reviewed from her glucometer on [DATE] at 11:52 a.m. with RN-D. During the review, RN-D verified the glucometer times for each entry were recorded as one hour ahead of the actual time because the machine had not been reset for day light savings time changes. The readings included: [DATE], at 10:56 p.m. results 448, documented on MAR as 409. Although the resident's physician order indicated the doctor was to be notified if her BS was over 400, that had not been done. [DATE], at 10:48 a.m. results 473, documented on MAR as 296 for the 7:00 a.m. reading. Although the resident's physician had ordered sliding scale insulin coverage of ,[DATE] units, for a reading over 473, the resident had onlyi received 6 units because the nurse documented the reading on the MAR as 296. In addition, the physican was not notified of the high blood sugar. [DATE], at 11:52 a.m. results 449, there was no documentation of this reading documented on the MAR, nor was the physician notified. [DATE], at 12:21 p.m. results 388 and accurately recorded on the MAR as 338. However, R218 should have received 9 units of insulin according to the physician ordered sliding scale, but only received 8 units. During an interview on [DATE], at 9:16 a.m. the D[NAME]S-A and DON verified each resident has their own personal glucometer. The above blood sugar readings for ,[DATE] and [DATE], accessed from R218's personal glucometer, had been reported to the DON and D[NAME]S-A. In addition, they'd been made aware of the concerns with the timing of the blood sugars and had been informed about R218's request to go to the ER, and the staff's decision not to pursue this in accordance with R218's request and fears about her blood sugars being elevated and her fear of going into ketoacidosis. The DON stated, (218) has been a type1 diabetic (juvenile onset) for the last [AGE] years. The DON stated, This is not acceptable for our staff to do (regarding not documenting accurate blood sugar readings, not following sliding scale for insulin coverage, and not contacting a resident's physician/provider for BS readings over 400). During the interview with the DON and D[NAME]S-A, the administrator walked in and was also updated regarding the significant concerns regarding R218's diabetic monitoring. The administrator stated, We will investigate this immediately. During interview with NP-A on [DATE] at 9:40 a.m., NP-A was updated regarding the surveyor's findings regarding R218's diabetic care management. NP-A stated, This defeats what we are doing here to address medications such as insulin and I am sick to hear this. NP-A stated she was not R218's provider, but does have other diabetic residents she provides care for in the facility. During interview on [DATE] at 12:41 p.m., LPN-A stated LPN-E did not have access credentials to chart in the electronic MAR. LPN-A acknowledged having given LPN-E his user name and password to document and stated he was monitoring LPN-E due to initial training. However LPN-A acknowledged having been assigned to a different area of the facility to work, making oversight of LPN-E difficult. LPN-A also stated he did not monitor LPN-E with each medication administration on [DATE], nor had he been aware of R218's request go to the ER. During a phone interview with NP-B on [DATE] at 2:31 p.m., NP-B stated she had been unaware of the inaccurately documented blood sugar readings for R218. NP-B added, I cannot adjust medications if not given the correct information. NP-B said if she had been aware of the accurate readings sooner she would have given approval for R218 to manage her own blood sugars and insulin dosing. NP-B said she was especially concerned when the resident told her about her high blood sugar results when staff had told her different results, such as when staff stated the BS was 296 when the BS was actually 473. During interview on [DATE], at 12:11 p.m. with the DON and D[NAME]S-A, they both verified R218's care plan failed to address monitoring of R218's diabetes related to hypo/[MEDICAL CONDITION] and corresponding interventions. R25's current face sheet dated [DATE], identified [DIAGNOSES REDACTED]. R25s quarterly MDS assessment dated [DATE], identified R25 as cognitively impaired and as requiring assistance with activities of daily living. R25's care plan (undated), identified R25 as full code, indicating cardio-pulmonary resuscitation (CPR) would be performed as ordered. The care plan further indicated R25 had diabetes and uses insulin. The goal included for R25 to have no complications r/t (related to) diabetes, and for her blood glucose to remain within prescribed parameters. R25's Order Summary Reports, dated and signed [DATE], indicated: blood glucose test strip (glucose blood) 1 each in vitro before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH [MEDICAL CONDITION]. Same titled report dated and signed on [DATE], [DATE], [DATE], [DATE] and [DATE], reads: blood glucose test strip (glucose blood) 1 each in vitro before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH [MEDICAL CONDITION]. Notify Mayo provider NP (nurse practitioner) or Dr.(name of physician) if glucose <(less than) 120 or >(greater than) 400. R25's physician progress notes [REDACTED]. -[DATE] to [DATE], R25 had several episodes per month of having low blood sugar readings, staff followed diabetic protocol as ordered by provider. -[DATE], at 6:10 p.m. BS was 29, insulin held. -[DATE], at 6:38 p.m. Resident's blood sugar level dropped to 29 at 1730 (5:30 p.m.) when she was taking a nap in bed. Resident was unresponsive. Writer notified clinical manager right away and injected [MEDICATION NAME] IM immediately. 10 minutes later, blood glucose level went up to 41. Another ten minutes later, blood glucose level went up to 80. Clinical manger(name) administered glucose gel. Blood glucose level went up to 102 at around 1810 (6:10 p.m.). Resident was able to wake up and drink juice. Clinical manager (name) notified resident's husband, NP(name), and Dr. (name). Will continue to monitor. -[DATE] at 12:29 p.m. Change of Condition Late Entry: Low Blood Glucose, resident was in the dining room on 2nd floor when it was noticed by staff she was showing signs of tiredness and was having hard time stay awake. Resident was taken to her room, blood glucose level was obtain reading 48. orange juice 240 ml was given immediately. Blood Glucose was Rechecked and reading was trending up 67 and another check read 201. Will continue to monitor, follow and changes in orders, update with interdisciplinary team (IDT) members and spouse. The following day provider and spouse were notified. (This entry had been completed after surveyor brought the concern to the facility). R25 personal glucometer was reviewed on [DATE] at 9:38 a.m. The blood sugar history was accessed from the glucometer as follows: [DATE] at 10:04 p.m. (the glucometer time of entry was ahead by one hour due to it not being reset when day light savings time began) =BS 65 [DATE] at 5:59 p.m. =BS 75 [DATE] at 10:33 p.m. =BS 81 [DATE] at 7:48 a.m. =BS 97 [DATE] at 9:06 a.m. =BS 75 [DATE] at 3:46 a.m. =BS 70 [DATE] at 8:20 a.m. =BS 55 [DATE] at 5:41 p.m. =BS 45 [DATE] at 5:51 p.m. =BS 51 [DATE] at 5:16 p.m. =BS 62 [DATE] at 10:17 a.m. =BS 42 R25's readings were compared to documentation in the MAR, and it was noted the provider had not been contacted even though there was an order to contact the provider when the resident's blood sugar level was below 70. During interview on [DATE] at 3:02 p.m., R25 verified she was diabetic. When asked whether she was aware of the signs and symptoms of [DIAGNOSES REDACTED], R25 stated she gets shaky. During interview on [DATE], at 3:20 p.m. NP-A verified R25 was last seen on [DATE]. At that time, R25's blood sugar readings accessed from her glucometer were reviewed with NP-A. NP-A stated, (R25) blood sugar plummets (drops) fast and anything under 100 should be reported to the medical provider. NP-A expressed concern with R25 describing her as a fragile diabetic, making it all the more reason to monitor her due to low blood sugars. NP-A said, low blood sugar levels could mean death for (R25) if not monitored. NP-A said she would have expected the facility to update R25's medical professional regarding the low blood sugars. During interview on [DATE], at 3:36 p.m. DON and D[NAME]S-A verified they would have expect staff to update provider of low BS and follow protocol. Also updated DON of the findings on R25 glucometer versus what was documented in the chart for R25. During interview on [DATE], at 3:49 p.m. LPN-D verified R25 had a BS of 44 and was unresponsive at the dining room table yesterday ([DATE]), LPN-D said that RN-D had also been aware of R25's BS of 44. However, neither LPN-D nor RN-D had documented the hypoglycemic episode nor what treatment was tried, or whether it had stabilized R25's blood sugar. During interview on [DATE], at 3:58 p.m. the DON, D[NAME]S-A and RN-D were interviewed regarding R25's hypoglycemic episode on [DATE]. RN-D stated he was aware of R25 having a low BS and stated it had occurred yesterday. RN-D said R25 had been found unresponsive in the dining room but verified there had been no documentation of the incident, nor had the provider been contacted even though the BS was 44. During follow up interview on [DATE] at 4:12 p.m., NP-A was updated of the additional findings for R25 and in fact R25 was found unresponsive again in the dining room yesterday ([DATE]) morning. NP-A asked surveyor if it was documented, surveyor stated they were unable to located any documentation nor had he facility provided any documentation regarding the hypoglycemic episode for R25. NP-A then stated she spoke with the medical director and he agreed with everything she had said, and agreed again with a resident as fragile as (R25) death can occur. During interview on [DATE], at 4:05 p.m. the administrator verified he is involved in the morning meetings with nursing to discuss cares of the residents. An update was given regarding the concerns with missing information in R25's charts that would be helpful for others who have to give care to the residents. Follow up interview on [DATE], at 9:07 a.m. LPN-D verified had not documented anything in R25's record regarding the low BS (44) on [DATE]. During interview on [DATE], at 9:21 a.m. RN-C verified she had received education on insulin today. RN-C was asked what the protocol was if a resident has a low BS. RN-C said nurses are not to hold insulin unless a doctor orders to hold it and they write up on a situation, background, assessment, recommendation (SBAR) which then goes in a box and sometimes the physician may not see it until the next day. On [DATE] at 4:31 p.m., NP-A said notification of low BS to the medical professional had been changed today from less than 100 to less than 70. The DON, also present at that time, verified they'd discussed the findings and said, if we continued to notify the doctor for readings less than 100, the facility would be calling the physician all the time. The facility policy Obtaining a Finger stick Glucose Level dated ,[DATE], indicated the person performing this procedure should record the following information in the resident's medical record: the date and time procedure was performed, the blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin). R14's [DIAGNOSES REDACTED]. R14's annual MDS assessment dated [DATE], indicated R14 was cognitively intact, and had no rejection of care behaviors. R14's MDS indicated R14 had [DIAGNOSES REDACTED]. R14's signed physician orders dated [DATE], included orders for: [MEDICATION NAME](a fast acting insulin with an onset of action of 5 to 15 minutes with the peak effect occurs in 1 to 2 hours. The manufacturer's package insert directed an injection of [MEDICATION NAME] should immediately be followed by a meal within ,[DATE] minutes.) R14's specific insulin orders included: [MEDICATION NAME] insulin100 unit/ml (milliliters) 11 units subcutaneously one time a day with breakfast, hold if not eating. [MEDICATION NAME] solution 17 units subcutaneously one time a day with lunch, hold if not eating. [MEDICATION NAME] solution 19 units subcutaneously one time a day with supper, hold if not eating. [MEDICATION NAME] (long acting insulin) Flex Pen Solution pen injector 100 unit/ml, inject 32 units subcutaneously two times a day. The physician orders did not reflect parameters for when to call the physician for high or low blood sugars. R14's (MONTH) (YEAR), MAR indicated a physician order with a start date of [DATE], to check blood sugars two times per day at 8:00 a.m. and 5:00 p.m. The MAR further reflected the [MEDICATION NAME] administration times were scheduled for 8:00 a.m. and 9:00 p.m. R14's diabetic care plan dated [DATE], lacked a goal for blood sugar ranges and indicated R14 had alteration in blood glucose due to insulin dependent diabetes mellitus. The care plan interventions included: administer diabetes medication as ordered, monitor and document side effects and effectiveness; labs per physician order and as needed for change in condition/manifestation of clinical signs or symptoms; monitor blood glucose as ordered; monitor/document/report as needed any signs/symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmal breathing, [MEDICATION NAME] breath (smells fruity), stupor, coma; monitor/document/report as needed any signs/symptoms of [DIAGNOSES REDACTED]: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination; Report abnormal results per physician parameters/guideline (However, R14's physician orders did not include parameters and/or guidelines for blood sugar results.) During an interview on [DATE], at 10:28 a.m. R14 stated she received [MEDICATION NAME]twice a day in the morning and at bedtime 32 units. R14 stated she got her short acting insulin ([MEDICATION NAME]) at 8:15 a.m., at 12:15 p.m. 17 units, and at 5:15 p.m. 19 units. R14 stated she had an episode two Sundays ago when she got her insulin at 12:15 p.m. and did not get her lunch until 1:00 pm. R14 stated her blood sugar then bottomed down to 88 milligrams/deciliter (mg/dl) which caused her to feel sweaty and shaky. R14 stated 88 was very low for her, and she was very shaky so LPN-A had given her cookies and M&M candies and was checking her blood sugar every 15 minutes until it came up to 120 mg/dl. R14 stated they were checking my blood sugar twice a day, then the doctor switched it to four times a day, and now I'm back down to twice per day. During a subsequent interview on [DATE], at 3:52 p.m. R14 stated when her blood sugar dropped a couple Sundays ago, staff had initially given her the wrong insulin. She stated staff had given her the [MEDICATION NAME] short acting at 12:15 p.m. however, she had not received her lunch until 1:00 p.m. R14 stated reiterated they were only checking her blood sugar twice a day at that time, at breakfast and supper. R14 stated when her meal had been served, there was rice on the plate, and she'd been shaking so bad the rice spilled all over the place. R14 also stated she had felt clammy, and her heart was racing, so she'd put on her call light for staff to come in as she'd been eating in her room. R14 stated she remembered LPN-A coming into the room, and her roommate told the nurse that something wasn't right so LPN-A had checked her blood sugar. R14 said now staff administer the [MEDICATION NAME] with the meal or give her ice cream so her sugars don't drop because meals trays are rarely ever on time. R14 stated after that happened LPN-A made a sign of what he was taught and hung it on her wall to help her know what to do when her blood sugar dropped: The sign that hung on R14's wall next to her bed read, COLD AND CLAMMY, EAT SOME CANDY. HOT AND DRY, SUGARS ARE HIGH. EITHER OR-CALL FOR YOUR NURSE. The sign was signed by LPN-A and dated [DATE]. During an interview on [DATE], at 7:57 a.m. LPN-A confirmed he had administered R14's insulin prior to her noon meal on [DATE]. LPN-A stated R14 demonstrated symptoms of [DIAGNOSES REDACTED] which included tremors and [MEDICAL CONDITION](fast heart rate) 110 beat per minute. LPN-A stated R14's blood sugar at the time was 88 mg/dl however, was not hypoglycemic because her blood sugar was not below 70 mg/dl. LPN-A stated R14 usually demonstrated hypoglycemic symptoms when she was below 100 mg/dl. LPN-A confirmed after he had taken the blood sugar he gave R14 M&Ms to increase her blood sugar because that was what was available at the time. LPN-A then stated he rechecked R14's blood sugars every 15 minutes until her blood sugar was in the triple digits. LPN-A stated, it was not the facility's protocol to administer candy to increase blood sugars, but instead stated the protocol directed to give orange juice. LPN-A also stated he hadn't documented the incident in R14's record but should have. LPN-A confirmed he had made the sign that hung on R14's wall because she requested something to be given to her to remind her of what she was supposed to do if she were symptomatic. LPN-A stated R14 did not have orders to check her blood sugar before meals, however, after the incident we were checking her blood sugar levels before all meals, but they were no longer doing that. LPN-A further stated, now he was not administering insulin until R14 had her meal tray in front of her. LPN-A indicated even though R14 was symptomatic of [DIAGNOSES REDACTED], he had not notified the physician because R14's blood sugar had not been below 70 mg/dl. R14's progress notes and MARs since [DATE] through [DATE]. Progress notes only reflected two occurrences of when insulin was held. The record did not reflect the [DATE], event per R14 and LPN-A interviews, which included the recording of any of the blood sugars that were obtained. R14's progress note dated [DATE], at 11:45 a.m. indicated R14 was not been given morning insulin dose and the on call physician was contacted; physician indicated it was ok not give a.m. dose of insulin. The note did not indicate which insulin was not given and why it was not given. The MAR for [DATE], reflected all scheduled insulin doses were administered. The MAR indicated R14's morning blood sugar was 131. R14's progress note dated [DATE], at 6:40 p.m. indicated R14 had a low blood sugar before the meal, after the meal the blood sugar was 247, and insulin was given. The MAR for [DATE], indicated R14's blood sugar was 98. The record lacked mention of any signs or symptoms associated with the low blood sugar. R14's personal glucometer recordings from [DATE] through [DATE], with corresponding blood sugars recorded in the electronic health record (EHR) under blood sugars, which revealed inconsistencies between what was recorded on the glucometer and what was recorded in R14's record. R14's EHR on [DATE], at 8:50 a.m. reflected BS of 134 mg/dl- this recording was not on R14's glucometer. The next BS that was recorded on the glucometer and on the EHR was 174 mg/dl at 5:17 p.m. The record nor the glucometer reflected R14's lunchtime blood sugar of 88 mg/dl or the rechecks that were completed per interview of R14 and LPN-A. However, the glucometer and/or the EHR did reflect an increase in BS checks to at least three times a day consistently from [DATE] through [DATE], despite the physician order for [REDACTED]. In addition, the record lacked evidence of a physician order to increase the number of blood sugar checks. -on [DATE], at 8:29 a.m. the BS on EHR was 168 mg/dl however, the glucometer did not reflect this recording. -on [DATE], at 12:15 p.m. the EHR and glucometer both reflected a BS of 190 mg/dl. -On [DATE], at 12:29 p.m. the glucometer reflected BS of 111 mg/dl, however the EHR did not reflect this recording. -On [DATE], at 5:04 p.m. the EHR and the glucometer both reflected BS of 130 mg/dl. -On [DATE], at 9:48 a.m. the EHR and the glucometer both reflected BS of 180 mg/dl. -On [DATE], at 12:24 p.m. the EHR and the glucometer both reflected BS of 154 mg/dl. -On [DATE], at 4:45 p.m. the EHR and the glucometer both reflected BS of 119 mg/dl. -On [DATE], at 7:43 a.m. the EHR recording indicated BS of 176 mg/dl and the glucometer indicated 171 mg/dl. -On [DATE], at 8:00 a.m. glucometer recording indicated BS of 85 mg/dl and the EHR did not reflect this recording and/or why this check was performed 17 minutes following the previous check. -On [DATE], at 10:16 a.m. glucometer recording indicated BS of 239 mg/dl, the EHR did not reflect this recording and/or why R14's blood sugar was checked at this time. -On [DATE], at 4:59 p.m. glucometer recording indicated BS of 172 mg/dl, the EHR reflected BS of 174 mg/dl. R14's EHR and glucometer also reflected the following inconsistencies: -On [DATE], at 9:22 a.m. the EHR reflected a BS of 149 mg/dl, however, the glucometer did not reflect that reading. -On [DATE], at 9:15 a.m. the EHR reflected BS of 164 mg/dl, however, the glucometer did not reflect that reading. -On [DATE], at 3:45 p.m. the glucometer reflected BS of 195 mg/dl, however, the EHR did not reflect that reading. -On [DATE], at 5:38 p.m. the EHR reflected BS of 1

Based on observation, interview and document review, the facility failed to implement interventions to prevent choking including assessment/reassessment, appropriate positioning and adequate supervision, for 1 of 1 resident (R14) reviewed who was a known choking risk. The facility's failure to implement interventions resulted in an immediate jeopardy (IJ) for R14. In addition, the facility failed to implement fall interventions for 1 of 5 residents (R36) reviewed for accidents with a history of falls with injury. The IJ began on [DATE], at 9:30 a.m., when the facility failed to appropriately position and supervise R14 during a meal and the resident choked, and staff had to provide the [MEDICATION NAME] maneuver. The IJ was identified on [DATE] when it was determined the facility failed to implement R14's care plan interventions to ensure appropriate positioning and supervision during meals. The administrator, director of nursing (DON), and registered nurse consultant (RNC) were notified of the IJ on [DATE], at 5:57 p.m. The IJ was removed on [DATE], but non-compliance remained at the lower scope and severity of D- isolated with no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings include: R14's [DIAGNOSES REDACTED]. R14's annual Minimum Data Set (MDS) an assessment dated [DATE], indicated R14 was cognitively intact, required extensive assist from two plus staff for bed mobility, dressing, and personnel hygiene, and displayed no refusal of care behaviors. The MDS further indicated R14 was independent with eating after set-up, had a therapeutic diet, and did not have any difficulties with chewing or swallowing. R14's fall Care Area Assessment (CAA) dated [DATE], indicated R14 had difficulty maintaining a sitting balance. R14's nutritional status CAA, indicated R14 had the inability to perform activities of daily living (ADL) without significant physical assistance and indicated R14 had poor memory which could interfere with eating. R14's ADL care plan from [DATE], indicated R14 was independent with eating after set-up. The care plan dated [DATE], included a revised problem: potential aspiration precautions related to eating in bed per resident choice. Resident often voices her positioning needs and does not need changed when eating and chooses to eat in a slumped down position despite redirection. Interventions included; diet as ordered, monitor meal consumption, proper positioning at meals, encourage her and assist as needed to get out of bed to eat to improve positioning when eating. The care plan also indicated R14 had a health/safety risk related to R14's denial of condition, with a goal of R14 would remain free from harm, and directed staff to provide supervision and redirection during meal service and snack times and provide screen/evaluations by rehab services as needed. R14's nutrition care plan indicated no texture modification, but indicated R14 was on a ConCHO (consistent carbohydrate) diet. R14's Kardex (abbreviated care plan) included: proper positioning at meals, encourage her and assist as needed to get out of bed to eat to improve positioning when eating. During an interview on [DATE], at 10:37 a.m. R14 stated she'd had a choking episode in (MONTH) (YEAR), and staff had to perform the [MEDICATION NAME] maneuver (emergency response technique used when people are choking). On recalling the incident R14 indicated she had put her call light on and when no one answered she had to pound on her table (over bed table). R14 said that was when the therapist found her and then registered nurse (RN)-C did the [MEDICATION NAME] maneuver. R14 stated staff had watched her the rest of the evening. R14 further stated she hadn't felt well later on that evening and had been sent to the emergency room where they did a chest X-ray and some blood work, before sending her back to the facility. On [DATE] at 3:52 p.m., R14 was observed sitting in her bed in a slouched position with the head of her bed elevated. R14 stated, a couple of weeks before the choking episode (that lead to the [MEDICATION NAME] maneuver), I choked on a piece of ice but didn't report it to staff. R14 said she had been worried about the ice because she knew it would melt. However, R14 again recalled her choking episode from a month or so ago and said it was a really dry hash brown and egg casserole that had gotten stuck in her throat. R14 again stated nobody had answered her call light so she started banging on her tray table and the therapist that was in the next room had been the first one to respond. The therapist had summoned RN-C who had come in and used the [MEDICATION NAME]. R14 stated she had begun coughing and between the coughing and the [MEDICATION NAME] she was able to spit things up. R14 then stated after the incident she had to go to speech therapy again because it was mandatory after a choking episode. R14 stated speech therapy had initially wanted her to eat in the dining room however, the two times she had gone to the dining room, no staff were present. R14 stated she'd thought to herself, If there is no aide or nurse, what's the point of going down there (to the dining room), nobody is there to help. R14 indicated in a meeting staff had told her it was fine to eat in her room as long as the bed was upright, to make sure she chewed her food up good, maybe moisten food with condiments if it is dry or request something different, and took her time eating. R14 then recalled that when she had been through speech therapy before they had thought whatever had happened was fluky and no special recommendation were made, however, after the recent episode speech had told her to take her time eating, make sure head of bed was completely up, stay up right for 30 minutes after eating or drinking, and to drink slow. R14 stated after the choking episode happened, staff had checked in on her for awhile, but weren't doing that anymore. R14 stated she always sat straight up in bed, and stated, staff are good at making sure I am sitting straight up in bed, and don't rush me to eat. R14 also stated she would put on her call light when she needed to be boosted up in bed. A nursing progress note dated [DATE], indicated R14 had felt nauseous, but had not vomited. The note indicated R14's head of the bed was elevated and R14 was educated to remain elevated until the nausea had passed so she would not aspirate. A change of condition nursing progress note written by RN-C on [DATE] at 9:30 a.m., included: Resident was found to be choking in bed. She was red in the face, gasping for air and appeared to be frightened. The note further indicated the nurse had jumped behind R14 in bed and attempted the [MEDICATION NAME] with three thrusts but had been unable to get a full grip to have effective thrusts, so she'd had a nursing assistant (NA) raise the head of the bed back up and had attempted three thrusts from the front. The note indicated R14 had gagged before having two emesis that included the egg bake she'd choked on, and the episode had lasted two minutes until it was resolved. The progress note further indicated following the episode, R14 had reported she had tenderness at the xiphoid process (a small cartilaginous process of the lower part of the sternum) after the [MEDICATION NAME] attempts, and had a tender throat from the gagging and emesis. The note indicated R14 had continued to cough after the episode and was encouraged to sip water and not finish her breakfast, but pudding had been provided instead. The following recommendations were also documented in the note: To remain seated in bed for an hour after episode prior to lying down; To encourage to drink more water or fluids with meals when eating in bed, and to monitor and document for 72 hours including temperature after every meal. R14's change of condition note dated [DATE] at 10:00 a.m., indicated the nurse practitioner had been notified at approximately 10:00 a.m. R14's clinical follow-up note dated [DATE], at 6:00 p.m. indicated R14 was at risk for choking and R14 had agreed to get out of bed for meals. R14's progress note dated [DATE], at 11:34 p.m. indicated the physician had given an order to send R14 to the emergency room for further evaluation because R14 had developed a temperature of 101 degrees Fahrenheit. R14's progress note dated [DATE], at 12:22 a.m. indicated R14's choking episode had occurred at 9:00 a.m. and vital signs had been stable throughout the day and evening shift, however, at 11:00 p.m. R14 had developed a temperature of 101 degrees and had chest and throat pain rated 9 out of 10 (zero no pain and 10 being the worse pain). The note indicated R14's heart rate was 99, blood pressure was ,[DATE], and respirations were 18 with no shortness of breath, and clear lung sounds with no secretions. The note indicated R14 had been transported by ambulance to the emergency room at 12:05 a.m. A progress note at 3:36 a.m. indicated R14 had returned to the facility with no new orders. R14's emergency room discharge note dated [DATE], at 3:02 a.m. indicated the reason for visit was for evaluation of possible aspiration related to fever after a choking episode where the [MEDICATION NAME] maneuver was used. The note indicated R14 had a chest X-ray with no negative or abnormal findings. R14's care plan progress note dated [DATE], at 12:47 p.m. indicated the assistant director of nursing (ADON) had spoken with R14 about the choking episode where the ADON had elaborated the importance of her getting up out of bed for meals to decrease the risk for aspiration. She (R14) states she is amenable to this but would like to review in a week. Staff updated and added to nursing orders and care plan. R14's care plan note dated [DATE], at 10:50 a.m. indicated a care conference had been held with R14 to discuss R14's refusals to get out of bed for meals following her recent choking episode. The note included, It was explained that the request was for her (R14's) own safety. She states that the episode was an isolated incident and she chooses to eat in her bed. She states that if she notices a food item that is too dry for her to consume she will request an alternative item. She also agrees to sign a risk and benefit, this is being prepared by the DON (director of nursing) A care conference note documented by the social worker indicated R14 had agreed during the care conference to get out of bed to eat if another choking episode would happen, and that R14 had reported the episode was isolated and reoccurrence was slim. The social worker's note indicated R14 had agreed to complete a risk benefit form in regards to the issue and R14 had stated she was competent to make her own decisions. R14's progress note dated [DATE], at 3:36 p.m. included, Resident (R14) agreed to sit up higher in bed when eating, she will ask for assistance if meals are dry, and she believes this was an isolated incident. She decided to continue to eat meals in her room per her choice. R14's record between [DATE] and [DATE], lacked documentation of any refusals about getting out of bed. There was no documentation of provided risk and benefits, or other interventions attempted and/or offered at the time of refusals. R14's dietary care plan did not reflect R14's choice to avoid dry foods. R14's Speech Therapy Plan of Care indicated a start of care date of [DATE]. The plan indicated R14 was discharged from speech on [DATE]. Additionally, the note indicated R14 had no history of dysphagia (difficulty swallowing), had been on a regular diet, and had a recent choking episode during a meal. The note indicated swallowing difficulties were likely caused by mealtime behavior with related medical history of [REDACTED]. R14's Speech Discharge Summary dated [DATE], indicated R14 could swallow a regular diet without assistance and had consistent use of compensatory strategies as needed. The summary also indicated skilled services included patient and caregiver training strategies for safe mealtime behaviors and strategies. R14's Therapy Communication To Nursing Staff dated [DATE], included; Patient to eat in dining room as often as possible. Please ask patient if she would like to get up in chair and eat in the dining room prior to every meal. If patient wishes to remain in room, aid patient with moving head of bed upright and proper positioning. The communication did not outline any other compensatory strategies provided. The care plan was not revised to include asking R14 to get up in her chair prior to every meal. R14's record was reviewed. There was no documentation about refusals of safe positioning in bed, or while eating between [DATE] through current ([DATE]). During an observation on [DATE], at 8:27 a.m. R14 was sitting in her bed in a slumped position with the head of the bed elevated to approximately ,[DATE] degrees; she was approximately ,[DATE] inches from the top of the mattress and was leaning toward her left side. R14 stated staff had not asked her about getting up in her chair for breakfast today because she often got up later in the afternoon. At 8:49 a.m., R14 continued to sit in the slumped position. R14 had her breakfast try in front of her, which included a muffin and a cheese omelet. Licensed practical nurse (LPN)-A was observed to administer R14's insulin. LPN-A did not offer to get R14 out of bed nor did LPN-A offer to boost R14 up in bed so R14 would be sitting up straight. At 8:57 a.m., R14 continued to be in the same position. RN-D was in the hall just outside R14's door and was asked whether R14 was eating in a safe position to prevent choking and/or aspiration. RN-D stated because of the type of bed R14 had, it caused her to slide down in the bed, but not to the point R14 was not able to swallow. RN-D stated R14 could sit in that position because it is the positron of her choice and we would get her up for meals if she wanted to get up. RN-D watched R14 take a bite of food and stated R14 did not tuck her chin like she was supposed to. RN-D entered the room and asked if R14 was comfortable in the position she was in. R14 stated she was comfortable, that was the position she always ate in, and that she always leaned to the left. RN-D did not offer R14 to be boosted up in bed, nor provide encouragement and/or education pertaining to R14's eating posture, and did not provide education to use the chin tuck maneuver to reduce the chance of choking. During an observation on [DATE], at 9:14 a.m. R14 was observed seated in bed and had her breakfast tray in front of her, which included a egg on an English muffin. R14's head of bed was elevated to approximately 80 degrees, R14 was not up at the head of the bed, and in a slouched position. R14 indicated that when the head of the bed was elevated to 90 degrees she slid down in bed, and even though R14 was not sitting up straight- stated she was sitting up straight. RN-C confirmed R14 was not up at the head of the bed, was in a slouched position, and the bed was not at a 90 degree angle and was more at an 80 degree angle. RN-C then offered to reposition R14, to which R14 refused. During an interview on [DATE], at 8:37 a.m. RN-D acknowledged being aware of R14's choking incident, and stated R14 has not had any further choking episodes since then so it was thought to be an isolated incident. RN-D stated R14 continued to eat in her room per her choice and said it was determined safe for her to do so. RN-D further stated R14 did not have a history of choking and/or aspiration. RN-D stated R14's safe eating interventions included; not eating and drinking at the same time, chewing well, and staff make sure she is boosted up in bed prior to meals. RN-D stated staff offered to get R14 up for meals every Monday, Wednesday, and Saturday for BINGO. RN-D stated R14 received speech therapy and the recommendations from speech suggested that she could eat in her room per her choice. During an interview on [DATE], at 9:36 a.m. nurse practitioner (NP)-A stated she thought staff asked R14 to go to the dining room for meals however, R14 had refused, and that was why she ate meals in her room. NP-A stated R14 had not been deemed to have cognitive impairment and opted to eat in her bed. NP-A stated the head of the bed should be up to prevent choking episodes, staff should educate on proper positioning, and if R14 was willing to take risks it should be care planned. During an interview on [DATE], at 11:10 a.m. speech language therapist (SLP)-A stated he was unaware R14 had developed a fever after the choking episode [DATE], but stated that would have been important to know. SLP-A stated he was not the SLP that wrote R14's recommendations and SLP-A said as written, the directions seemed conflicting related to level of supervision during meal times. SLP-A stated if R14 chose to eat in her bed, R14 needed to sit straight up at a 90 degree angle and that he would expect nursing staff to check on her at least a couple of times during the meal to make sure she was eating appropriately and safely. SLP-A stated ideally R14 should be sitting in her wheelchair, and said she should be encouraged to do so. SLP-A stated the staff and R14 had received education about cutting food up in small pieces, taking small bites, alternating foods, and use of the chin tuck method when drinking but not when swallowing food. SLP-A stated R14 should ideally be up in her chair for meals and if she chose to remain in her bed, R14 should sit straight up at 90 degrees. SLP-A stated the reason for the choking was probably related to not sitting up straight. SLP-A stated during the course of therapy he had observed R14 to eat meals in bed, when she had been sitting up straight, and not slouching or leaning to either side. SLP-A stated he was unaware of R14 refusing to be positioned upright at a 90 degree angle. During an interview on [DATE], at 12:00 p.m. R14 stated she may have signed a risk benefit form pertaining to eating in her bed, but was not sure. In response to the question, what are the risks and benefits for you to eat in bed? R14 stated if she choked again she would have to get out of bed and eat out of her room. R14 also stated no staff did periodic checks on her during meals she ate while in bed. During an interview on [DATE], at 12:15 p.m. the director of clinical services (D[NAME]S) nursing consultant stated R14 had not signed a risk benefits form because that was not the facility's practice and stated she was not sure why the nurse would have written in a progress note that a risk benefit form was signed. The D[NAME]S stated the nurse that wrote the progress note was no longer employed with the facility or she would follow up with corrective education. During an interview on [DATE], at 2:54 p.m. with the director of nursing (DON) and D[NAME]S, they both stated staff should encourage R14 to go down to the dining room and if she chose not to go to the dining room staff should make sure R14 was in a safe eating position. When asked, how do staff know what R14's proper eating position while in bed? The DON stated special instructions were supposed to be on top of the care plan however the DON verified R14 did not have any special instructions and/or interventions listed. The D[NAME]S stated the expectation was for the care plan/Kardex (abbreviated care plan for NA's) to specifically describe safe eating positions while in bed. The D[NAME]S confirmed the care plan/Kardex did not include specific instructions, and that R14 should be encouraged to get out of bed to eat. The DON further stated even if a risk benefits form was signed, and it was R14's choice to eat in bed, it would not negate staff from encouraging and/or offering R14 to eat in a safe position, or getting up out of bed. The D[NAME]S reiterated, staff should be offering these options. On [DATE], at 8:01 a.m. RN-C confirmed she had been the nurse that had performed the [MEDICATION NAME] on R14 when she experienced the choking episode while eating in bed. RN-C said, R14 had been sitting up in her bed eating that morning, and the occupational therapist (OT)-A had been the first one to respond after hearing R14's banging. RN-C stated she performed the [MEDICATION NAME] a couple of times and then did mouth sweeps. RN-C said on the second sweep, R14 gagged and it all came up. RN-C stated after that R14 had gotten up for meals for a couple of days but wasn't happy. RN-C stated R14 ate meals in bed, but verified the head of the bed needed to be up, and staff were always supposed to boost R14 up before meals. RN-C stated R14 was not resistive to that. During an interview on [DATE], at 3:36 p.m. OT-A confirmed she had been the first responder to R14's choking episode. OT-A stated she had been in the next room with another patient when she heard really loud continuous noise; and realized after one or two minutes something wasn't right so she went out into the hallway and went into R14's room where the noise had been coming from. OT-A stated R14's call light had not been on, when she entered the room R14 was tapping on her chest, had normal color, was breathing heavily, and coughing. OT-A stated she asked R14 if she was choking and R14 had responded yes. OT-A stated she looked in R14's mouth and did not see any food, so she attempted to get behind her, pushed her forward, and attempted two or three thrust but they were not effective. OT-A indicated because of R14's position and size it was difficult. OT-A stated she didn't want to leave R14 alone so she put on the call light, when no one immediately responded after approximately 30 seconds she went into the hallway, the first person that was coming down the hallway was NA-C. OT-A then stated, the NA-C went on one side of the bed and she went on the other side, and both of us together tried two more thrusts. OT-A stated some spit and sputum came out and R14 looked better. OT-A stated since the NA-C was there, she left the room and went to get the nurse, and then she returned to the patient she had been previously working with. On [DATE], at 3:37 p.m. NA-C confirmed she was the NA who had witnessed R14's choking episode. NA-C stated R14 had been sitting in bed per her norm and had been eating hash brown bake that had egg, ham, and bacon pieces. NA-C stated she had been serving breakfast to other residents that morning when she had heard the tapping; R14 had been tapping her plate with her fork (later it was learned that the call light was found under blankets and R14 could not find it so she used fork on plate for noise). NA-C indicated OT got to the room first and when she arrived OT told her R14 was choking. NA-C stated she then yelled down the hallway for RN-C to come stat. NA-C stated that R14 was breathing and kind of coughing. NA-C then indicated her and the OT-A positioned themselves on each side of R14, interlaced their arms and gave three thrusts, which didn't seem to be effective. NA-C stated that during the thrust R14 had stated ouch. NA-C indicated because of R14's size, it was difficult to get into a good position for the [MEDICATION NAME]. NA then stated, RN-C arrived in the room, crawled up on R14's bed and gave a couple more thrusts, and R14 said ouch again. NA-C indicated nothing came out until RN-C gagged her, then not very much came out at all, just a small piece. NA-C stated the piece was really dry and thought it just got stuck in the back of her throat. NA-C indicated after the incident occurred she had to write up something for an incident report. NA-C stated she was not currently certified in cardiopulmonary resuscitation (CPR). NA-C indicated after the choking incident, she was not aware of any new interventions and/or changes to R14's care plan. NA-C stated R14 did not like to get out of bed for meals and when staff boosted her up in bed she was all the way up to the top of the mattress, but had the tendency to slide down a little bit after a while. NA-C further indicated R14 did not ever refuse to be boosted up. Upon review of the incident report dated [DATE], reiterated the choking incident as described in the nursing progress notes with brief witness statements from OT-A, NA-C, and RN-C. The incident report indicated the root cause was a result of poor positioning while eating in bed and the elevated temperature could have been related to potential aspiration. The report lacked documentation of interventions related to what was determined to be the root cause analysis of poor positioning in order to reduce the risk and/or prevent further choking/aspiration episodes. The investigation did not address the position of the call light at the time of the incident, nor the competency levels of staff who responded to the event. LACK OF OPERATIONALIZING ASSESSED FALLS INTERVENTIONS: R36's quarterly MDS an assessment dated [DATE], identified R36 had severe cognitive impairment, required weight bearing assist of one person for transfers and locomotion on and off the unit and [DIAGNOSES REDACTED]. R36's physician progress notes [REDACTED]. R36's current care plan undated, included at risk for falls related to use of medication (anti-depressant. history of repeated falls; muscle weakness, abnormalities of gait and mobility. Attempt to offer diversional activities when agitated to defuse behaviors to reduce potential frustration that might lead to her independently trying to ambulate. Bed in low position. Call light or personal items available and in easy reach or provide reacher (hand tool used to pick up items). Encourage resident out of room as much as possible during the day Footwear to prevent slipping: gripper socks or shoes. Keep room well lit and free of clutter. Move room closer to nurse station. Observe for side effects of Medications including narcotic pain medication and [MEDICAL CONDITION] medications. Toilet schedule: at HS (bedtime), one time during N[NAME] (night) rounds and upon rising. Walks independently. (MONTH) use wc (wheelchair) for weakness. Resident has impaired functional mobility as evidenced by altered gait or balance, cognitive deficit, history of fracture/injury. Nursing will provide assistance as needed for transfers. R36's current Kardex identified footwear to prevent slipping: gripper socks or shoes. Ambulates independent on unit. Uses wheelchair when weak. During observation on [DATE], at 8:25 a.m., R36 in bed sleeping with bare feet. At 8:52 a.m., R36 sat in a chair at the dining room chair and had slippers on her feet. At 9:05 a.m., R36 remained seated at the dining room table with slippers on her feet and an unidentified staff person was encouraging R36 to eat. At 10:03 a.m., R36 remained seated at the dining room table with slippers on her feet. R36's Therapy Screen Form, dated [DATE], staff reminded patient is assist of one with FWW (forward wheeled walker) for support. R36's current care plan lacked to be updated to include R36 required one assist with FWW for support. R36's progress note identified on [DATE], at 8:00 p.m. to have had a witnessed fall in the hallway. Resident was trying to go into another room. Trained medication aide went towards R36 to redirect her and R36 stepped again, lost her balance, and as she fell to the floor hit her head on the wall. R36 was crying. Resident had been agitated prior to fall. Nurse was assessing resident when resident began vomiting. Medical provider was called and R36 was sent to the emergency room (ER). R36's record included a witnessed fall report, dated [DATE] with a revision date of [DATE], and included an IDT (interdisciplinary team) note, which indicated the root cause of the fall is believed related to unsteady gait influenced by dementia and post ER visit, was identified to have a UTI (urinary tract infection),which most likely influenced her overall clinical status. On [DATE], the facility received x-ray results that indicated R36 had obtained an acute minimally displaced right anterior lateral tenth rib fracture. R36's care plan was reviewed and updated. However, review of R36's current care plan identified, no interventions were implemented after the fall for the acute minimally displaced right anterior lateral tenth rib fracture and UTI. R36's ED/ER (emergency department) Provider Note, date of service [DATE], included impression/plan: female with vomiting and diffuse pain after fall from standing, advanced dementia. Final [DIAGNOSES REDACTED]. R36's record lacked to include neuro checks for hitting her head following the fall dated ,[DATE]. During interview on [DATE], at 10:23 a.m., nursing assistant (NA)-E stated R36's fall interventions were one to one, activity, talk to the (family member) and she was not aware of any other interventions for R36. NA-E stated most of the time I work on the second floor. Interventions for R36 may have changed, I can check. During the interview NA-E observed R36 and stated R36 had no socks on her feet and had slippers on. Observation of R36's room during the interview revealed R36 had a pair of slip on tennis shoes in the closet. During interview on [DATE], at 10:34, a.m., NA-F stated (when asked what fall intervention R36 had) I would have to go look that up. NA-F stated she had gone into R36's room to bring her out to breakfast and R36 was sitting on the side of the bed with slippers on her feet. During interview on [DATE], at 10:40 a.m., licensed practical nurse (LPN)-C stated R36's fall interventions were keep out of her wheelchair as R36 tends to fall when sitting in her wheelchair. R36 should have good shoes on feet, toilet R36, keep R36 in vision and know where she is. LPN-C stated as long as R36 had gripper socks on her feet slippers would be o.k., but she would have to look at the slippers to know if they had a good grip surface. LPN-C stated the fall protocol for the facility when a resident hit their head was to do neuro checks. During interview on [DATE], at 3:47 p.m., the director of nursing (DON) reviewed R36's record and stated R36's care plan was not updated to include the therapy recommendation dated [DATE]. The DON stated R36's care plan was not updated after the fall on [DATE]. The DON stated the care plan should have been updated following the fall addressing R36 having a fracture, with interventions implemented. The DON stated she would expect neuro checks to be completed anytime a resident hits their head. The staff should start the facility neuro sheet. The DON confirmed there was no neuro checks completed after the fall on [DATE]. The DON stated the facility had a protocol to follow regarding neuro checks. The DON stated (regarding R36 having bare feet and slippers on) R36 should have gripper socks on or shoes. Slippers are not shoes. The facility policy Care Planning, undated, indicated the facility will use the results of a resident's assessments to develop, review and revise a resident comprehensive care plan. This person-centered care plan will include measurable objectives and timelines specific to the resident to meet the individual resident's medical, nursing, mental and psychosocial needs as identified in the assessments. The care plan will be updated and revised as needed per individual resident changes, and per OBRA (Omnibus Budget Reconciliation Act) and Medicare requirements. The facility policy Fall Prevention and Management Guidelines, dated ,[DATE], indicated Policy: The facility will maintain a fall prevention and management program. In as much as it is in the power of the facility, the facility will prevent and/or manage the resident's at risk

Based on observation, interview, and record review the facility failed to ensure staff have the knowledge, competencies and skill sets to provide care, and respond to each resident's individualized assessed needs safely in a manner that promotes each person centered care, basic nursing skills, infection control and identification of changes in condition, mental and psychosocial well-being. This practice was evident for director of nursing (DON), 2 of 12 registered nurses (RN-C & RN-D) and 3 of 10 licensed practical nurse (LPN-A, LPN-D & LPN-E). Finding include: Refer to 554: LPN-A left medications at bedside for a resident who was deemed not safe to do so. Refer to 609: DON did not report a significant med error to the state agency. Refer to 610: DON did not do a thorough investigation of a significant medication error Refer to F697: LPN-A did not provide resident's prescribed pain treatment resulting in resident having pain. Refer to 684: LPN-A allowed LPN-E access to charting rights in electronic medical record, in addition to inconsistent records, RN-D neglecting to document and notify medical professional of a decrease in blood sugar and RN-C had not identified change in condition for wound resulting in death of a resident. In addition LPN-D gave a resident the wrong kind of insulin to a resident who experienced side effects and resident was not monitored for it. LPN-A failed to assess a resident's respiratory status: when checking oxygen saturations did not make sure the flow rate of oxygen was on as prescribed. Refer to 689: Interdisciplinary team (IDT) overlooked supervision for risk of choking and failed to identify education needed for providing the [MEDICATION NAME] maneuver. Refer to 690: Indwelling catheter management- monitoring and evaluating signs and symptoms of infection Refer to 697: LPN-A failed to apply a precribed treatment patch to a resident's back resulting in resident having pain. Refer to 755: LPN-A failed to give resident medications timely by leaving medications in room and failed to follow up to see that they were taken. Refer to 760: LPN-D gave a resident a significant amount of the wrong insulin, failed to monitor for signs and symptoms of [DIAGNOSES REDACTED] and failed to document the event thoroughly in the progress notes. Refer to 761: LPN-A changing a medication label before reviewing physician orders. Refer to 880: DON was not current with infection control and LPN-A had not performed hand hygiene during blood sugar checks. Competencies were requested for staff although none provided for licensed staff. During interview on 9/18/18 at 9:40 a.m. director of nursing DON stated, LPN-D was hired on 8/31/18, through agency staff, she no longer works here as of Friday the 14th, we found her to be incompetent. Review of LPN-D's personnel file indicated on 8/31/18, was hired as a new facility staff and was oriented to the facility, the DON obtained computer passwords for LPN-D. DON said she had spent the afternoon ensuring that LPN-D was able to log onto the computer along with training on electronic Medication Administration Record [REDACTED]. Facility Action Plan dated 9/2/18, LPN-D was having difficulties with medication pass, timing and med errors, goal medications, and treatments will be administered as ordered using the 10 rights and triple check systems to manage their medical needs thru next 90 days. Intervention indicated LPN-D will be retrained on PCC, will provide return demonstration and will be given opportunity to ask questions and will acknowledge any questions or concerns with unit manager (UM), DON, or co-working nurse. Comments handwritten: LPN-D was overheard telling a resident's daughter that she hadn't been trained. Asked to retrain, completed PCC, MAR, TAR and documentation in PCC. Return demonstration completed. LPN-D felt better after training. On 9/3/18, RN-B worked with LPN-D to help her learn med pass. Difficulties in timing. On 9/7/18, RN-E was assigned to assist you because you were falling behind. On 9/9/18, RN-D spent time on the floor. On 9/10/18, and 9/11/18, RN-C spent time with LPN-D to help her gain confidence and support.

Based on observation, interview and document review, the facility failed to ensure appropriate treatment and services for management of an indwelling catheter, including ongoing monitoring, evaluation, and interventions for signs and symptoms of infection, were implemented for 2 of 5 resident (R38 and R36) who were reviewed for incontinence. The facility's failure to adequately monitor and implement interventions resulted in harm for R38 who [MEDICAL CONDITION]/septic shock. Finding include: R38's re-Admission Record dated 9/17/18, included [DIAGNOSES REDACTED]. R38's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R38 had moderate cognitive impairment with rejection of care behaviors one to three days during the assessment period. The MDS also indicated R38 required extensive of two plus staff for bed mobility and toileting, and extensive assist of one staff for dressing and personal hygiene and dressing. The MDS further reflected R38 had an indwelling urinary catheter, was always incontinent of bowel, and was on antibiotics during the assessment period. R38's indwelling catheter Care Area Assessment (CAA) dated 5/17/18, indicated R38 had no cognitive impairment with some confusion, had an indwelling urinary catheter and was incontinent of bowel. The CAA indicated staff performed catheter cares and R38 did not care for it himself. The CAA included R38 had a history of [REDACTED]. The CAA further indicated staff would provide catheter care throughout the day, monitor and notify the physician with any signs and symptoms of UTI. R38's urinary catheter care plan initially identified 9/30/14, indicated a goal of having no complications related to indwelling catheter through next review, and will have no signs or symptoms of UTI through review. The care plan interventions included the following: 16 French Foley catheter to straight drainage due to benign prostate hypertrophy with retention (11/13/14) Change catheter bag as ordered (4/3/17) Change Foley catheter as ordered (4/3/17) Check catheter tubing for patency and positioning (4/3/17) Indwelling catheter care as ordered (5/24/17) Monitor and report signs and symptoms of UTI, changes in color, odor, or consistency of urine, dysuria (painful urination), frequency, fever, pain (9/30/14) Urinary output monitored every shift (4/3/17) R38's care plan dated 7/22/18, indicated R38 had received antibiotic therapy for post [DIAGNOSES REDACTED]. Interventions included: Administer antibiotic as ordered and monitor for any adverse side effects, monitor for signs and symptoms of infection report if noted, and monitor temperature during antibiotic and after antibiotic for 72 hours. R38's record indicated a history of urinary tract infections (UTI's) [MEDICAL CONDITION] related to UTI's. R38's record indicated the most recent occurrence had led to [MEDICAL CONDITION] and septic shock, and indiated R38 was hospitalized from [DATE] through 7/11/18. R38's physician visit note dated 4/20/18, indicated a past medical history of [REDACTED]. The note further indicated R38 had intermittent hematuria (blood in urine), required a permanent indwelling urinary catheter and was using [MEDICATION NAME] (medication for benign prostate hypertrophy-[MEDICAL CONDITION]) to try and minimize trauma with catheter changes. The note further indicated he would continue with regular catheter changes and would monitor for infection. R38's signed physician orders dated 6/18/18, (prior to hospitalization ) included: 18 French catheter with 10 ml (milliliter) balloon, change once a month on the 24th of every month (start date 5/24/18) change bags (urine collection) and tubing weekly on Wednesday (start date 6/15/16) R38's (MONTH) Treatment Administration Record (TAR) reflected the following physician orders: irrigate urinary catheter once daily with 60 ml of sterile saline every evening shift (start date 4/27/18) Catheter output every shift (start date 5/24/16) R38's physician orders, did not include a directive to perform catheter care as directed by the care plan (Indwelling catheter care as ordered (5/24/17). R38's record lacked evidence any daily and/or routine catheter care was provided. R38's record reviewed from 6/24/18 to 7/1/18, lacked monitoring and/or documentation of signs and symptoms of urinary tract infection that lead to the hospitalization for [MEDICAL CONDITION] and septic shock including evaluation of urine output from the catheter and urine integrity. R38's record lacked fluid intake monitoring for comparison to output monitoring prior to the hospitalization . The catheter outputs reviewed from 6/25/18 through 7/1/18, indicated a substantial decrease in the amount of urine collected by shift and/or within 24 hours. Furthermore, the record lacked assessment/evaluation of the decrease in amount of urine collected. -On 6/25/18: day shift 800 ml, evening shift 350 ml, and night shift 175 ml. Total of 1325 ml -On 6/26/18: day shift 250 ml, evening shift 400 ml, and night shift 700 ml. Total of 1350 ml -On 6/27/27: day shift 250 ml, evening shift 500 ml, night shift 625 ml. Total of 1375 ml. -On 6/28/18: day shift 350 ml, evening shift 700 ml, night shift 350 ml. Total of 1400 ml. -On 6/29/18: day shift 100 ml, evening shift 200 ml, night shift 200 ml. Total of 500 ml. -On 6/30/18: day shift 300 ml, evening shift 100 ml, night shift zero ml. Total of 400 ml. -On 7/1/18: day shift 200 ml, evening shift 5 ml. R38's progress notes (PN) dated 6/24/18, indicated R38 had adequate urine output; amount was not recorded. R38's PN dated 7/1/18, at 6:21 p.m. included, sent to ER (emergency room ). The PN indicated at 6:30 p.m. R38's staff and family were upset with R38's appearance-R38 was pale, pasty and did not respond to questions. Note indicated R38 had his hand over right side of his bladder, and appeared to be in pain. Vital signs were recorded as: temperature 96.5 degrees Fahrenheit (F), pulse 113, blood pressure 114/45, and oxygen saturations of 88%. Note indicated R38 would not allow catheter to be flushed, so the doctor and guardian gave permission to send to the emergency room for further evaluation. R38's hospital discharge summary stated 7/11/18, indicated R38 was admitted to the hospital on [DATE], and discharged on [DATE]. [DIAGNOSES REDACTED]. The hospital course indicated R38 presented to the emergency department with fever, [MEDICAL CONDITION](fast heart rate), [MEDICAL CONDITIONS], and abdominal distention and was felt to be septic upon admission with lactic acidosis. Abdominal computerized tomography (CT) demonstrated new wall thickening of multiple loops of small bowel possibly secondary to infection or inflammation, no obstruction, or free air. Urinalysis and blood cultures were positive for E.Coli and required intravenous (IV) antibiotics. On 7/5/18, a repeat CT scan indicated a small bowel obstruction and fluid collection, that was likely an abscess. Infectious Disease was consulted during the hospital course and recommended an oral antibiotic regimen that would be prolonged beyond usual duration. In addition, the discharge summary indicated general surgery had evaluated R38, and recommended against surgery, and the decision was made with power of attorney to pursue comfort-orientated care, and hospice assessment upon return to the facility. R38's hospital After Visit Summary (AVS) including the hospital course summary, indicated R38 was returned back to the facility with new physician orders that included: [MEDICATION NAME] ([MEDICATION NAME]-antibiotic) 300 milligrams (mg) every 12 hours for 38 doses related to blood stream infection/sepsis syndrome, [MEDICATION NAME] (antibiotic) 500 mg three times a day for 55 doses related to blood stream infection/sepsis syndrome. R38's PN dated 7/11/18 indicated R38 returned to the facility from the hospital. R38's signed physician orders dated 7/12/18, included: -[MEDICATION NAME] 300 mg twice per day with a start date of 7/11/18, until 7/29/18 -[MEDICATION NAME] 500 mg three times per day until with a start date of 7/11/18, 7/29/18 - Catheter output every shift with a start date of 7/11/18 R38's record lacked evidence of consistent ongoing monitoring and evaluations of the effectiveness of the treatment or any side effects during the antibiotic course. The extent of documentation of monitoring/evaluation of antibiotic effectiveness during the course of therapy mainly consisted of R38's temperature in progress notes. The record lacked ongoing monitoring for signs and symptoms of infection after completion of the antibiotic course, and routine catheter care. Although fluid intake monitoring was being recorded after 7/11/18, the record lacked evidence the intake and output was assessed. R38's record lacked documentation of antibiotic monitoring and catheter management on 7/13/18 and 7/17/18. R38's (MONTH) TAR indicated no urine output (recorded as x) for evening shift of 7/16/18. The record lacked a completed evaluation. R38's PN dated 7/17/18, at 3:00 a.m. indicated R38 had no urinary output with distention of the bladder. The note indicated the nurse attempted to irrigate the catheter (even though there was not a physician order to irrigate the catheter) with no returns. The note then indicated the catheter was changed with return of clear amber urine with bloody shreds. The note indicated R38's penis had much debris when foreskin was retracted. R38's PN dated 7/21/18, at 3:12 a.m. indicated the catheter was changed related to R38 screaming out, unable to flush the catheter, and had no urine output. R38's record lacked documentation of antibiotic monitoring and catheter management on 7/18/18, 7/20/18, 7/21/18, 7/22/18, 7/23/18, and 7/28/18. R38's (MONTH) TAR indicated no urine output (was left blank) was recorded on 7/23/18, for the evening and night shift; the record lacked evidence of a completed evaluation. R38's record lacked evidence of ongoing monitoring for signs and symptoms of infection and routine catheter care from 7/28/18 through 9/10/18. R38's (MONTH) TAR indicated no urine output was recorded on the night shift of 8/10/18; the record lacked evidence of a completed evaluation. R38's PN dated 8/22/18, indicated nursing assistant (NA) had found R38 without urine output at 5:00 a.m. and new catheter was placed with good amber urine return. R38's (MONTH) TAR indicated no urine output was recorded for day shift of 8/24/18 and 8/29/18, the record lacked evidence of a completed evaluation. R38's (MONTH) TAR indicated zero urine output for the day shift and night shift on 9/5/18. The record lacked a completed evaluation. R38's PN dated 9/6/18, 4:48 p.m. indicated R38 had not complained of any bladder fullness or pain but had urine draining from around the catheter and lower abdomen was distended and upon palpation was firm. A new catheter was inserted with return of clear odorless urine. The documentation did not reflect if the catheter was patent prior to changing the catheter or how much urine was initially drained after insertion. The TAR for 9/6/18 indicated, output for day shift was 360 ml and evening shift output was 700 ml. R38's (MONTH) TAR indicated no urine output (left blank) was recorded on 9/8/18. The record lacked a completed evaluation. During an observation on 9/10/18, at 1:48 p.m. R38's catheter bag was observed to be lying on the floor not covered; an unidentified staff member answered the call light and did not pick R38's catheter bag up off the floor. At 2:01 p.m. staff member went into the room again. At 2:09 p.m. the catheter bag remained on the floor. At 2:46 p.m. the catheter remained on the floor uncovered. At 3:10 p.m. the bag was hanging on the side of the bed. During an interview on 9/17/18, at 10:05 a.m. director of clinical services (D[NAME]S) stated the intake documentation was not monitored prior to 7/11/18. D[NAME]s indicated fluid intake monitoring would have been designated as a task for the aides to record in the record. During an interview on 9/17/18, at 11:30 a.m. with D[NAME]S and director of nursing (DON), DON reviewed progress notes from 6/27/18-7/1/18, and indicated, according to the notes R38 hadn't had any symptoms of UTI until 7/1/18. DON indicated nursing assistants were recording urine output totals and should be reporting urine characteristic to the nurse. DON reviewed the urine output totals just prior to hospitalization and indicated nurses should have done an evaluation as to why there was a decrease in urine output and called a physician and implement a plan of care. DON verified the record lacked evidence of physician notification pertaining to decreased urine output. DON verified the record lacked evidence of evaluations of fluid intake and/or urine output even after R38 was hospitalized and had a history of [REDACTED]. DON stated, there should be documentation of the monitoring for signs and symptoms of infection as indicated on the care plan. DON verified the physician orders did not include catheter care and the record lacked evidence catheter care was ever completed. DON stated catheter care is a standard of practice and consist of cleaning the catheter at least twice per day with soap and water; usually nursing assistants performed this task. DON also indicated a physician's order was required to flush a catheter, and the nurse should not have flushed the catheter without getting an order from the physician. The facility's policy Catheter Care, Indwelling Catheter dated 6/2017, included: Purpose: to prevent infection and reduce irritation. ASSESSMENT GUIDELINES: may include but not be limited to: Color, consistency, amount of urine;Condition of skin at site of insertion; level of acuity; Nutritional intake, Hydration and fluid balance status. The policy also directed staff on how to perform routine catheter cleaning including: to use warm water and soap, to take care to wash front to back, and a bolded/highlighted note that included, do not contaminate with feces. If resident has had an involuntary bowel movement, clean this area first. Wash your hands and obtain clean equipment for catheter care. The procedure further directed to cleanse the area well at the catheter insertion and all debris must be removed from the catheter at the insertion site. D[NAME]UMENTATION GUIDELINES included: Date, time, procedure-CNA's (nursing assistants); condition of the perineum and catheter site (licensed nurse). Any unusual condition or change in condition; Color, amount, consistency, and odor of urine; Notification of the physician of any condition change; Intake and output and evaluation of intake and output per facility procedure R36's quarterly MDS an assessment dated [DATE], identified R36 had severe cognitive impairment, had [DIAGNOSES REDACTED]. During observation on 9/14/18, at 8:52 a.m., R36 was seated at the dining room table eating breakfast. R36 had a glass of milk, toast, oatmeal, scrambled eggs and sausage. R36's hospital discharge summary, dated 4/11/18, indicated R36 was hospitalized from [DATE] through 4/11/18, final primary [DIAGNOSES REDACTED]. Abdominal CT (Computerized Tomography) was significant for large amount of stool in the colon and rectum. R36's physician orders, dated 6/7/18, included check bowel records and ensure resident is having a bowel movement (BM) every two days. On 8/16/18, change [MEDICATION NAME] (laxative) to 17 grams every day. On 9/10/18, change Senna (laxative) to 8.6 milligrams two tablets one time a day and two tablets every 12 hours as needed for constipation. R36's Medication Administration Record [REDACTED]. R36's MAR's, dated 8/2018 and 9/2018, identified no as needed medications were given to promote a bowel movement. R36's current care plan included gastrointestinal distress due to history of fecal impaction. Administer medications as ordered, observe labs and response to medication and treatment. Give stool softener/laxative as ordered (okay to hold for loose stools) and encourage increased fluid intake to help promote better stool motility. Monitor for bowel movement every two days as she is prone to constipation. Observe for complaints of pain, specific locations of pain, response to nursing interventions taken to relieve pain. Observe for presence of nausea/vomiting, intake or weight changes, difficulty chewing. Resident is continent of urine; history of fecal impaction. Administer bowel medications as ordered. Monitor bowel patterns to ensure resident is having regular bowel movements, administer standing orders per facility protocol. R36's Kardex (abbreviated care plan) included give stool softener/laxative as ordered (okay to hold for loose stools) and encourage increased fluid intake to help promote better stool motility. Monitor for bowel movement every two days, as she is prone to constipation. R36's bowel elimination record, dated from 8/28/18 through 9/14/18, identified documented bowel movement history including amounts: on 8/28/18 R36 had a small BM; and on 9/1/18 R36 had a small BM (four days between bowel movements). On 9/2/18 R36 had a large BM and on 9/7/18 a small BM (five days between bowel movements). On 9/11/18 had a small BM (four days between bowel movements from 9/7 to 9/11) and no documented bowel movements through 9/14/18 (a total of three days since last bowel movement on 9/11). During interview on 9/14/18, at 10:40 a.m., licensed practical nurse (LPN)-C stated she was responsible for the residents where R36 was located. LPN-C stated the facility bowel protocol included, if no bowel movement (BM) in three days give milk of magnesia (MOM) (laxative) in the evening. If no BM after MOM give a suppository in the a.m. or as needed medications (PRN) if the resident had orders for PRN medications. LPN-C stated R36 does not like to take medications right away. We try to give prune juice with breakfast. LPN-C reviewed R36's BM documentation and confirmed R36 had a BM on 9/1, 9/2 and then not again until 9/7 and 9/11. LPN-C stated the clinical manager used to monitor BM frequency residents have and would give a list to the nurse on the floor for residents who needed to be given something to promote a BM. LPN-C stated she was now trying to monitor the frequency residents had BM's, as there was no clinical manager. LPN-C stated they had not given any as needed laxatives to R36 to promote a bowel movement when she did not have one for three days. During interview on 9/14/18, at 3:27 p.m., the director of nursing (DON) reviewed R36's bowel movement size documented and confirmed the above. The DON stated the facility protocol was if no bowel movement three days, she would expect an intervention. DON stated for R36 there are four day stretches occurring. DON reviewed R36's current care plan and confirmed R36 was to be monitored to have a bowel movement every two days. A policy for bowel management was requested, but not provided.

Based on observation, interview and document review, the facility failed to ensure the correct kind of insulin was administered for 1 of 4 residents (R9) reviewed for diabetic management. R9 suffered harm, symptoms of [DIAGNOSES REDACTED] (low blood sugar, lightheadedness, overall sick feeling) due to the facility's deficient insulin administration practices. Findings include: R9's Admission Record, identified an admitted [DATE], and [DIAGNOSES REDACTED]. R9's care plan dated 3/25/18, indicated an alteration in blood glucose due to insulin dependent diabetes, with a goal that patient will experience minimal signs and symptoms associated with [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. Interventions were to administer medications as ordered, observe for high blood sugar symptoms-increased thirst, increased hunger, increased urinary output, and observe for low blood sugar symptoms-flushed face, sweating, change in usual mental status, lethargy, irritability, fruity breath odor, coma, nervousness, trembling, trouble concentrating, and lightheadedness, and report abnormal results per physician parameters/guideline. R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R9 had intact cognition, and was independent with locomotion on and off the unit. R9's Order Summary Report signed by medical provider on 7/20/18, identified an order for [REDACTED]. R9's Medication Administration Record [REDACTED]. A note on the MAR indicated [REDACTED]. A note on the MAR indicated [REDACTED]. R9's Medication Error report dated 9/3/18, at 4:29 p.m. and revised on 9/11/18, at 7:52 p.m. indicted predisposing physiological factors are diabetic/hypoglycemic, and predisposing situational factors are medication administration process and incorrect medication route/time/doe/resident-specify. Statement: licensed practical nurse (LPN)-D accidentally gave (R9) the wrong insulin. Medical doctor (MD) on call notified and ordered to give 4 extra units of [MEDICATION NAME]-N insulin with regular dose and to call HS blood sugar to him. Client blood sugars 7:00 a.m. 86, 11:00 a.m. 284, and 2:00 p.m. 308. Client refused any further insulin from this nurse. Physician notified on 9/3/18, at 4:45 p.m. R9 notified on 9/11/18, at 7:06 p.m. Med error report does not identify exactly what insulin was given or how much was given. R9's physician progress notes [REDACTED]. On call provider was notified. Patient was aware and immediately drank juice and upped her carb intake. Blood sugars remained stable. Patient stated that she felt unwell most of the day. She reports she has felt lightheaded and overall not well. She thought it was most like due to her blood sugars. The Assessment/Plan was identified to: discontinue [MEDICATION NAME] starting today 9/12/18, change [MEDICATION NAME] N to 54 units each after breakfast and 4 units after supper. Continue to check blood sugars QID (four times a day), and NP (nurse practitioner) to review blood sugars in 1 week. During an observation and interview on 9/10/18, at 12:18 p.m. R9 stated, I get insulin three times a day, I get [MEDICATION NAME]-N twice a day, and a couple units of [MEDICATION NAME] at lunch time. Sometimes if the nurses are new they make mistakes, they gave me [MEDICATION NAME] last week, 56 units instead of my [MEDICATION NAME]-N. I know they gave me [MEDICATION NAME] because it was in a pen, my [MEDICATION NAME]-N is in a vial. I didn't realize it until she pulled the pen out, I can feel the difference when they use the pen versus a syringe. I was sick all day, it made my blood sugar pretty low. I had to drink juice and all kinds of things. Someone had to catch me and stop me from falling, I was so light headed due to being hypoglycemic. During interview on 9/12/18, at 3:49 p.m. the director of nursing (DON) stated LPN-D had been educated today on medication basics in regards to the insulin med error for (R9) on 9/3/18. During interview on 9/14/18, at 11:57 a.m. LPN-D verified she'd given R9 [MEDICATION NAME] by accident instead of her [MEDICATION NAME]-N on the morning of 9/3/18. LPN-D stated she called the doctor (unsure of the time) and that he'd directed her to recheck the resident's blood sugar. LPN-D verified it was meal time and no one stayed with R9 to monitor for low blood sugar symptoms. Further, LPN-D stated, R9 never told me she was lightheaded. LPN-D stated, I am not sure if I documented it or not, I have a hard time with the system, I don't even know how to get into the computer progress notes. During interview on 9/18/18, at 9:40 a.m. the director of nursing (DON) verified on 9/3/18, in the a.m., R9 had received [MEDICATION NAME] instead of [MEDICATION NAME]-N. The DON confirmed the med error report for 9/3/18, did not specify what insulin, what dose or what time the insulin was administered. The DON stated, side effects from this type of medication error would be symptoms of [DIAGNOSES REDACTED]. This could have resulted in serious harm and even death. No staff ever told me (R9) had experienced any hypoglycemic side effects. Absolutely, giving the correct insulin is a standard of practice that is nursing 101. At 10:20 a.m., the DON verified that (R9's) wrong type of insulin given was a significant med error and an error which had caused the resident discomfort and jeopardized her safety. The facility's undated policy Medication Basics, indicated: if you find a medication error, complete the medication error form. That doesn't mean you are the responsible for the error but you are responsible to follow through. We need to take the time and administer medications by the Triple check method. You check the MAR indicated [REDACTED]? Is it a generic version? Medication errors are all too often the result of carelessness. Taking and giving medications needs to be taken very seriously. We need to take every effort to avoid errors.

Based on observation, interview and document review, the facility failed to implement, monitor and/or revise interventions to ensure efficacy for 3 of 3 residents (R54, R40 and R53) reviewed for accidents. This resulted in harm for R54 who sustained a [MEDICAL CONDITION] during a fall on 1/12/18. Findings include: R54's admission Minimum Data Set (MDS) assessment indicated R54 had been admitted to the facility 2/20/17, from the hospital after a fall with injury sustained in a different facility. In addition, the MDS indicated R54 had [DIAGNOSES REDACTED]. R54's quarterly MDS assessment dated [DATE], indicated R54 had experienced a fall with injury and needed extensive assistance of one staff member for bed mobility, and extensive assistance for transfers with two staff. The quarterly MDS also indicated a Brief Interview for Mental Status (BIMS) interview was attempted but the resident was unable to complete, so staff interview had been completed which identified R54 had long and short term memory loss. R54's significant change MDS assessment dated [DATE], indicated R54 had no previous falls (inaccurate coding), and required extensive assistance of two staff members for bed mobility and transfers. R54's progress notes were reviewed from 11/2017 to 2/28/18, and contained information in a situation, background, assessment/appearance and recommendation (SBAR's) format of the following falls: 11/3/17, R54 had a fall from bed with no injuries or bruises. Resident was found on the floor of her room laying down on her side. no injuries. Resident was assessed and no injuries found or bruises. Vital signs checked and was within normal, denies pain. Recommendations: will communicate with morning nurse to monitor, Reminded resident to use the call light and don't get up by herself. Family notified. 11/17/17, R54 had been found on floor of her room, close to her roommate's bed. Resident stated she was trying to close the door of her room. Resident stated her right leg and head hurt. A small scrape was noticed on her coccyx. No other injuries noted. Resident had been confused all day. Resident was helped off the floor. Director of nursing, nurse practitioner, clinical manager, and family member were notified. Educated patient. Recommendations: (none were documented for this fall). Possible contributing factor for falls dated 11/21/17, Continuous low blood pressure readings. Resident with history [MEDICAL CONDITION](hypertension) and [MEDICAL CONDITION] (congested heart failure). Assessment (RN (registered nurse))/Appearance LPN (licensed practical nurse)): Lethargic, dizziness with position changes. Assessment: Resident continues to have blood pressure readings on AM shift ranging from systolic (highest reading) of 90 to 110. Response: [MEDICATION NAME] (to lower blood pressure) being held at this time, request for provider review of necessity of medication. Blood pressure and pulse readings printed for provider review. Recommendations: See above. 11/21/17, progress notes indicated the certified nurse practitioner (CNP) had visited R54 with a plan to stop [MEDICATION NAME] (a diuretic used to lower blood pressure) and for staff to monitor blood pressure. The report also indicated the CNP had been updated on R54's prior falls. Possibly related to the 11/17/17, fall, resident complaining of right hip and leg pain, increased with weight bearing. Recommendations: Request for in house X-ray of right hip to rule out fracture from recent fall. On 11/28/17, the CNP visited R54 regarding leg/hip pain and ordered X-ray to rule out fracture. The limited evaluation clinical document included, X-ray results noted an addendum to report which revealed a possible fracture and will need a computerized tomography (CT) scan to confirm [DIAGNOSES REDACTED]. A facility report initiated (FRI) an incident reported on 11/29/17, by the director of nursing in regards to the 11/17/17 incident with confirmed fracture of hip (11/29/17) to the Office of Facility Complaints (OHFC). The complaint registration form included the following information: Description, A resident ((R54)) sustained a pelvic fracture identified on 11/27/2017 that the facility attributes to a fall that occurred on 11/17/2017. The facility assessment(s) did not identify the sign and symptoms of pelvic fracture. emergency room for Outpatient CT scan. Results returned 11/29/17 showing pelvic fracture. Review of medications completed by consultant pharmacist. No recommended changes at this time. Falls Committee reviewed falls on 11/5/17. With fall on 11/3/17, resident fell while trying to self transfer out of bed but her feet slipped on the floor. Non-skid strips were added to the floor next to her bed. Falls committee reviewed falls again on 11/21/17 - resident said she was trying to get up to close her door. Sign is posted outside her room that her door is closed per her request at night. PT/OT to evaluate and treat as appropriate. Review of care plan completed with addition of the above changes added. Under description of harm it reads, resident with pelvic fracture presumed from fall 11/17/17. The facility sent an Investigation status to OHFC on 12/6/17, in regards to the incident reported on 11/29/17. The information contained the following: (R54) has been a resident at the facility since 7/10/17. Her primary [DIAGNOSES REDACTED]. Last BIMS score was 10 on 10/9/17. Fall history includes: 11/3/17 @ 0527 (5:27 a.m.) with no injury, and 11/17/17 @ 2000 (8:00 p.m.) with pain in right hip at time of injury but then back to baseline on subsequent checks. Resident pain is monitored daily and she receives scheduled [MEDICATION NAME] for pain from arthritis. On 11/27/17 resident had increased pain in right hip, especially with weight bearing or movement. SBAR completed and reviewed by nurse practitioner, x-ray ordered . Results recommended additional imaging for conclusive diagnosis. On 11/28/17 approval obtained from POA (power of attorney) to send resident for CT scan. Resident sent to St. [NAME]'s emergency room for outpatient CT scan. Results returned 11/29/17 showing a pelvic fracture. Review of medications completed by consultant pharmacist. No recommended changes at this time. Falls Committee reviewed falls on 11/5/17. With fall on 11/3/17 resident fell while trying to self transfer out of bed but her feet slipped on the floor. Non-skid strips were added to the floor next to her bed. Falls committee reviewed falls again on 11/21/17 - resident said she was trying to get up to close her door. Sign is posted outside her room that her door is closed per her request at night. PT/OT to evaluate and treat as appropriate. Review of care plan completed with addition of the above changes added. Under description of harm it reads, resident with pelvic fracture presumed from fall 11/17/17. 1/12/18, R54 sustained another fall documentation included in the progress notes the SBAR format included: fell to floor in resident room, pain all over sent in to emergency room and was admitted due to a [MEDICAL CONDITION]. A facility reporting incident was submitted to the Office of Health Complaint (OHFC) on 1/15/18, regarding the fall with fracture incident on 1/12/18. The description of incident read, Resident self transferred from her bed saying 'I heard (a persons first name) snoring.' on floor next to bed. Able to move all extremities. Pain increased during night while monitoring so resident sent to ER (emergency room ) Saturday morning for further evaluation. diagnosed with [REDACTED]. Now [DIAGNOSES REDACTED]. Car plan being followed at time of fall. Plan is conservative management/pain management. Also included the incident was reviewed by pharmacist with no changes, fall committee review fall on 11/5/17 and 11/3/17, resident fell while trying to self transfer out of bed but her feet slipped on floor. Non-skid strips were added to the floor next to her bed. Also reviewed all form 11/21/17 and resident said she was trying to get up to close her door. No falls since 11/21/17 until 1/12/18. Care plan completed, review of room placement completed. Mayo Rochester Emergency Department record dated 1/13/18, included under nursing assessment: Extremity Lower, Patient had a fall at 10:30 p.m. last evening unwitnessed at Rochester Health services East skilled nursing facility (SNF), states she had her slippers on and did hit her head. Under the History of present illness, it read, (R54) was hospitalized (MONTH) 13 through (MONTH) 16, (YEAR) following a fall. CT scan demonstrated acute left superior and inferior pubic rami fractures, subacute right superior an inferior pubic rami fractures, and the chronic L2 vertebral body fracture. She was admitted for pain management . During observations of R54 in her room on 2/26/18, at 8:28 a.m., 2/27/18, at 12:16 p.m. and on 2/27/18, 4:08 p.m. there were no non-skid strips on floor next to her bed. The sign on door read to keep door open at night even though the fall intervention following the 11/27/17, incident directed the sign to say closed. Interview with registered nurse (RN)-D on 3/1/18 at 1:35 p.m. regarding the falls interventions of non-skid strips in front of R54's bed following the fall on 11/17/17, RN-D observed no non-skid strips next to R54's bed. At 1:45 p.m. following the interview with RN-D of no non-skid strips on R54's floor. Maintenance-A was observed to have placed non-skid strips on the floor in front of R54's bed. R54's care plan with a focus of Resident is at risk of falls r/t (related/to) History of falls, Pain. Date initiated: 12/06/2017 included interventions of Anticipate and meet the Resident's needs. Encourage the Resident to always call for assistance. Call light in reach. Defined parameter Mattress -(scooped side). Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries. Also added to care plan on 3/1/18 after surveyor queried the use of safety strips Zip/non-skip strips on floor at bedside. Record review and interview with therapy on 3/1/18, at 4:23 p.m. physical therapy assistant (PTA)-G verified R54 last evaluated in (MONTH) of (YEAR), and none since then. Interview on 3/1/18, at 3:57 p.m. with nursing assistance (NA)-D stated R54 is a fall risk and receives fall risk interventions from the nurse. NA-D states they use routine interventions like gait belt. Clinical manager will update with new interventions. On review of the NA's care sheet (has information specific to resident cares/treatments) showed only use of gait belt and no other interventions to prevent falls. Interview on 3/1/18, at 4:00 p.m. with licensed practical nurse (LPN)-A stated R54 is a fall risk, intervention would double check bed in low position, call light in reach. LPN-A stated would review care plan and proceeded to check the electronic care plan for R54. LPN-A said nurses always complete a SBAR and notify family, CNP, nurse manager and can put intervention in place after fall. Neuros completed on any fall unwitnessed or when a resident hits their head. LPN-A also added they start a post fall assessment and the report is very self-explanatory and is on the computer. The facility started a review of falls called a trip form. Interview on 3/1/18, at 2:06 p.m. with CNP-F stated they are update with a SBAR notes but does not always include an update. CNP-F stated according to R54's note on 11/28/17, she had not been updated on the 11/3/17, and 11/17/17, falls until the [MEDICAL CONDITION] episode on 11/21/17. CNP-F's document dated 11/28/17, notes that there had not been a request for provider to evaluate. Interview on 3/1/18, at 1:40 p.m. registered nurse consultants (RNC)-B, H, & J and Administrator were asked what the policy/procedure following a fall. This included investigation, assessment, develop interventions following each fall for R54. At 1:47 p.m. interview with administrator regarding further information regarding R54's falls. Administrator had post falls assessment completed after return from hospital emergency room with [DIAGNOSES REDACTED]. Administrator was not aware the post falls interventions to prevent further falls had not been documented at time of post fall assessment until surveyor brought it to his attention. Administrator also said the safety strips are now in place for R54. Administrator verified the current policy/procedure had not been followed regarding R54's falls. Follow up interviews with RNC-B on 3/1/18, at 3:31 p.m. regarding the requested information regarding the falls for the last four months. RNC-B said there was no more information found. On 3/2/18, at 11:41 p.m. RNC-H verified the facility continued to look through charts and files and was not able to identify any of the facilities paper work or additional investigation paper work on R54 falls. R40's current [DIAGNOSES REDACTED]. R40's annual Minimum Data Set (MDS) an assessment dated [DATE], indicated severe cognitive impairment, extensive assistance of two persons for transfers and extensive assist of 1 person for ambulation and toileting, and two or more falls since the prior assessment. During observation on 2/26/18, at 12:57 p.m., R40 is sitting in her wheelchair and propelling self out of the dining room while singing, What a friend we have in Jesus. During observation on 2/27/18, at 11:59 a.m., R40 is sitting in her wheelchair, wheeling self-down the hall away from the secured exit. R40's care plan, last reviewed 1/2/18, indicated R40 was at risk for injury due to falls, history of falls. The goal listed was: resident will remain safe and injuries from falls will be minimized through her next review. Approaches included: (1) attending staff listen for R40 in the am and assist with transfer out of bed as soon as possible, (2) encourage resident to rest in the dining area/recliner room mid-day, (3) grab bar to be installed on wall next to bathroom in residents room, (4) offer to rest resident in the recliner chair with inconsolable yelling, agitation. (R40) is able to demonstrate placing foot rest up and down independently in recliner, (5) reinitiate 3 day bowel and bladder diary as/when indicated, (6) staff to stay with resident after assisting onto toilet until after successful transfer off toilet, (7) toilet schedule before meals and at bedtime. 3/6/17: also toilet at midnight, (8) turn on Facility Channel music for resident to listen to when more anxious, (9) when resident is especially anxious, encourage resident to wear sweaters/warmer clothing rather than blankets when in bed, and (10) PT to evaluate and treat per increased difficulties with balance. A Fall Risk Assessment was requested for R40 and was not received. R40's Incident Reports, Post fall Assessments and Emergency Record revealed the following from 9/21/17 to 2/18/18, revealed the following: 9/21/17, at 2:40 p.m., R40 was heard screaming and was found lying on the floor in her room, stated that her right elbow hurt, no evidence of injury. Predisposing factors: impaired memory, transferring self, ambulating without assist. Interventions to prevent further falls: reeducation to resident. Care plan not updated. Emergency department record dated 9/22/17, at 3:43 a.m., revealed, R40 presents after a fall from standing. This occurred earlier in the evening of 9/21/17. R40 denies any head trauma but reports hitting her right arm with the fall. R40 has a right upper arm laceration that will require repair with sutures. R40's CT scan showed [MEDICAL CONDITION] and 10th ribs. discharged back to the nursing home. Nursing assessment indicated, R40 had a fall 13 hours ago while trying to get up to the bathroom herself. R40 sustained bruising and a 5 centimeter laceration to right upper arm. Tenderness noted over the ribs on the right side. There were falls recorded on 10/10/17, 10/20/17, 10/21/17, 10/21/17, 10/22/17, 11/8/17, 11/11/17, 11/13/18, 11/15/17, 11/18/17, 11/24/17, 11/21/17, 1/21/18, 1/26/18, 1/29/18, 1/30/18, and 2/18/18. The falls were related to toileting needs, getting tangled in blankets, attempting to get out of bed alone, left alone on toilet, and transferring from bed to her wheelchair. Many falls lacked interventions developed after fall and the care plan had not been updated. During interview on 3/2/18, at 12:11 p.m., (LPN)-C stated R40 was moved to this secured unit on 1/17/17 after her last stroke and has had several falls over the last year. I have not always completed a post fall assessment after each fall. The floor staff should be identifying an immediate intervention after each fall and they have not been doing that. Further stated there is not always a new intervention added to the care plan. I got behind in November, (YEAR), we had 48 falls on this secured unit. I told the director of nursing that I was behind. LPN-C verified R40's fall on 9/21/17, was not properly assessed, and she did end up in the emergency room , ER 13 hours later with a laceration to her right upper arm and 2 fractured ribs. The fractured ribs and the sutures on her right upper arm were not documented in the progress notes. We did do a root cause analysis in the interdisciplinary team, (IDT) meetings, but the interventions were not always implemented timely. Interview on 3/2/18, at 12:41 p.m., registered nurse (RN)-E stated the fall system has not been followed, incident reports and post fall assessments are not always being filled out, and interventions are not always put in place or being implemented. My expectation is that when a fall occurs, an assessment should be done timely to determine the cause of the fall, appropriate interventions need to be put in place immediately, and the falls need to be reviewed at a later date to determine their effectiveness. RN-E further stated there should be thorough documentation of falls in the medical record, with an injury to include monitoring, treatment, and reporting to appropriate delegations. R53 was admitted to the facility on [DATE] according to the admission form. The electronic medical record (EMR) identified [DIAGNOSES REDACTED]. R53's quarterly Minimum Data Set (MDS) an assessment dated [DATE], identified R53 as having severe cognitive impairment, requiring extensive assist of one with walking, and unsteady only stabilizing with human assistance. During an observation on 3/2/18, at 12:42 p.m. R53's wheelchair was sitting empty in the hallway and R53 was walking down the hall slowly, holding the attached railing. His knees are slightly bent and he is unsteady. No staff was present or in view of R53. During an interview with licence practical nurse (LPN)-K on 3/1/18 at 2:10 p.m., regarding R53's falls from 10/2017 to 2/2018, LPN-K reviewed examples of revised fall interventions in place and included, keep in the dining room during meals, encourage fluids, monitor for urinary tract infection, alternate choices for snacks, and more frequent toileting. LPN-K verified that none of the interventions were on the care plan or the nursing assistant (NA) care sheet and that the staff would not know to follow the revised interventions. LPN-K stated she updated care plans sporadically when she can find the time. A facility policy dated 12/16 Care Plans-Comprehensive identified that assessment of residents is ongoing and care plans are revised as information about the resident and the resident's condition change. Facility policy, Fall Prevention and Management Guidelines, dated 2/2017, indicated the facility will maintain a fall prevention and management program. In as much as it is in the power of the facility, the facility will prevent and /or manage the residents risk for falls. The elderly are at an increased risk for falls related to several different factors. The facility will implement a fall program for residents determined to be at risk for falls in order to better manage these factors and prevent and/or manage as much as possible the resident from falling and/or sustaining injuries related to falling.

Based on observation, interview and record review, the facility failed to implement passive range of motion (PROM) and a palm guard per physician orders [REDACTED]. As a result, R23 sustained actual harm, a decline in functional range of motion (ROM) to the left wrist. Findings include: LACK OF ROM SERVICES AS ORDERED: R23's Admission Record document identified an admission date of [DATE], and [DIAGNOSES REDACTED]. An occupational therapy assessment identified in the Functional Limitation assessment dated [DATE], to have R23's left upper extremities (LUE) to have a 1 percent (%)-19% impairment. An occupational therapy assessment identified in the Functional Limitation assessment dated [DATE], to have R23's LUE to have 60% - 79% impairment. A quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R23 to be severely cognitively impaired, with limited range of motion (ROM) in bilateral upper and lower extremities, contractures of the left hand and ankle, and contractures of the right ankle. R23's physician Order Review Report, identified an order initiated 7/27/16, included to do passive range of motion PROM to left upper extremity (LUE), focusing on wrist and fingers, per patient tolerance once a day. The 3rd West CNA (certified nursing assistant) Care Guides (contain services/treatments for residents assigned to the nursing assistant) dated 2/13/18, identified R23's Prevalon (heel protector) boots to be applied bilaterally to both lower extremities (LE) when in bed, and ortho booties when up in chair. There was no mention of (PROM) for LUE on the care guide. R23's Restorative Administrative Record (RAR), reviewed from 5/1/17, to 2/28/18, did not have documentation that LUE PROM had been completed as ordered. During an observation in the dining room on 2/26/18, at 8:20 a.m., R23 sat in a reclining wheelchair with leg extenders. Both feet appeared to point downward and inward, and were resting in blue heel protectors. At 12:59 p.m. R23 was observed to be seated in the reclining wheelchair and leaning forward and to the right. During observation on 2/27/18, at 12:19 p.m., R23 was observed sitting in a reclining wheelchair with her legs extended straight out. Both feet were observed to point downward and inward, and the resident was wearing blue heel protectors. During observation on 2/28/18, at 9:51 a.m., R23 was seated in her reclining wheelchair with a blanket covering her lap, she had the blue heel protector on both feet. At 1:49 p.m. R23 was observed to be lying on her back in bed with her right knee bent. During observation on 3/1/18 at 11:07 a.m., R23 was observed in the dining room seated in her wheelchair. She was observed to have heel protectors on both feet. R23's care plan revised 4/3/17, read, Patient to use BLE (Bilateral Lower Extremity) orthotics for ankles every day as tolerated and to remove orthotics if patient appears to be in distress/pain from orthotics. Please check skin integrity before and after orthotics are donned/doffed (on/off). Perform light ROM to each ankle before donning to ensure proper placement of the device so the Achilles and back of calf are all the way back in the orthotic. Goals included: I will maintain my current level of physical functioning as long as possible. Additional interventions included: PROM to LUE focusing on wrists and fingers, per patient tolerance x 3 sets of 10 reps for 15 minutes. Goal: decrease risk of further contractures in LUE in order to provide comfort and reduce pain, and to ensure skin integrity and reduce risk of skin irritation. During an interview on 2/28/18, at 10:13 a.m. nursing assistant (NA)-F stated they have not had a restorative aide for about a year. At 10:44 a.m., NA-G stated when a resident is started on PROM, therapy would demonstrate how to complete it, and staff had to acknowledge the training. NA-G said this was usually documented in the communication book where staff would find their assignments to do restorative nursing. During an interview on 3/1/18, at 11:12 a.m., NA-H verified she'd gotten R23 out of bed that morning, but had not completed PROM. NA-H stated, It says on my care plan that she does not get range of motion. During an interview on 3/1/18, at 10:53 a.m., licensed practical nurse (LPN)-C stated, We have not had a restorative aide for about a year, we train our nursing assistants to do it, like ambulation and range of motion. I am not sure where the aides find the information on who is on restorative, I think it is on their care sheets (care plan sheets for the Na's). During an interview on 3/1/18, at 11:16 a.m., trained medication aide (TMA)-B stated, Our aides are not responsible for restorative nursing. The only person we have on this unit for ROM is (a different resident then R23). During an interview on 3/1/18, at 2:02 p.m., certified occupational therapy aide (COTA)-D verified R23 had been discharged from occupational therapy (OT) with a restorative program on 4/18/17. During interview on 3/2/18, at 10:01 a.m., LPN-C verified R23 had not been getting PROM since (MONTH) of (YEAR), because although the order got put in restorative, it was not on the treatment administration record (TAR) or on the CNA care sheet. LPN-C stated, My expectation is to have passive range of motion done daily as ordered. During an interview with COTA-D on 3/2/18, at 10:52 a.m., she said that the purpose of R23's PROM program was to prevent worsening of contractures and to prevent a decrease in the mobility of her left hand. During an interview on 3/2/18, at 11:48 a.m. Physical Therapy Assistant (PTA)-A verified the PT (physical therapy) Discharge Summary dated 9/21/16, identified bilateral lower extremity (BLE) ROM continued to be limited, limiting patient's participation in mobility. PTA-A also verified there was no restorative program put in place to maintain lower extremity range of motion. During an interview on 3/2/18, at 12:08 p.m., Licensed practical nurse (LPN)-C stated R23 did not currently have a range of motion program in place for her lower extremities. The Occupational Therapy (OT) Plan of Care dated 3/2/18, included for R23 now presents with a decline in functional ROM of L (left) wrist, metacarpophalangeal joints, proximal interphalangeal joints and the distal interphalangeal joints. The caregiver started noticing a decrease in ROM approximately two weeks ago, they also report inconsistent use of palm guard, which has since resulted in the patient now requiring significantly more assistance for hygiene and joint mobility. Due to medical complexity, this patient will require skilled OT to assess appropriate and effective ROM program, educate caregiver on skin integrity, hygiene, wearing schedule of soft brace. LACK OF CONSISTENT USE OF ORDERED LEFT PALM GUARD: Doctors order dated 7/26/17, for R23 to wear a left palm guard in the morning following morning cares and hygiene; Remove after 4 hours and check for redness and irritation; Replace after 2 hours off, for 4 hours two times a day for palm guard, wear 4 hours two times a day. A Therapy Communication note to nursing dated 4/7/17, identified recommendations for the resident to wear left palm guard during the day, off at night, to complete hygiene and range of motion, and stretching fingers out straight when taking palm guard on and off. The 3rd West CNA (certified nursing assistant) Care Guides (contain services/treatments for residents assigned to the nursing assistant) dated 2/13/18, identified R23's to need a rolled wash cloth in left hand, palm guard on right. During an observation in the dining room on 2/26/18, at 8:20 a.m., R23 sat in a reclining wheelchair with a palm protector in place on her left hand. During observation on 2/27/18, at 12:19 p.m., R23 was observed sitting in a reclining wheelchair with no palm protector in her left hand. During observation on 2/28/18, at 9:51 a.m., R23 was seated in her reclining wheelchair with no left hand palm protector in place. At 1:49 p.m. R23 was observed to be lying on her back in bed with no palm guard on her left hand. During observation on 3/1/18, at 11:07 a.m., R23 was observed in the dining room seated in her wheelchair. She was observed to have the left palm guard on with her fingers curled around it. When R23 was asked whether she could open her left hand, R23 was unable to do so. R23's care plan revised 4/3/17, identified a focus area of contractures of hands, and need for wash cloth rolled in left hand and palm protector in right hand. During an interview on 3/1/18, at 2:02 p.m., certified occupational therapy aide (COTA)-D verified R23 had been discharged from occupational therapy (OT) with a restorative program on 4/18/17, and to wear a left palm guard during the day and off at night. The Occupational Therapy (OT) Plan of Care dated 3/2/18, identified R23 had a previous order to left palm guard to promote skin integrity and comfort. The plan indicated R23 .The caregiver started noticing a decrease in ROM approximately two weeks ago, they also report inconsistent use of palm guard, which has since resulted in the patient now requiring significantly more assistance for hygiene and joint mobility. Due to medical complexity, this patient will require skilled OT to assess appropriate and effective ROM program, educate caregiver on skin integrity, hygiene, wearing schedule of soft brace. The facility's policy Restorative Nursing Care dated 12/2016, included: restorative nursing care is that which does not require the use of a qualified professional therapist to render such care. Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of restorative nursing which is developed and coordinated through the resident's care plan. The facility's restorative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Restorative nursing is provided daily for those residents who require such a service. Program includes assisting residents with their routine range of motion exercises.

Based on observation, interview and record review, the facility failed to ensure an allegation of verbal abuse was thoroughly investigated, and failed to ensure protection of residents during an investigation for 1 of 1 residents (R42) who had reported verbal abuse. This resulted in an immediate jeopardy situation. The immediate jeopardy (IJ) began on 4/11/17 when the facility became aware of R42's allegations of allegation of verbal abuse. Although the facility was aware of the incidents of alleged abuse on 4/11/17, they failed to conduct a thorough investigation and failed to protect R42 and others during the investigation. The alleged perpetrator was assigned to another unit and was allowed to work independently. The IJ was identified on 4/13/17 and the administrator and director of nursing were notified of the IJ situation at 5:38 p.m. on 4/13/17. The immediate jeopardy was removed on 4/14/17, at 1:49 p.m., but non-compliance remained at the lower scope and severity of a D. Findings include: Interview with R42 on 4/10/17, at 1:11 p.m , stated three to four nights prior to this date (4/6/17 or 4/7/17) a nursing assistant (NA)-D had placed her call light where she couldn't find it and had been yelling and swearing at her. R42 stated she had reported this incident to the facility staff. R42 stated she was worried NA-D would be mean to her and stated staff wasn't very nice to her that night. Even though R42 had reported this allegation of abuse, the facility had not operationalized their abuse/neglect policy and no protection was provided to R42 and other residents who may receive care from the alleged perpetrator, NA-D. In addition, the facility failed to comprehensively investigate the allegation. Interview with R42 on 4/11/17, at 11:39 a.m. stated NA-D had gotten into a yelling match with R42 again last night when NA-D had administered her medications. R42 stated NA-D had not provided her water to take with her medications. R42 stated she had not reported this incident to any staff yet. R42 stated she felt NA-D took her anger out on her (R42). On 4/11/17, at 11:58 a.m. the director of nursing (DON) was notified of R42's allegations that NA-D had verbally abused her. The first alleged to have occurred on 4/6/17, and the second allegation from the previous night shift which had been reported that morning by R42 to the surveyor. The DON verified NA-D was a nursing assistant. R42's [DIAGNOSES REDACTED]. R42 has a BIMS (brief interview for mental status) score of 12 out of 15 which indicates R42 to have moderate cognitive impairment; last dated 3/6/17. Comprehensive care plan with print date 4/14/17, indicates R42 to have a self-care deficit related to impaired mobility which requires the assistance of one staff for dressing, grooming and bathing. R42 transfers with a mechanical lift and staff assistance of one. Also includes alteration in mood and behaviors as evidence by [DIAGNOSES REDACTED]. Currently utilize [MEDICAL CONDITION] medication for this diagnosis. On occasion becomes upset and tearful and makes statements that she feels like no one likes her and that no one wants her here. Will hit and yell at staff when frustrated, can be manipulative at times. Can become very upset at staff when not toileted immediately date initiated 12/14/15. The care plan did not identify any concerns related to R42 making false accusations of staff abuse/neglect or misusing the grievance process. When interviewed on 4/11/17, at 5:11 p.m., R42 stated no one from the facility staff had followed up with her regarding her concerns about NA-D's verbal abuse/yelling at her. During an interview with licensed practical nurse (LPN)-D on 4/12/17, at 4:00 a.m., LPN-D stated she was aware that R42 had expressed concerns about staff including a nurse manager, aides and nurses being verbally abusive towards her. LPN-D stated she had talked with the DON following her shifts about the complaints of R42 in the past. LPN-D would not give specific examples of verbal abuse when asked to clarify what verbal abuse meant. LPN-D stated the DON had called her on 4/11/17, to ask her about the NA-D having administered R42's medications without offering water. LPN-D stated she herself was the one who had administered R42's medications during the night shift and denied allowing NA-D to administer any medications. In addition, LPN-D denied having heard any yelling between R42 and NA-D. LPN-D said she would expect an aide to come and tell her if there were any concerns with a resident. LPN-D stated NA-D had not told her of any incident occurring the night of 4/11/17. During a follow-up interview with LPN-D at 5:48 a.m. on 4/12/17, regarding abuse protocols, LPN-D stated whenever a staff member yells at R42 she has the staff write down what happened and then she speaks with that specific staff member. LPN-D stated she does this because even if the staff member thinks they are in the right, they are wrong. LPN-D stated she then gives the written material to the DON. LPN-D stated she has the staff write down what happened so that it is in their own words. LPN-D stated she hasn't witnessed any staff yelling at R42 but when R42 has told LPN-D about staff yelling at her, she will talk with that staff member directly. I document it as a behavior and report the incident. LPN-D stated, I don't want the State of Minnesota to know we have staff clashing with residents, I want the DON to address it. During interview with NA-D on 4/12/17, at 5:05 a.m., NA-D stated she is usually assigned to the second floor when she works but because of a resident concern had been moved to the first floor for the current night shift. NA-D stated, R42 had told someone that I gave her medications and that I refused to give her water. The DON called yesterday but I wasn't able to call back so she came in and talked to me when my shift started. NA-D then described her perspective of the incident regarding R42's allegation from the previous night shift. NA-D stated she had followed LPN-D into R42's room after her medications had been administered to offer R42 repositioning. NA-D stated R42 was upset with her because she wanted more water and NA-D stated she hadn't noticed the water was almost gone. NA-D stated she'd left the room and R42 had begun yelling. NA-D said when she went back into R42's room she'd told her, you can't yell because other residents complain about the noise. NA-D stated she had reported the issue to LPN-D, about R42 yelling and about the other residents complaining of the noise, during that same night shift (the night shift starting on 4/10/17 and ending early a.m. 4/11/17) . R42 was interviewed again on 4/12/17, at 7:05 a.m. at which time she again stated no facility staff had followed up with her regarding her allegations about the staff yelling at her, or refusing to give her water to swallow her medications. During interview with social worker (SW)-B at 11:04 a.m. on 4/12/17, SW-B stated she had not spoken with R42 this week and was unaware of any concerns R42 had related to any verbal abuse of staff having yelled at R42. On 4/12/17, at 12:15 p.m. the administrator verified during interview that no Abuse/Neglect reports had been filed to the Office of Health Facility Compliance (OHFC) in regards to R42's alleged verbal abuse. The director of nursing (DON) was interviewed on 4/13/17, at 8:34 a.m. The DON stated she was first made aware of R42's alleged abuse from NA-D, one from 4/6/17 and the second from the 4/10/17 night shift, when the surveyor had reported the incidents to her on 4/11/17. The DON stated once she was notified of these allegations, she'd informed the administrator and had attempted to call both LPN-D and NA-D who had worked the night shifts when the alleged verbal abuses had occurred. The DON stated neither LPN-D nor NA-D had answered their phones, so she'd left messages for both of them to return her phone call. The DON stated she had heard back from LPN-D and who had denied hearing any yelling, and had denied knowing about any negative interactions that had occurred between R42 and NA-D. The DON stated she'd reported the allegation of verbal abuse to the state department (OHFC) around 2:30 p.m. on 4/11/17. The DON stated she was unable to get a hold of NA-D by telephone so she'd come into the facility at 10:00 p.m. on 4/11/17 to speak with NA-D before NA-D started her night shift. The DON stated she'd reassigned NA-D to the first floor for that shift. The DON further stated NA-D had denied administering medications to R42, and had informed her R42 was yelling at her (NA-D) about not having water to drink. The DON stated she'd spoken with R42 to let her know that NA-D would not be working on the 2nd floor the night of 4/11/17, but had not documented the conversation. When asked whether she had interviewed R42 in regards to the investigation of alleged verbal abuse, the DON stated she had not. The DON stated she'd spoken with LPN-D and NA-D and based on their interviews had determined the allegation of verbal abuse was unsubstantiated and her investigation was complete. The DON also said that NA-D had left her a hand written note dated 4/13/17, regarding the incident which occurred on the night shift of 4/10/17 between she and R42. The DON said after hving read NA-D's note, she would be looking at changing NA-D's work assignment. The DON stated she felt R42's allegations were a result of R42 being frustrated about not wanting to be in the facility. When asked for documentation related to her investigation, the DON stated her notes were all on separate pieces of paper as she hadn't had time to complete the investigation form. The DON provided a copy of the note left from NA-D describing the incident which had occurred on the night shift of 4/10/17. When asked whether she'd heard about R42's allegation of verbal abuse from 4/6/17, the DON denied hearing from LPN-D concerning any other incidents involving staff yelling at R42. Further, the DON denied finding any other documentation of incidents involving staff yelling at R42. The note NA-D had given to the DON regarding the allegation of verbal abuse from the night shift of 4/10/17, was reviewed. The note was dated 4/13/17 and indicated R42 had been upset and uncomfortable which resulted in R42 requiring to be repositioned multiple times. The note indicated NA-D had responded to R42's call light 16 times between 10:00 p.m. and 1:00 a.m. NA-D had further indicated R42 was yelling at her and calling her names. NA-D indicated she'd told R42 she wouldn't engage in her behavior and would return to the resident's room once R42 had calmed down. NA-D also indicated she'd left the room to answer another resident's call light and R42 had begun yelling about the call light. NA-D indicated that when she'd entered R42's room, R42 was attempting to throw herself on the floor and that R42 had thrown her pillows and sheets on the floor. NA-D's notes indicated R42 had threatened to sue her (NA-D), and that R42 had told NA-D she was going to throw herself on the floor and report that NA-D pushed her, so NA-D would get fired. NA-D indicated R42 continued to attempt to throw herself on the floor and that NA-D had told R42 if she wanted to throw herself on the floor there was no way NA-D could prevent it, and would not try to break the fall. NA-D's note indicated that she'd left the room then to get assistance from another staff with repositioning. NA-D indicated R42 expressed feeling that staff were treating her awful and couldn't wait to leave the facility. NA-D also documented in the note that she had notified LPN-D and LPN-G who had both been on duty. NA-D indicated NA-G and LPN-G had answered R42's call light for the rest of the shift. During interview with R42 on 4/13/17, at 9:05 a.m., R42 stated no one had followed up with her regarding her concerns related to NA-D regarding the 4/10/17 allegation of abuse. R42 reitereated she had been hollering out for help because she needed water and her tray table was in the middle of the room instead of beside her bed. R42 stated NA-D entered the room and told her she'd been in there 12 times. R42 stated NA-D, gave me a sermon. R42 stated she kept hollering and hollering last night because she was tangled up in her sheets and no one would come in and help her. NA-D stated LPN-G entered the room and told R42, that she wouldn't send NA-D in because she's had enough of you and that she hadn't been very nice to NA-D. R42 stated although she felt safe in the facility, she felt like a heel, like I'm not much when staff are yelling at her. Facility call light reports were requested, but the facility reported they had none available. During interview with the administrator at 9:23 a.m. on 4/13/17, the administrator stated the allegation of verbal abuse which occurred the night of 4/10/17 had been reported to him. The administrator said initially upon hearing of the allegation, the administrator had been told LPN-D and NA-D had been telephoned but because they worked the night before hadn't been able to be reached. The administrator stated he had been told other residents on the floor had been interviewed regarding the allegation and the report was that R42 was the one yelling and no one had heard any yelling from staff. The administrator described R42 as very abusive to staff and manipulative. The administrator stated he wasn't sure who'd completed the interviews and was unsure whether R42 had been interviewed regarding the allegation of verbal abuse. He stated it was difficult to take R42 as a viable source due to her lying, manipulating and threatening to get staff in trouble. The administrator stated he felt 42's goal was to get us into trouble, that's my belief, she's a bright woman and she understands that this is going to happen. Then the administrator stated because the allegation was against a nursing assistant, he hadn't taken the lead for the investigation, but instead left it to the DON and SW to complete. He stated he personally had not interviewed any staff related to the allegation and stated the DON had notified him of who had been interviewed. The administrator stated a complete investigation should include interviewing all those involved in the allegation; other staff, other residents, and definitely the resident making the allegation. The administrator stated he was unaware NA-D had worked with R42 on 4/10/17, and stated that wasn't a good idea because he would have liked to protect NA-D. He stated with where the facility was in their investigation, and because of other resident interviews, it contradicted what R42 had alleged. The administrator stated if they had any evidence that allegation was true they would have suspended NA-D immediately. Finally, the administrator stated at this time he did not feel the investigation was complete. On 4/13/17 at 11:01 a.m. the DON was observed on 2nd floor interviewing residents in regards to the alleged verbal abuse that had occurred on the 4/10/17 night shift. The DON was again asked for for any documenation including investigation notes in regards to R42's alleged verbal abuse. At that time, the DON stated they had just started interviewing other residents and that was what she was working on. Later that day, upon receiving copies of the investigative notes, it was noted the notes included minimal information from LPN-D and NA-D dated 4/11/17. The interview notes were dated 4/13/17, indicating other staff and residents, including R42, had been interviewed at around 10:30 a.m. that day. The interview notes did not indicate names of staff/residents and were unspecific as to time/dates conducted. During an additional interview with the administrator and SW-A on 4/13/17, at 2:06 p.m., they who were asked how the facility ensured protection of residents during an investigation of an alleged abuse/neglect. They both stated they would want to interview other residents to see whether they had experienced any negative experiences with that staff member. They said if they think it is more of a grievance versus abuse, they might just remove the staff member from working with that resident. SW-A said, We would keep them separated until we determined whether the claim was substantiated or not. They further stated if they had somebody they believed was being verbally abusive they would not just move them to another floor. The administrator stated they'd determined through investigation that it was actually R42 that had abused NA-D, and that this had been determined before NA-D had returned to work on Tuesday 4/11/17. However, the administrator also stated the investigation was not complete, because they still had more people to talk to. He said, what we have determined is that (R42) is being abusive towards (NA-D) and is continuing her assault through this complaint. The only evidence that we have found so far was no co-workers heard (NA-D) yelling, and the residents were upset with (R42) for yelling with (NA-D). He further stated a suspension of a staff member is done immediately upon notification of an allegation, and added the employee would be suspended until we can determine if the allegation is unsubstantiated. He said if an allegation was substantiated, they would terminate the employee. During interview with NA-G on 4/13/17, at 3:22 p.m., NA-G stated she'd worked the night shift with NA-D on 4/10/17 and had assisted NA-D with repositioning R42. NA-G stated upon entering the room, R42 had been upset and had thrown everything on the floor and was almost falling out of bed. NA-G stated when she was in the room NA-D was quiet and wasn't yelling. NA-G stated she'd assisted with repositioning R42 and had left the room to go back to her wing and answer other call lights. NA-G stated when she was finished assisting other residents she'd seen NA-D crying. NA-G stated she'd then been instructed to work with R42 for the rest of the evening. NA-G stated she had no concerns related to R42 the rest of the night. The immediate jeopardy that began on 4/11/17, was removed on 4/14/17, when the facility removed the staff alleged to have verbally abused R42 from work pending an investigation; the DON and Social Services Director re-interviewed the resident involved and intiated interviews with other residents regarding any allegations of abuse or neglect; and education was intiated for all staff as they reported to work regarding the facility's abuse/neglect policies to assure adequate investigation and protection of residents during an investigation would be initiated. Noncompliance remained at the lower scope and severity level of a D (actual or potential for minimal harm/discomfort) because the facility provided an immediate removal plan but had not met as an interdisciplinary group to implement measures to sustain continued compliance.

Based on observation, interview and document review, the facility failed to provide skin care in accordance with physician orders, to promote healing and prevent further pressure ulcers from developing for 2 of 2 residents (R122 and R100) reviewed for pressure ulcers. As a result of the facility's failure to assess and provide appropriate pressure ulcer care and services, R122 sustained harm when she developed a second pressure ulcer, and later developed a [MEDICAL CONDITION] infection of the wounds. Findings include: R122 was observed in her wheelchair sitting in the hallway outside her room on 4/11/17 at 5:13 p.m. The resident was observed wearing a specialized boot on her lower leg. When asked why she was wearing the boot, R122 said she'd had something rubbing her foot that had caused a sore and now she has a scab on her foot so wears the boot for protection. During a review R122 records found on physicians orders that the dressing change is completed every other day for a stage 3 left lateral malleolus pressure ulcer dated to start 3/29/17 treatment is to : 1) Cleanse with normal saline. 2) Apply hydrogel to wound edges only. 3) Apply [MEDICATION NAME] AG to wound edges only. 4) Cover with [MEDICATION NAME] and wrap with Kerlix. order dated in the physician order [REDACTED]. On 4/12/17 at 1:31 p.m. R122 was transferred to her bed for staff to complete a dressing change. Registered nurse (RN)-B, the facility's wound care nurse, said the resident's treatment order is to apply hydrogel to both wounds, and that since she had developed the wounds, she had undergone debridement two times. RN-B said that the area around the wound is redder than before. When asked when the treatment had last been completed, RN-B said yesterday. She said when she completed the wound care, the wound areas were always chronic pink all the time. RN-B said the pressure ulcer on R122's heel had been acquired while living at the facility, and her ankle ulcer was hospital acquired. RN-B stated they continue with the dressing changes. RN-B was observed to then scrape with her gloved thumbnail at the soiled dressing and stated, there is a minimum to moderate purulent drainage. RN-B also acknowledged there was an odor. At 1:51 p.m. RN-B continued with the assessment of the wound on R122's ankle and stated it was unstageable, and that the heel ulcer was a stage 3. RN-B shared that R122 would be going to the wound clinic if her sister took her. RN-B said that she would update the provider regarding the drainage and odor of the wounds. In addition, she said the CNP (certified nurse practioner)-A was at the facility. At that time, RN-B asked CNP-A to assess the ulcers. CNP-A stated she thought the wounds looked infected, and would start R122 on antibiotic for [MEDICAL CONDITION]. CNP-A gave RN-B directions to mark the reddened area in order to monitor the progression. At 2:04 p.m. RN-B was observed drawing around the reddened area; measurements included 0.6 x 0.6 cm on heel, ankle measured 1.8 cm X 1.5 cm X 0.2 cm, she said she could not really tell the depth of the open area but was guessing it would be 0.2 cm, and the red area measured 6.5 cm X 6.2 cm. On 4/12/17 at 2:14 p.m. RN-B tried to get the slough off when cleaning the wounds in a circular motion, RN-B stated pretty much necrotic, not getting much off. CNP-A told RN-B to place hydro gel all over wound perimeter while she was out of the room, RN-B applied hydro gel with finger to both wounds however, did not use application appliance such as q-tip, follow rest of written order. RN-B stated R112 wears boots 24 hours a day. R122's Admission Record form identified an admission date of [DATE], also [DIAGNOSES REDACTED]. The clinical document copy titled Primary Care Internal Med Nursing Home physician visit notes dated 9/27/16, indicated R122 was in the hospital after a fall from a previous nursing home possibly caused by her polypharmacy, and that nursing would not take her back due to her aggressive behaviors. The note indicated R122 realized she could not go home and was aware she could not mobilize herself to go to the bathroom or perform her own activities of daily living (ADL) in light of her comorbidities. R122's admission Minimum Data Set ((MDS) dated [DATE], indicated the resident had no pressure ulcers, but was at risk to develop skin break down, including Moisture Associated Skin Damage (MASD). The MDS further indicated R122 required extensive assistance of 2 assist to meet repositioning, locomotion, toileting and dressing; and required supervision with oversite, encouragement, and cueing for eating. R122's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R122 required extensive assistance (two persons for physical assist) to complete transfers, bed mobility and toileting; and one-person assist for dressing and personal hygiene. In addition, the quarterly MDS indicated R122 had one stage III pressure ulcer and one unstageable pressure ulcer. A review of R122's care plan indicated a problem with impaired mobility, alteration in skin integrity and diabetes. The goals included for R122 to have good wound healing with no signs and symptoms of infection and to have no further skin break down. Interventions for care included: inspect skin with care, report reddened areas, rashes, bruising or open areas to the charge nurse, conduct weekly skin inspection, heel lift boot on left lower extremity when in bed, pressure reduction mattress to the bed, and pressure reduction to the chair, treatments as ordered, monitor for effectiveness and monitor/document/report any new or non-healing wounds, or signs and symptoms of infection to any open areas, redness, pain, heat, swelling or pus formation. R122's Nursing Assistant (NA) 3/28/17 care guide/assignment card, (which included specific care plan interventions the NA should implement for R122), indicated R122 required one assist with ADL's, two assist with transfers using a mechanical lift, heel lift boot on the left lower extremity in bed, and (in capital letters) BOOT ON LT (left) FOOT AT ALL TIMES. Clinical Document Copy notes from attending physician/Certified nurse practitioner dated 10/21/16, indicated the pressure ulcer to R122's left lateral heel had been discovered 10/18/16. The note further indicated that on 10/18/16 the blister was intact, and the provider thought it was a pressure related area. The note included, Tried to protect area and yesterday it ruptured and we now have an open draining lesion. Will have foam boot and will try to keep on her. The ulcer is about a 50 cent piece size. About half of the overlying skin has come off, revealing an [DIAGNOSES REDACTED]tous (red) base with some serous drainage. Plan to apply a moisturizing dressing, start on antibiotic for early signs of [MEDICAL CONDITION] and will arrange wound clinic appointment, foam boot on to protect and take pressure off and facility to make sure she is positioned correctly both in the chair and in bed, especially. The Clinical Document Copy note dated 10/24/16, indicated the resident's skin was dry and intact, and under system review indicated skin: heel wound, nurse observing. Clinical Document Copy notes dated 1/12/17, indicated the resident had a nursing home readmission after a stay in the hospital for an exacerbation of her asthma. Documentation included, left heel pressure developed in October (2016) last wound clinic 12/6/16 and has not been back since. There remains a small eschar over the ulcer which has been healing. Denies any pain, and no evidence of infection. Measures approximately 3 cm (centimeter) in diameter. Plan for the wound is to arrange to have it debrided to heal faster, either at the wound clinic or have a nurse practitioner who is certified in debridement complete. Clinical Document Copy notes dated 1/18/17 included: full thickness wound present that is covered with hard black eschar. After eschar removal, debridement with wound base measurements 2.0 centimeters X 2.2 cm X 0.3. Per nursing staff at facility they have been providing daily dressing with 50% iodosorb and 50% hydrogel Clinical Document Copy notes dated 1/25/17 included: stage II pressure ulcer, left foot. Dressing changes with iodosorb and [MEDICATION NAME] covered with [MEDICATION NAME]. Will re-evaluate in approximately a week. Clinical Document Copy notes dated 2/3/17 included: ulcer on left foot measure 1.5 X 1.5 cm wound, healing. Clinical Document Copy notes dated 2/24/17 included: left heel ulcer slowly improving. Resident is reluctant to attend the Wound Clinic due to transportation issues. Staff to address the tiny ulcerations on the lateral malleolus. (This is a new finding located on outside of left ankle). Dressing daily with [MEDICATION NAME] and iodosorb. They do have a special boot that does keep her foot from tipping on to the left, which is likely the cause of those previous ulcerations. Clinical Document Copy notes dated 3/28/17, included documentation about the right lateral heel ulcer. They do have a special boot that does keep her foot from tipping on to the left, which is likely the cause of those previous ulcerations. Consultation/Clinic Referral notes dated 10/25/16, problem of wound care, referral for the vascular center notes derided left lateral heel. Appears superficial. Care Plan Report Vascular Ulcer/Wound Healing Clinic dated 10/25/16 document included, [DIAGNOSES REDACTED]. Wash hands, 2. Remove old dressing, 3. Gently cleanse ulcer base with normal saline and gauze, 4. Apply iodosorb/[MEDICATION NAME] (50:50) mixture to ulcer base, 5. Cover with [MEDICATION NAME] border, 5. Change dressing once a day. Special instructions use foam boot at all times. Keep pressure off heel at all times, check feet daily for any signs of pressure spots and or new wounds forming follow up appointment in 4 weeks. There is no measurements from this wound clinic visit. Consultation/clinic referral for the vascular center notes dated 12/6/16, included plan for patient needs to obtain PRAFO boot, ulcer with increased necrotic eschar (dead skin), patient needs physical therapy to maintain large muscle strength, but needs to avoid walking on the left foot, PRAFO to be worn in the wheelchair and in bed. Additional information from this day. Check feet daily for any signs of pressure spots and/or new wounds forming. Follow up appointment in 3 weeks. There is no measurements from the wound clinic. Nutrition note dated 3/27/17 does not address additional nutrition supplement for wound healing. Facilities most current Order Summary Report dated 2/23/17 signed by physician 2/24/17 included, LEFT LATERAL HEEL WOUND DRESSING, change once daily, start 1/11/17. Monitor of wound changes, pain at site, redness or other changes in the skin, status of surrounding tissue, presence of possible complications (redness, swelling, increased drainage). If pain is present, how it was controlled. Document note in PCC (point click care) with dressing changes. One time a day. Start 1/19/17. R122's progress notes were reviewed from 10/1/16 to 10/17/16 with no new skin issues noted. On 10/18/16 at 1:41 p.m. the resident had a change in condition, with blister on right outer side of right (R122 has [MEDICAL CONDITION]) ankle, area intact, no drainage 4 cm X 4 cm in diameter, family aware, SBAR -change in condition (form used to update physicians) 10/19/16 at 5:59 p.m. R122 has a blister on the left heel and dressing is intact. 10/21/16 at 1:07 p.m. apply dry gauze and Kerlix to left heel blister. Apply protective heel boot over. Float heel when in bed, done by wound nurse today. Antibiotic for [MEDICAL CONDITION]. 10/23/16 at 9:08 p.m. resident continues to have open are on left heel from popped blister. Dressing was changed this shift. 10/29/16 at 1:56 p.m. skin around ulcer is dry and peeling. Ulcer is over a 50 cent piece in size. No drainage observed. No complaints of pain during cleaning and dressing the wound. Foam boot reapplied. 10/30/16 at 2:40 p.m. left foot ulcer completed per treatment instructions. Some tenderness when cleansed, wound lightly smaller. 11/2/16 at 3:36 completed by wound nurse. 11/4/16 at 2:19 p.m. changed to left heel area dry and peeling. 11/5/16 at 10:29 a.m. left heel dressing changed this shift area around wound dry and skin peeling off. wound area is red in color. 11/6/16 shower tonight no new skin issues noted. 11/7/16 dressing to left heel changed, skin around the wound is dry and peeling. Wound is pink and one quarter size in area is dark red. Some tenderness when cream applied. 11/10/16 at 10:53 a.m. left heel dressing changed. Center of wound is dark brown in color and outside area is red. Skin around wound is peeling. Resident stated it is sore while the writer is doing her treatment. 11/12/16 dress changed to left heel tender to touch. Area is dark red/brown in color and approximately 1 ½ x 1/12 inch. Skin around wound is dry and peeling. 11/13/16 wound on left heel is dark in color. No change from yesterday. Wearing foam boot constantly. Shower tonight no new skin issues noted. 11/15/16 wounds bed is dark reddish black in color. 11/16/16 much of dry skin had peeled off around the wound. The wound is dark blackish red, scab-like with out drainage. Slightly tender to touch. 11/20/16 refused 11/21/16 shower no other skin issues noted heel continues to have treatments. 11/22/16 dressing completed by wound nurses. 11/27/16 small area bleeding from callused area falling off. denies pain, wound base is necrotic. 11/30/16 left heel/sole wound is about a 50 cent piece in size, is tender to touch, no drainage, is dark reddish/black in color. Foam boot re-placed on foot. 12/5/16 wound is dark brown in color, no drainage noted, no bleeding, no odor on it. The are around the wound is dry . moderate amount of pain was noted during the dressing change. 12/6/16 done by wound nurse this morning. 12/7/16 left heel/foot ulcer dressing changed, very tender to touch, heel boot was on and reapplied after dressing done. 12/10/16 dressing completed, very tender to touch, no drainage. 12/11/16 dressing changed slight tenderness to touch, wound is dry. 12/13/16 done by wound nurse. 12/14/16 done by wound nurse this morning. 12/16/16 dressing changed, resident grimaced some during procedure and said it hurt a little foam boot replaced once dressing was done. 12/22/16 dressing change to left heel. 12/23/16 no new skin issues. 12/27/16 done by wound nurse. 12/28/16 dressing changed to Right heel (right [MEDICAL CONDITION]) wound bed is dark in color, some pain during dressing change, brace reapplied. 12/29/16 dressing completed to left heel no changes from yesterday 12/30/16 send to emergency room . 1/4/17 return from hospital, no reassessments completed, left lateral heel wound dressing, done in hospital. 1/8/17 left heel wound is dry and without drainage-does not complain of pain or tenderness when dressing changed. 1/12/17 dressing completed area is dry, dark brown. 1/17/17 done by wound nurse. 1/18/17 left lateral heel wound dressing, soaked wound in acetic acid saturated gauze x 10 minutes, then washed with saline, no dry skin was removed in the process, no drainage, no tenderness or pain. 1/18/17 certified nursing practitioner (CNP) derided today 1/19/17 dressing changed to left heel. 1/24/17 dressing change to left heel, wears brace over dressing. 1/25/17 dressing change to left heel daily, today was completed by wound nurse. 1/26/17 dressing changed to left heel. 1/29/17 shower this shift. Dressing on left heel changed no discharge noted, no swelling, area is dry, dark brown in color. 2/4/17 dressing to left heel done, denies pain, wound is healed over 2/5/17 left heel dressing changed wound area is white-yellow in color, area around the wound is pink. 2/8/17 wound is open about the size of a quarter. Resident did not complain of pain during the soaking or dressing change. 2/11/17 dressing on left heel, area is pink around. White yellow in the mid area. 2/12/17 shower no new skin issues noted open are noted on left heel wears boot at all times. 2/18/17 unable to complete dressing change 2/19/17 left heel dressing completed. 3/8/17 resident has two openings on left foot-one on heel and one on lateral ankle. Dressing change done per treatment instructions. 3/10/17 wound is red/pink. Resident complain of pain for the duration of the dressing change. 3/12/17 dressing completed, resident complained of pain during dressing change and movement of her leg. 3/19/17 heel wound nearly healed but has wound on left lateral, expressed pain during the process. 3/22/17 dressing to left heel changed, two areas appears dry, dark brown in color, no drainage. Skin around wound area red, no increased swelling noted. 3/25/17 treatment completed for ulcers on the left heel and left lateral malleolus. Left heel stage 3 ulcer and lateral malleolus was previously unstageable but was able to remove eschar/necrotic tissue/slough with acetic acid soak today. 4/12/17 a significant change noted in the left lateral malleolus unstageable ulcer compared to 4/11/17 dressing change. Tissue surrounding is red and warm to touch. Measurements 1.8 cm X 1.5 cm X 0.2 cm, red area 6.5 cm X 6.2 cm. 4/11/17 1.5 cm X 1.5 cm X 0.2 cm, 4/12/17 measurements of left heel 0.6 cm X 0.6 cm 4/11/17 was 0.3 cm X 0.5 cm X 0.1 cm, left lateral malleolus moderate drainage with a foul smell. CNP updated and ordered antibiotic. Both wounds cleansed with normal saline per order. Hydrogel applied to entire wound bed per CNP recommendation, rather that just the wound edges, due to previous dressing being difficult to remove (wound was dry). [MEDICATION NAME] AG ([MEDICATION NAME] AG) applied to wound, covered with [MEDICATION NAME], and wrapped with Kerlix. Daily dressing changes and notes were completed on the wounds. RN-B was interviewed on 4/14/17 at 10:44 a.m., regarding wound tracking for R122. RN-B stated the tracking was in the computer, except for the last week. When asked whether there was documentation available for review, RN-B stated her assessments were all in the computer, and she had no other notes available. Review of the facility's Treatment administration record for April 2017, revealed R122's physician had prescribed dressing treatments to the left lateral malleolus pressure ulcer once daily. There was no documentation to identify the wound on the left heel or whether or not the treatments had been completed for the heel wound since 3/28/17. There was no documentation on the treatment record, nor in the progress notes that identified dressing changes had been completed on April 6, 8, or 10, 2017. Documentation was also lacking to indicate a dressing change had been conducted on April 14, 2017. During interview with RN-B on 4/17/17 at 9:48 a.m. she stated she completed wound rounds once a week for measurements. RN-B said she expects nurses to place a note in the computer when they do the dressing changes. RN-B said she is aware that is not always completed and is planning to educate staff because they lack understanding. RN-B was asked about the missing documentation. She stated she would expect an initial or some sort of document showing the dressing change had been completed. RN-B verified the missing documentation on the treatment records and confirmed that the wound is now infected. RN-B stated the heel wound had started in October 2016, and the ankle wound in January of 2017. RN-B verified interventions put in place for the heel wound continued to stay in place even after the development of the wound to the ankle and no new interventions were reviewed to help prevent the development of additional wounds. RN-B verified CNP-A had made mention in a past notation that the facility had utilized a boot that may have caused the ulcerations, but that there was no additional follow-up regarding the comment. RN-B verified that the same boot remained in place. During interview with RN-B on 4/17/17 at 10:38 a.m. RN-B verified there could have been a more comprehensive wound assessment completed for the pressure ulcers. The facility policy Skin integrity Guideline, included: Patients/residents will be assessed or observed for the risk of skin breakdown within 24 hours of admission or readmission, quarterly, before transfer or discharge to a setting . develops a routine schedule to review wounds on a weekly basis. The interdisciplinary plan of care will address problems, goals and interventions directed toward the prevention of pressure ulcers concerns identified. If there is a decline in skin integrity, pressure redistribution surfaces will be reviewed for appropriateness and implement as indicate by the individualized plan of care. If resident is refusing, review risk, benefits and alternatives. Re-evaluate and attempt other interventions. R100's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R100 had a stage three pressure ulcer, slough (yellow or white tissue in the wound bed), was receiving pressure ulcer care, application of non-surgical dressing and had pressure relieving devices in chair and bed. R100's Admission Record dated 4/17/17, included [DIAGNOSES REDACTED]. R100's Braden Assessment (scale for predicting pressure sore risk), dated 4/2/17, indicated score of 11, high risk. R100's current care plan dated 4/17/17, included focus: actual/potential for alteration in skin integrity related to impaired mobility, [MEDICAL CONDITION], left below knee amputation, pressure ulcers, Foley catheter. Interventions included: 8/29/16 from OT (occupational therapy): use 'G' size [MEDICATION NAME] (compression bandage) and two layer wraps for compression of stump right lower extremity (LE) 23 x 7. Monitor the wraps during the day for good skin integrity. Left LE use the compression sleeve of prosthesis. Monitor skin integrity. Bed mobility (resident sleeps in recliner); assist of two reposition every two hours and prn (as needed) as resident will allow. Encourage resident offload frequently. Risk and benefit signed by resident and daughter due to non-compliance with repositioning. Complete Braden Scale per living center policy. Keep skin as clean and dry as able. Monitor positioning of catheter tubing to ensure no pressure areas on skin. Monitor skin wraps and prosthetics for skin breakdown. OT as ordered. ROHO (pressure relieving) cushions in wheelchair and recliner to help avoid pressure. Skin assessment to be completed per living center policy. Treatments as ordered. Monitor for effectiveness. Weekly Wound assessments. R100's nursing assistant (NA) care guide assignment sheets updated 3/28/17, included do not put footrest on bottom of leg rest. ROHO cushion when in recliner and wheelchair, do not cover with anything. Sleeps in recliner. Assist to turn and reposition every two hours and prn. Monitor skin with cares and report changes to nurse. R100's physician orders [REDACTED]. R100's medication/treatment administration record (MAR/TAR) dated 4/17, included Santyl ointment 250 unit/GM apply to wounds/ulcer topically every day right lower extremity wound beds after cleansing with normal saline. There was no documentation to identify whether or not the treatments had been completed on April 3, 5 or 6, 2017. On 4/12/17, at 10:06 a.m., RN-B was observed to provide wound treatment to R100's right lower extremity wounds (three total). RN-B cleansed three wound bases with acetic acid 0.25 percent and gauze and then applied a 50:50 mixture of Iodosorb (antimicrobial) and Hydrogel (a gel in which the liquid component is water) to all three wound bases. RN-B failed to follow the current physician orders [REDACTED]. On 4/12/17, at 11:13 a.m., RN-B when queried regarding what the current physician orders [REDACTED]. When queried regarding the Hospital Discharge order dated 4/2/17, for Santyl to the wound areas, RN-B stated oh crap, the hospital orders from 4/2/17 would trump the wound clinic orders. The DON was present at the time and stated to RN-B you need to call the wound clinic and clarify what treatment they want and write a clarification order. R100's progress notes and wound evaluation flow sheets dated from 11/28/16 to 4/2/17 were reviewed with RN-B on 4/14/17, at 10:53 a.m. At the time, review of the documentation and interview with RN-B identified the following: RN-B stated the pressure ulcer was first identified on R100's right lower stump on 11/28/17, and the cause of the pressure ulcer was due to pressure from R100's wheelchair footrest. RN-B stated R100's wheel chair was modified (footrests were removed) and R100 was offloaded (pressure to bony areas removed) with a pillow under her legs. RN-B stated R100 currently only had pressure ulcers located on her right stump. Nursing notes dated 11/28/16, indicated 2.8 x 1.5 suspect deep tissue, treatment cover with Allevyn foam dressing, legs wrapped daily, leg propped pillow in wheelchair. Nursing notes 12/6/16, 2.5 x 1.8, changed to stage two, not deep tissue, right foot peddle removed primary source pressure, educate resident, no signs of symptoms infection. Nursing notes 12/16/16 3 x 3, patient refusing to remove foot pedals, pillow placed for reduction. Nursing notes 12/23/16 1.5 x 1.5 will have NP (nurse practitioner) evaluate, further recommendations. Patient continues to be non-adherent to pressure reducing recommendations of floating and no wheelchair peddles. R100's record lacked documentation of weekly wound assessments after 12/23/16 until January 17, 2017. RN-B confirmed at the time and stated my best guest would be she refused and I did not document. RN-B stated when looking at her progress notes she was refusing many things at the time. Nursing notes 1/17/17 0.5 x 0.5 x 0.1 eschar scab derided from wound, wound bed visible stage three. Nursing notes R100 was in the hospital from 1/23 through 1/26. Nursing notes 1/27/2017 readmit from the hospital. The Hospital Dismissal Summary dated 1/27/17, indicated primary [DIAGNOSES REDACTED].#2 sacral decubitus ulcer stage 2 due to #3 non-st elevation [MEDICAL CONDITION] infarction due to #1. #4 right plantar stump ulcer with possible soft tissue infection, less likely contributor to #1. Skin alterations: right foot unstageable, no drainage, color black, scab. R100's record lacked wound assessment for the right stump upon return from the hospital on [DATE] through 2/7/17. RN-B stated I charted regarding R100's left buttock, but nothing about the right stump. RN-B verified wound assessment for R100's right stump upon return from the hospital was first dated 2/8/17. Nursing notes 2/8/17, right stump 4.5 x 5.2 cm, unstageable pressure continues to be non-compliant cares and requires a lot of encouragement to get dressing done. NP will be referring patient to wound clinic to ensure that they look at this area for possible debridement. Area appears to have eschar covering wound base at this time, making it invisible. Will continue to follow on wound rounds. Nursing notes 2/20/17, late entry for 2/14/17, 5 x 3 wound has been derided showing healthy [MEDICATION NAME] tissue. Will continue to monitor on wound rounds. Nursing notes 2/22/17, Weekly wound rounds completed today. Patient initially noncompliant with dressing change. After re-approaching and explaining the importance of preventing another infection from arising, patient complied with dressing change. Dressing completed to pressure ulcers on right stump and buttocks. Wounds are stable at this time. Again, re-educated patient on the importance of compliance with repositioning to promote wound healing. Patient verbalized understanding; however, patient is historically noncompliant with this aspect of care; risk and benefits documentation in place. The note lacked measurements and detail of the wound appearance. RN-B confirmed. R100 was hospitalized from [DATE] through 2/28/17. The Hospital discharge summary dated 3/1/17 indicated primary [DIAGNOSES REDACTED]. #5 right stump ulcers, non-infected. Skin alterations: right lower extremity unstageable. Nursing notes 3/1/17, upon return from the hospital lacked measurements and wound appearance for the right stump. RN-B confirmed and stated the first measurements upon return from the hospital was on 3/7/17. Nursing notes 3/7/17, right stump area #2 was 3 x 5 cm unstageable, area #1 with 1 x 1 cm, 50/50 [MEDICATION NAME]/granulation. Resident readmitted from the hospital. No signs or symptoms of infection. No complaints of pain. Will continue to follow on rounds. Nursing notes 3/15/17, with a 5 x 11 cm blister has enveloped both necrotic areas with copious amounts of rusty colored drainage exuding from wound. Patient sent to emergency room (ER) for evaluation. Nursing notes 3/15/17, included, seen at emergency department, [MEDICAL CONDITION] - please follow up with wound care return if fever or spreading redness beyond markings. RN-B stated the [MEDICAL CONDITION] location was above the wound areas. R100 was hospitalized from 3/16 through 3/23/17. Nursing notes 3/24/17, included upon admission, it was noted R100 had two open blisters just below her right inferior scapula (sustained in hospital due to hot liquid burn spilled coffee). Areas are healing and remain open to air. Wound nurse notified and observed. All other wounds are consistent with those had prior to hospital transfer. The not lacked measurements and appearance of right stump wounds. RN-B confirmed. Nursing notes 3/30/17, included a 7 x 4 x 0.5 and 1 x 1 cm, wounds continue to improve slightly, no obvious signs of infection. Will continue to monitor. R100 was again hospitalized from [DATE] through 4/1/17. The Hospital Dismissal Summary dated 4/2/17 indicated primary [DIAGNOSES REDACTED]. Skin alterations: right lower extremity (LE) as unstageable color tan, right LE unstageable color tan, right LE ulcer color red, right LE color black. Nursing notes 4/2/17, progress note upon readmission identified Skin: resident has four wounds to right stump. Measurements of wounds to stump from frontal aspect of stump moving in distal direction: 1. 2.6 cm x 4.2 cm (open area with wound bed yellow) 2. 2.8 cm x 1.6 cm (open area with wound bed pink) 3. 3.8 cm x 2.0 cm (Open area with wound bed pink) 4. 1.4 cm x 1.0 cm (intact and eschar tissue) Left stump is currently intact. Licensed nurse to complete weekly skin checks. Braden skin score is 11. On 4/14/17, at 11:31 a.m. RN-B stated staff were to be signing off on the treatment administration record (TAR) for treatment of [REDACTED]. On 4/14/17, at 3:56 p.m., the DON stated she would expect weekly wound measurements and documentation. The DON stated the facility policy was to do an assessment of wounds upon readmission from the hospital within 24 hours. The DON stated she would expect treatment orders to be followed, if conflict make a call to the provider. The DON stated she would expect staff to provide the treatment daily and staff to sign for the treatment completed daily. A policy for wound assessments and implementation of physician orders [REDACTED].

Based on observation, interview and document review, the facility failed to complete a skin reassessment after development of pressure ulcer/s and develop treatments and services interventions to promote healing and prevent new pressure ulcers from developing for 3 of 3 residents (R51, R147, R203) reviewed with pressure ulcers. This resulted in harm for R51. Findings include: R51 returned from the hospital on April 7, 2015 and was observed to have a redden groin area extending to buttocks area which was treated with powder. On 4/21/15 progress notes identified two open red areas on buttocks which were treated and covered with dressings. However, was no skin reassessment completed after finding these open area and no new preventative skin interventions put in place to help the open wounds heal and prevent new ones from developing. On April 29, 2015 surveyors observed two stage II pressure ulcers on buttocks and again there had not been a skin reassessment or interventions based on the skin reassessment completed from 4/21/15 when the facility was first aware of the open wounds on buttock area. 21/15. After surveyors brought this to the facility's attention a comprehensive skin reassessment was completed, the doctor was notified of the presence of the two stage II pressure ulcers and care plan interventions were being developed. Also R51 had not been repositioned from 7:00 a.m. to 12:00 p.m. a total of 5 hours on April 29, 2015. The lack of skin reassessment and development of skin interventions and development of two stage II pressure ulcers resulted in harm to R51. R51 was admitted to the facility on [DATE] according to the physician's orders [REDACTED]. Also the report included [DIAGNOSES REDACTED]. R51 admission Minimum Data Set ((MDS) dated [DATE] noted R51 was cognitively intact and needed extensive assistance with activities of daily living except supervision with eating. Used a wheelchair for all movement as only able to stand with one assist. Also indicated he was at risk for developing pressure ulcers, and had pressure reducing device for bed and on a turning/repositioning program. However the current care plan did not support a turning or repositioning program. R51's quarterly MDS dated [DATE] indicated no cognitive impairment with a Brief Interview for Mental Status score of 15, required extensive assistance from one staff for bed mobility, extensive assistance from two staff for transfers, and used an indwelling urinary catheter. In addition, the MDS indicated a risk for pressure ulcers and a clinical assessment was used in the determination of pressure ulcer risk (a pressure ulcer risk assessment was not evident in the medical record during or near the assessment time frame). During an interview with R51 on 4/29/15 at 2:04 p.m. he said, "I've been sitting here all day, they (nursing assistants-NAs) have only come in to stand me up one time all day long!" During observation at 2:15 p.m. nursing assistant (NA)-K used a mechanical lift to stand R51 and observed two brown dressings on each buttock cheek. Licensed practical nurse (LPN)-A then removed the two brown adhesive dressing from R51's right and left buttock. There was red blood noted to drip from the dressings and from the buttock wounds to the floor. LPN-A took measurements at this time with left wound measured 0.75 centimeters (cm) by (x) 0.2 cm and right wound measured 0.1 x .0.001 cm. Surrounding skin of bilateral wounds was deep red colored with some excoriation present. R51 displayed facial grimaces during the procedure and stated, "hurry up that hurts and I can't breathe." The resident was then lowered to the recliner that had a pad that was soiled with body secretions and wrinkled sheet with the undressed wounds coming in contact with the soiled pad. LPN-A came back a short time later and applied dressings to the open wounds. The lack of barrier between the open ulcers and the soiled pad was an infection concern. Progress note dated 4/21/15 read, "Continued redness but has decreased, two areas noted that get bleedy. Resident had extra large stool and caused more bleeding from wounds d/t (do to) pressure. Cleansed area, applied zgard all over groin and buttock area, applied two [MEDICATION NAME] (non-adherent bandage) to areas that bled." R51's care plan that had a last review date of 11/12/14 indicated R51 had a physical functioning deficit related to self-care impairment, and mobility impairment; required a mechanical lift for transfers. The care plan directed staff to inspect skin with care and report reddened areas, rashes, and bruises to charge nurse. The care plan included, Pressure ulcer actual or at risk due to; assistance required in recliner mobility, [DIAGNOSES REDACTED]. The interventions to decrease the risk or prevent pressure ulcers included but was not limited to complete Braden scale per living center policy, conduct weekly skin inspection, do not massage over bony prominence, skin assessment to be completed per living center policy, and treatments as ordered. The current care plan did not contain any repositioning schedule. R51's Treatment Administration Record (TAR) for April 2015 included the order to perform weekly skin checks with vital signs every Wednesday evening. Documentation reflected the last skin check was performed on 4/1/15, however documentation of the skin evaluation was not found in the medical record. The order for skin checks and vital signs was discontinued on 4/7/15, a physician or nursing order to discontinue the skin checks was not found in the medical record. Documentation on the TAR indicated Z-Guard had not been applied as ordered by the physician seven times between 4/14/15 through 4/29/15. Documentation also reflected Gold Bond Powder had not been applied as ordered by the physician 4 times between 4/23/15 through 4/29/15. The Gold Bond powder was used to treat the redden scrotum rash. During an interview on 4/29/15, at 2:04 p.m. R51 explained he could not sleep in a bed related to breathing difficulties and had the bed removed so he had room for the chair. R51 stated he was unable to come to a standing position independently and depended on staff for mobility. During an interview on 4/29/15, at 2:36 p.m. registered nurse (RN)-C explained R51 was given education about pressure ulcers prevention and treatment when he refused to use the bed and R51 did not want the bed. Progress notes dated 4/17/15 at 2:22 p.m. staes bed was tried the week previously and lated only three days then removed. The bed was removed from the room to save space. RN-C stated R51 did not tolerate laying down. RN-C stated R51's usual routine was frequently up and down during the day. RN-C did not know when the last time R51 was repositioned today. During an interview on 4/29/15, at 3:04 p.m. director of nursing (DON) confirmed wound tracking for R51 had not been completed well, and explained a better system was needed. DON further said the resident's red perineal area should have been tracked on the blue sheets so we could make sure it was healing and not getting worse. Also if the wounds do get worse we would notify the physician and get new orders for a different treatment. On 4/29/15, at 4:01 p.m. a nursing progress note authored by RN-A, wounds were referred to as "excoriation" and "some bleeding" was noted. The progress note indicated the current treatment ordered was Z-guard ointment (not consistent with physician's orders [REDACTED]. During an interview on 4/29/15, at 4:32 p.m. RN-A confirmed she had contacted nurse practitioner (NP). During an interview on 4/29/15, at 5:08 p.m. DON indicated she had completed an assessment of the buttocks wounds. DON then stated, "I am staging those wounds at stage II pressure ulcers they are both located over the ischium where there would be pressure." DON stated a foam dressing had been applied and explained the Bourdreaux's Butt Paste was not appropriate for those wounds. DON further explained a bed would be put in R51's room so that he could be laid down to obtain an accurate wound assessment and an appropriate dressing would be applied. The DON further explained the NP would look at the wound on 4/30/15. The corresponding nursing progress note authored by the DON at 5:22 p.m. read, "Resident has a dark red bottom with an open area on lower right ischium and left lower ischium ...right wound measures 1.1 x .75 (cm) left wound measures 1.2 x .3 (cm). Areas are stage II from pressure and exacerbated by moisture association ..." During an interview on 4/29/15, at 5:40 p.m. LPN-A stated at 2:00 p.m. she had cleaned the area with normal saline and applied another [MEDICATION NAME]. LPN-A confirmed she did not document the wound findings nor treatment given. During an interview on 4/29/15, at 5:57 p.m. NA-B stated she had worked the day shift. NA-B stated she had provided morning cares around 7:00 a.m. for R51 (R51 was assigned to NA-B for the day shift for cares) that had included perineal care and a partial bed bath; during cares the dressings had come off the wounds. NA-B stated she stood R51 at noon and there had been blood on sheet that covered the chair and bottom looked raw. NA-B stated R51 reported his bottom hurt. NA explained a nurse applied dressings to the wounds after she had reported it to the nurse. NA-B stated she had not stood him or repositioned him between 7:00 a.m. and 12:00 p.m. the next time R51 stood up again was around noon and blood had been observed on the chair pad. During an interview on 5/1/15, at 8:24 a.m. DON confirmed the current care plan for R51 was initiated and revised on 11/12/2015 and no changes have been made since then. DON further explained the care plan would be now updated to reflect the two stage II pressure ulcers and skin condition. The DON stated R51 should be on repositioning program and included in the care plan. The DON also explained wound treatment concerns were identified in the past and they are currently working on them. R147 lacked timely repositioning (went over 6 hours) when assessed as having two pressure and lacked a comprehensive skin reassessment and development of interventions to promote healing: During an interview on 4/30/15, at 12:16 p.m. R147 stated he did not get out of bed because of weakness and pain. R147 stated he had sores on his bottom that had been there for a long time. R147 stated staff had not assisted or reminded him to reposition at all today. During an observation on 4/30/15, at 1:06 p.m. nursing assistant (NA)-E rolled R147 onto right side. Bottom revealed chafing of bilateral upper buttocks, and entire upper portion of the sacrum and upper gluteal's were red in color with areas that were slow to blanch. The right buttock showed 2 open wounds one covered by slough. During an observation and interview on 4/30/15, at 1:16 p.m. RN-B rolled R147 to right side. RN-B measured the wounds and stated the right upper buttock is 0.3 centimeters (cm) x (by) 0.7 cm. RN-B explained wound was a stage II pressure ulcer. RN-B then measured the wound below and reported the measurements of 0.4 x 0.4 cm. RN-B stated that this wound was an unstageable pressure ulcer because the base cannot be seen. RN-B then stated she would dress the wounds and notify the physician. R147 was admitted to the facility on hospice on 4/2/15 according to the facility admission record with [DIAGNOSES REDACTED]. R147's admission Minimum Data Set ((MDS) dated [DATE] indicated no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 14, required extensive assistance of two staff members for activities of daily living of bed mobility, transfers, dressing, and toileting. The MDS indicated R147 did not ambulate and bilateral lower extremities had range of motion impairments. The MDS further revealed a formal and clinical skin assessment were used, did not have pressure ulcers, and no topical applications of ointments were used. R147's hospital discharge summary dated 4/2/2015 indicated a gluteal skin alteration described as red [DIAGNOSES REDACTED] and the wound bed was mixed. The summary indicated the wound was covered with a [MEDICATION NAME] (type of bandage). R147's Admission Clinical Health Status assessment dated [DATE] indicated no skin alterations or problems. The Braden Scale for Predicting Pressure Ulcers score indicated moderate risk for pressure ulcers with a score of 14. The assessment further indicated R147 had generalized weakness. R147's Hospice admission Physical/Clinical Monitoring nursing documentation dated 4/2/15 indicated a non-surgical wound and read, "See detailed skin assessment: Not applicable" The documentation lacked description, location, and measurements of the wounds. The documentation also indicated a stage I pressure ulcer on buttocks, it was protected, and the area was not measured. R147's Hospice Physical Clinical Monitoring nursing documentation dated 4/7/15 again indicated the presence of a non-surgical wound and a detailed skin assessment was not applicable. The documentation reflected the stage I pressure ulcer on buttocks had healed. R147's Hospice Physical/Clinical Monitoring nursing documentation dated 4/21/15 indicated intact skin. However, the corresponding skilled nursing note dated 4/21/15 read, "pt has irritated skin on coccyx region. RN (registered nurse) applied barrier cream to this area and wrote order for staff to apply TID (three times per day) and prn (as needed)." According to the documentation on the TAR the treatment was not provided on four occasions between 4/21/15 and 4/28/15. R147's Comprehensive Skin Assessment that included Tissue Tolerance Observation (a skin assessment used to determine skin tolerance to pressure over bony prominences; used to determine repositioning schedule) dated 4/2/15 was not completed. Progress notes dated 4/5/15 read, "No new skin concerns" and indicated to treatments or dressings. Progress note dated 4/9/15 read, "... no apparent skin issues were noted at this time." These were the only two progress notes that mentioned R147 ' s skin conditions. R147's care plan dated 4/10/15 indicated R147 was non-weight bearing and required the use of a mechanical Hoyer lift for transfers. The care plan instructed staff to inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse. The care plan also included under pressure ulcer actual or risk due to; assistance required in bed mobility, Braden score of 18 or < (less), obesity, dx (diagnoses) [MEDICAL CONDITION], pain, use of [MEDICAL CONDITION] medications. R147's individualized goal was skin will remain intact. The care plan further instructed staff to complete Braden scale per living center policy and conduct weekly skin inspection and provide throughout skin care after each incontinent episode and apply barrier cream. However, the care plan lacked a turning and/or repositioning schedule based on a comprehensive skin assessment. During an interview on 4/30/15, at 1:31 p.m. NA-E stated she had checked on R147 a number of times however, did not reposition him since arriving to work at 7:00 a.m. During an interview on 5/1/15, at 8:24 a.m. DON confirmed the care plan had not been updated to include the two current open pressure ulcers nor revised to include interventions based on the comprehensive skin reassessment. The DON stated R51 should be on a consistent repositioning schedule. A facility policy Clinical Guideline: Skin Integrity last reviewed 2/25/10 read All resident will be assessed/observed for risk of skin breakdown within 24 hours of admission, quarterly and as necessitated by change in condition. Living Center develops a routine to review residents with wounds or at risk on a weekly basis. Director of nursing services (DNS) will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. Assessment/observation is to be completed within the first twenty-four hours of admission/quarterly/significant change of condition using the Clinical Health Status Tool, If identified risk present the interventions will be documented in the immediate plan of care or comprehensive care plan. To demonstrate satisfactory compliance with guideline wound evaluation flow sheet is being used, DNS or designee evaluates wounds on a weekly basis. Residents will be observed by certified nursing assistant (CAN) daily for reddened/open areas. Changes will be reported to the licensed nurse and documented, initiate positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. The nursing order for weekly observation will be entered on all resident's and print out on the Treatment Administration Record and licensed nurse to document weekly on all wounds using the wound evaluation glow sheet. R203 was admitted to the facility on [DATE] with three current pressure ulcers and the facility had not completed a temporary care plan to include treatments and services and provide these services on a consistent basis to promote healing and prevent further ulcers from developing. R203 was asked by surveyor on 4/27/15 at 3:03 p.m. if they had any medical concerns and R203 stated she had open wounds. I just got a cast today located on left lower extremity and that nobody would wrap my leg before the cast. Ulcerations on my bottom are supposed to be treated daily. " Treated one time since a week ago Friday when I came in on 4/17. One dressing change since then. The hospital assured me the treatments would continue but they have not. I know my bottom is a lot sorer. I had terrible diarrhea, it takes 45 minutes to get cleaned up." R203 was observed sitting in her wheelchair, frequently shifting positions while being interviewed. On 4/28/15 at 9:00 a.m. the director of nursing (DON) was unable to find treatment sheets for dressing changes, but would continue to look. On 4/29/15 at 3:12 p.m. RN-A stated, the treatment record does not list wound dressing changes. RN-A provided a copy of the treatment record which indicated no charting exists for wounds. On 4/17/2015 at 3:25 p.m. R203 was admitted to the facility with admission [DIAGNOSES REDACTED]. Hospital Dismissal Summary dated 4/17/15 indicates the following skin alterations: 1. Location: left ankle Type: ulcer Treatment: cast 2. Location: left lower extremity Type: ulcer Treatment: cast 3. Location: Anal Type: ulcer Treatment: Nugauze (packing) soaked & cleaned with normal saline 4. Location: Anal Type: ulcer Treatment: Xeroform ([MEDICATION NAME] dressing gauze) cleansed with normal saline covered with Mepilite (self-adhesive absorbent dressing). 5. Location: right lower extremity Type: puncture Treatment: Kerlix (compress applied to a wound to promote healing) Wound Evaluation Flow Sheet dated 4/17/15 completed by RN-B lists the following areas assessed: 1. Abscess of coccyx 1 cm length x 0.2 cm width. Stage 1 pressure ulcer. Current treatment, cleanse cover with Mepiborder (self-adhesive absorbent dressing). No interventions listed. 2. Abscess coccyx 2 cm length x 1 cm width x .3 cm depth. No treatment listed. Current preventative interventions include wheelchair cushion and turn reposition. No time frame listed for repositioning. No ulcer stage/type listed. 3. Abscess coccyx 2 cm length x 1 cm width. Current treatment mepiborder. Current preventative interventions wheelchair cushion, turn and reposition. No times frames listed for repositioning. No ulcer stage/type listed. Wound Evaluation Flow Sheet dated 4/23/15 completed by RN-B lists the following areas assessed: 1. Abscess of coccyx 1 cm length x 0.2 cm width. Current treatment, cleanse cover with Mepiborder (self-adhesive absorbent dressing). No interventions listed. 2. Abscess coccyx 1 cm length x 0.3 cm width x 0.2 cm depth. No treatment listed. Current preventative interventions include wheelchair cushion and turn reposition. No time frame listed for repositioning. 3. Abscess coccyx 1.5 cm length x 0.7 cm width. Current treatment mepiborder. Current preventative interventions wheelchair cushion, turn and reposition. No times frames listed for repositioning. Clinical Health Status dated 4/17/15 3:25 p.m. completed by RN-B section B, skin conditions, indicated three skin concern areas; one a coccyx abscess and two perianal abscesses along with a note stating "others unable to visualize." Also included was Braden Scale for Predicting Pressure Sore Risk with a total score 16 indicating at risk for developing pressure ulcers. Care plan dated initiated 4/17/2015 includes a focus of "pressure ulcer actual or at risk due to: pressure ulcer present under cast. Has three open areas on coccyx area." No information related to the management of the current pressure ulcers to promote healing or inventions to minimize the risk of development of new pressure ulcers was found on the temporary care plan. No comprehensive assessments provided that included clinical, physical, and environmental risk factors. Clinical Guideline: Skin Integrity dated 2/25/10 read, " page 1 Documentation and Care Interventions for Skin Integrity: If identified risk present the interventions will be documented in the immediate plan of care or comprehensive care plan, initiate positioning schedule to meet the individual resident needs and minimize concentrated pressure to skin, nursing notifies dietary of any newly admitted or acquired pressure ulcers, nutritional assessment determines need for nutritional interventions, documentation completed by registered dietician occurs on initial notification of a new pressure ulcer." Treatment protocol on page 3 provides guidelines to care for stage 2, 3, 4, and unstageable ulcers; does not give the guidelines how to care for stage 1 pressure ulcers. Skin and Wound Care Guidelines, undated, was provided in addition to the clinical guideline. According to the skin and wound care guidelines "Reddened Area stage 1 treatment options include evaluate pressure reduction methods and for moisture cleanse after each incontinence episode with cleanser or wipes. Apply Dimethicone Barrier or Paste PRN."

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for pain management for 1 of 3 residents (R15) in the sample reviewed for chronic pain. This resulted in actual harm to the resident. Additionally, The facility failed to comprehensively assess skin bruises for 2 of 3 residents (R49 and R6) in the sample who had skin conditions that were not pressure related. Findings include: R15 had ongoing chronic pain/spasms without consistent monitoring of the effectiveness of the pain medication, demonstrated an increase in pain intensity and fluctuating frequency of as needed (PRN) pain medication use for the past five months without a pain reassessment to determine optimal pain control for R15. R15 was admitted to the facility 4/5/10, with [DIAGNOSES REDACTED]. R15 had a history of [REDACTED]. During observations on 2/27/12, at 4:27 p.m. R15 was lying in bed on her back holding the trapeze with her right hand and grimacing at times. R15 verbalized pain mostly in left leg with no relief. During an interview at this time R15 said that she was having left leg spasms that occurred about every 15 minutes. R15 continued to say that the spasms have been occurring for months but have gotten worse lately and the pain medication did not always relieve the pain. During observation on 2/29/12 at 11:54 a.m. nursing assistant (NA)-B and NA-E were going to get R15 up for lunch and R15 requested to stay in bed due to having the diarrhea. During an interview at this time R15 indicated she was having pain and rated it at a 10/10. NA-B said that she would let licensed practical nurse (LPN)-B know about the pain. As NA-A lifted R15 in bed R15 began to crying and say " ouch " 6 times while being repositioned. R15 continued to cry out " ouch, oh my god " . While NA-B and NA-E provided perineal care, R15 said " ouch " " oh my god " several times. On interview R15 complained of her leg hurting. NA-E then told R15 that the nurse would be bringing in her " oxy " ([MEDICATION NAME]) a pain medication. During an interview with NA-B following R15 ' s cares at 12:11 p.m. it was learned that R15 typically complained of pain during cares. During observation on 3/1/12 at 7:18 a.m., NA-E entered room to get resident ready for breakfast. NA-E informed R15 that she was going to remove the gown and R15 said " Ouch " while the gown was removed. NA-E asked what was wrong and R15 stated my leg hurts and rated the pain at " 7 " on scale of 0-10. NA-E asked if R15 had any pain medication and R15 said they had given her some at 5 a.m., NA-E then said that it must have not kicked in yet. NA-E continued to complete cares for R15. R15 said " ouch, that hurts " , several times with movement. During an interview after R15 ' s cares, NA-E said that R15 always felt " crampy " (having feeling of pain) and R15 preferred to stay in bed a lot and frequently refused to be repositioned. A quarterly Minimum Data Set (MDS) (a resident assessment and care screening tool) was completed 12/8/11. The MDS indicated that R15 was able to clearly express ideas and wants. A brief interview for mental status (BIMS) (cognitive assessment) was completed and R15 scored 11 out of 15 which indicated moderate impairment in mental status. The MDS also indicated R15 had almost constant pain that made it hard to sleep at night and limited day-to-day activities. R15 had rated the pain as a 10 however the intensity section of the pain section had not been completed on this MDS. R15 ' s care plan date initiated 1/11/11 and revised on 12/9/11, indicated that R15 had identified pain management needs and monitoring needs related to generalized deconditioning (decline), bilateral knee contractures (which R15 was admitted with) due to mild Parkinson ' s disease, [MEDICAL CONDITION] disorder and left ulnar [MEDICAL CONDITION] with a goal to maintain adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain, distress or verbalizing satisfaction with level of comfort. There had been no new pain interventions added to the care plan since 1/11/11. Review of R15 ' s current physician orders [REDACTED]. The quarterly clinical health status form dated 9/23/11 completed by registered nurse (RN) clinical manager-B indicated R15 had constant, burning, aching, throbbing pain in legs and back with a pain rating of " 7 " on a scale of 1-10. R15 ' s acceptable level of pain was 6. The documentation indicated that the pain impacted quality of life, sleep, functioning and mood. The clinical health status form identified " current pain treatment plan: Effective " . The quarterly clinical health status form dated 12/9/11 at 8:00 a.m. completed by registered nurse (RN) -B indicated R15 had constant, sharp pain in left hip and thigh with a pain rating of " 6 " on a scale of 1-10. R15 ' s acceptable level of pain was " 4 " on scale of 0-10. The documentation indicated that the pain impacted quality of life by limiting activities. The clinical health status form identified " current pain treatment plan: Effective " . During review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] July 2011, R15 had received 7 as needed (PRN) doses of [MEDICATION NAME] 5 mg for pain rating ranging from 8 to 10. August 2011, R15 had received 13 as needed (PRN) doses of [MEDICATION NAME] 5 mg for pain rating ranging from 6 to 10. September 2011, R15 had received 3 as needed (PRN) doses of [MEDICATION NAME] 5 mg for pain rating ranging from 8 to 10. October 2011, R15 had received 13 PRN doses of [MEDICATION NAME] 5 mg for pain rating ranging from 7 to 10. November 2011 it revealed 41 PRN doses of [MEDICATION NAME] 5 mg was given for pain ratings ranging from 6-10. December 2011 revealed 38 PRN doses of [MEDICATION NAME] 5 mg was given for pain ratings ranging from 6-10. January 2012 revealed 25 PRN doses of [MEDICATION NAME] 5 mg was given for pain ratings ranging from 6-10. For the month of February 2012 it revealed 17 PRN doses of [MEDICATION NAME] 5 mg had been given for pain rating ranging from 7-10. Upon review of the effectiveness of the PRN pain medication from July 2011 to March 1, 2012, it was noted that numerous doses of pain medication had not been evaluated for effectiveness. A review of progress notes indicated the following concerns with pain as follows: On 10/20/11 at 9:17 p.m., written by licensed practical nurse (LPN)-A indicated that resident R15 was alert, orientated, and able to communicate her needs to staff ...Resident complained of pain of 8 out of 10. R15 received a scheduled tylenol and [MEDICATION NAME]. However, there had been no follow up documentation on the effectiveness of these pain medications. On 11/21/11 at 14:51 (2:51 p.m.), written by registered nurse (RN)-D said that R15 received prn [MEDICATION NAME] 5 mg at 10:00 a.m. for pain in legs which had been rated 10 out of 10 (worst pain possible.) Follow up rating was 7 out of 10. On 11/24/11 at 11:39 p.m. written by RN-E said that the resident continued to complain about pain affecting both legs, pain rating at a 9 to 10. This was two hours after the resident received as needed [MEDICATION NAME]. No other interventions or follow up was noted following the complaint of severe pain not being relieved. On 12/1/11 at 10:26 p.m. written by LPN-A said that R15 offered complaints of pan in hip and legs this evening at 9:30 p.m. and received an as needed [MEDICATION NAME] 5 mg. No follow up documentation on the effectiveness of pain medication was documented. On 2/23/12 at 2:21 p.m. written by LPN-B revealed resident was alert and oriented, resident refused shower this shift due to pain and resident rated pain at an 8. LPN-B administered prn [MEDICATION NAME] and it had provided little relief. During an interview on 3/1/12 at 7:11 a.m., RN-C, who worked the night shift, indicated that the previous shift had given R15 pain medication around 9 p.m. the evening before and then RN-C usually gives another as needed pain dose around 4:00 a.m. RN-C stated she had not noticed any changes in pain, just that the pain increased with movement. Staff would offer reassurance, deep breathing and repositioning. R15 usually rated her pain as 8-10. RN-C stated she would go back in R15 ' s room to check on the resident about an hour after prn pain medication was given and R15 was usually sleeping. RN-C said that R15 was repositioned every 2 hours during the night shift and usually complained of pain during repositioning. During an interview on 3/1/12 at 7:55 a.m., registered nurse clinical manger (RNCM)-A who had worked the day shift, verified that R15 had chronic pain and received pain medication. RNCM-A verified that R15 had an order for [REDACTED]. RNCM-A stated that the licensed nurses would let RNCM-A know of any changes in R15 ' s pain and prn medication frequency and then she would let the nurse practitioner know. The nurse practitioner would than look for frequently used prn medications and if the pain was controlled with the scheduled medications than may need to adjust times and doses. When asked about the increase in PRN [MEDICATION NAME] medication use from October 2011 to current date (March 1, 2012), the RNCM-A indicated that she was unaware of the frequency of use. RNCM-A felt that R15 ' s pain was managed as well as it can be managed and that R15 came to the facility with the contractures and chronic pain. On 3/1/12 at 8:42 a.m., a family member (F1) was interviewed and confirmed R15 had experienced a lot of pain and there were times where the pain did go away. F1 indicated that mornings were rough for R15. F1 indicated that pain management had been discussed during quarterly care conferences and it was said that when R15 begins to feel pain she was to put on the call light. F1 indicated that R15 had rated the pain from 8-10. F1 indicated that they were not aware of any discussion on other options available for pain management for the past several months. F1 discussed bringing up acupuncture as an option for pain relief to the facility and felt it may be a good idea that R15 be reevaluated for pain control. On 3/1/12 at 1:23 p.m., R15 ' s primary medical doctor (MD) was contacted and verified that R15 had a [DIAGNOSES REDACTED]. The MD said that she and the nurse practitioner discussed the resident ' s current health conditions, medications R15 currently receives and possible side effects. They had also discussed the possible use of an anti-Parkinson ' s medication to help with mobility. When asked about the pain management for R15, MD indicated that she would expect the facility staff to update her if there was a change in R15 ' s pain so further evaluation could be done. On 3/1/12 at 1:56 p.m., the Director of Nursing (DON) was interviewed and indicated that R15 gets very nervous and anticipatory of pain any time staff want to move her. The DON indicated that staff administers pain medication before moving R15. When questioned about R15 ' s ongoing use of prn pain medication and lack of monitoring of medication effectiveness since October 2011, the DON said that she would expect the staff to inform the NP to assess the resident ' s pain management regimen. The DON indicated the staff needed to complete a comprehensive pain assessment on R15 as soon as possible and have the NP reviews it to evaluate the effectiveness of the pain regimen. During a telephone interview on 3/2/12 at 8 " 18 a.m., the NP responsible for R15 ' s care, indicated that R15 would never fully get rid of pain and spasms, that she was aware the spasms were worse in the morning and when applying braces on both legs, and indicated the spasms/pain got better throughout the day. The NP indicated R15 received [MEDICATION NAME] before cares were provided and before putting on the leg braces. NP indicated R15 had been seen by her on 1/30/12 and R15 ' s pain management was evaluated and seemed to be the best at this time. NP indicated that there had been no nursing concerns expressed to her in regards to R15 ' s pain management. NP verified she had not been informed by nursing staff of the lack of pain medication effectiveness from October 2011 through February 2012. NP indicated that she evaluated the underlying condition/s for R15 ' s medication regimen especially how they affect the heart and kidney function. NP verified that physical therapy interventions had been attempted over the past year for R15. R49 had bruising that was not identified or monitored. R49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/27/12 at 7:19 p.m., R49 had a bruise on outer aspect of left arm above the elbow. R49 was unaware of the bruise and how it had happened. Review of the resident's record did not show any documentation of the bruised area on the left arm. R49 ' s care plan with date initiated 10/25/10 was reviewed and it indicated R49 was at risk for complications related to anticoagulant medication secondary to [DIAGNOSES REDACTED]. Interventions included observe for signs and symptoms of bleeding: tarry stools, blood in urine, bruising, petechiae. On 3/1/12 at 8:36 a.m., registered nurse (RN) clinical manager-B indicated she was unaware of a bruise and verified that there was no documentation regarding a bruise on his arm and that she would go and assess the area at this time. On 3/1/12 at 9:13 a.m., RN-B indicated that when staff identified bruises it was to be reported to the nurse manager and the executive director. Staff perform an investigation, measure the area, document and investigate further to make sure resident was safe. Staff performs a skin inspection weekly and nursing assistants are to let the nurses know if bruises are noted during cares. On 3/1/12 at 1:49 p.m., director of nursing (DON) confirmed the clinical manager would take measurements, talk with resident to ensure no abuse and investigate what happened when a bruise had been identified. R6 lacked a skin assessment and monitoring of a bruise. R6 was observed at 4:56 p.m., on 2/27/2012, to have bruising on the back of both hands, forearms and finger. Incident reports were reviewed from 12-11-11 to 2-11-12 and no reports identified bruises on the resident. Primary Care Internal Med Nursing Home Limited Exam completed 7/12/11 by the certified nurse practitioner (CNP) indicated R6 had been experiencing an increase in bruising of forearms and hands. Review of quarterly Minimum Data Set ((MDS) dated [DATE] revealed moderate cognitive impairment, extensive assist with bed mobility, transfers, walking, dressing, toilet use, personal hygiene and required supervision with locomotion by wheelchair. MDS did not identify concern with bruising. Care plan dated 1/10/12 did not identify risk for bruising with interventions to decrease risk for bruising. During an interview at 11:22 a.m., on 2/29/12, clinical manager (CM)-B stated R6 does always pay attention to where going and gets bruises from hitting hands and arms on things when moving around. CM-B stated there are no incident reports or nursing notes related to bruising on back of R6 ' s hands and forearms. CM-B indicated the bruising should have been assessed when found and documented. During an interview at 2:40 p.m., on 2/29/12, CM-B stated that she and the CNP believed the bruising was chronic and related to kidney disease.