Every finding on record at Salem Rehab Center

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to follow proper thawing practices when defrosting clams, to ensure that food was dated in the main kitchen and in one of two unit kitchenette refrigerators. Findings include: Review of the facility's policy titled Food from Outside - Safety, revised January 2023, indicated, but was not limited to, the following:It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to resident by family and other visitors. Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy.Foods requiring refrigeration will be received by the facility designee (activity department, food and nutrition department, charge nurse, etc.) for proper and immediate storage including labeling and dating. Review of the undated facility policy titled Thawing Foods, indicated, but was not limited to, the following:Thawing foods under cool running potable water (This process is not recommended and should only be used in an emergency and if you cook food immediately).a. Clean and sanitize the sink that food should be thawed in.b. Food items should be completely submerged under running water at a temperature of 70 degrees Fahrenheit or lower.c. Cold water must be running continuously throughout the thawing process, (avoid splashing on other food items and food contact surfaces) and they should never be thawed in the 3-compartment or hand sink. Review of the facility's policy titled Labeling and dating foods (Date Marking) dated 2020, indicated, but was not limited to, the following:Expiration dates on commercially prepared, dry storage food items will be followed. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in - first out method rotation.Once opened, all ready to eat, potentially hazardous food will be re-dated with use by date according to current safe food storage guidelines or by the manufacturers expiration date. Prepared food or opened food items should be discarded when:o The food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days.o The food item is leftover for more than 72 hours. o The food item is older than the expiration date. On 9/3/25 at 7:02 A.M. the surveyor made the following observations during the initial walkthrough of the main kitchen:An opened bag of shredded cabbage with significant signs of decomposition including color and textural changes with a best if used by date of 8/27/25. A pan containing hot dogs in the walk-in refrigerator, there were globules consistent with the appearance of fat coating the hot dogs indicating the hot dogs had already been heated; the pan was labeled with two dates, 8/2 and 8/5.There was an undated package of sliced deli turkey, the package was opened and wrapped in plastic in the walk-in refrigerator.There was a container of thickened juice with a best if used by date of March 19, 2025, in the dry-storage area. On 9/3/25 at 7:17 A.M. the surveyor made the following observations in the [NAME] unit kitchenette refrigerator:A brown paper bag labeled with a Resident name and room number containing two bags of cookies and food wrapped in aluminum foil. There was no date on the inside or outside of the brown paper bag, either bags of cookies or tinfoil.A container of food labeled with a Resident name and dated 8/30.An undated and unlabeled container of food consistent in appearance with a creamy soup. On 9/4/25 at 11:00 A.M. the surveyor observed four bags of clams in a pan submerged in water at the bottom of a two-bay sink; there was no running water. On 9/4/25 at 11:25 A.M. the surveyor observed that the clams were still submerged in water, that the water was luke warm to the touch, that there was no water running, that the clams were completely defrosted and luke warm to the touch. During a continuous observation beginning on 9/4/25 at 11:25 A.M. the surveyor observed that the clams remained submerged in luke warm water without water running until 11:55 A.M. when the surveyor called over the Food Service Director (FSD). During interviews on 9/3/25 at 9:31 A.M. and 9/4/25 at 11:55 A.M. the FSD said that all food should be labeled and dated, and that the kitchen staff conduct daily rounds during which they would discard anything unlabeled, undated, or beyond the printed date. The FSD said that kitchen staff conduct daily rounds on the kitchenettes and would discard any food that was unlabeled or that was over three days old. The FSD said that when defrosting food the food should be placed under continuously running cold water for a few minutes, and that someone must have shut the water off in regard to the clams. The FSD said that the clams feel warm to touch and should be discarded as they are no longer safe to eat. During an interview on 9/3/25 at 7:22 Nurse #2 said food in the kitchenette refrigerator must be labeled, dated, and discarded after 72 hours or if undated. Nurse #2 inspected the inside and outside of the brown paper bag, and said the bag was not labeled but should have been. Nurse #2 said the brown paper bag containing food was brought in yesterday and that she would label the bag.

Based on observations, interviews, and record review, the facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team for one Resident (#71) out of a total sample of 19 residents. Specifically, for Resident #71, the facility failed to revise the comprehensive care plan relating to the need for a geri chair (a sturdy, padded chair on wheels that can recline which is designed to be more supportive and comfortable than a standard wheelchair, especially for people who have limited mobility and spend a lot of time sitting) for comfort and skin integrity concerns upon the care plan review following the completion of the last quarterly assessment.Findings include:Review of the facility policy titled Care Plans, revised January 2023, indicated:-PROCEDURE: Interdisciplinary team conferences shall be held for each resident at 90-day intervals and more often if needed. The Interdisciplinary team shall: Revise the plan of care, treatment, and services. Care plans shall be updated at the time of the conference or on the shift immediately following the conference.Resident #71 was admitted to the facility in August 2023 with diagnoses including diabetes and hypertension.Review of the most recent Minimum Data Set (MDS) assessment, dated 4/17/25, indicated Resident #71 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of plan of care related to potential for alteration in skin integrity, revised 4/26/25, indicated:-Geri chair while up to assist with comfort and positioning. -Encourage resident to limit time up in geri chair to promote healthy skin integrity and promote wound healing. On 9/3/25 at 7:50 A.M., the surveyor observed Resident #71 in bed. Resident #71 said he/she spends all day in his/her wheelchair, and it hurts his/her backside. Resident #71 said the standard wheelchair that was at the foot of his/her bed was the wheelchair he/she used.On 9/3/25 at 10:45 A.M., the surveyor observed Resident #71 sitting in a standard wheelchair. Resident #71 said his/her backside hurts so bad and this wheelchair is so uncomfortable. Resident #71 further said he/she used to have a reclining, padded wheelchair a long time ago and that it was very comfortable. Resident #71 said he/she would love to have one like that again.On 9/4/25 at 8:25 A.M., the surveyor observed Resident #71 sitting in a standard wheelchair.On 9/5/25 at 8:17 A.M., the surveyor observed Resident #71 sitting in a standard wheelchair. Resident #71 said his/her backside hurt so bad all day yesterday from this standard wheelchair. Resident #71 said he/she just got into this wheelchair this morning, so he/she is comfortable now, but after a while he/she knows it will hurt again.During an interview on 9/5/25 at 9:29 A.M., Certified Nurse Assistant (CNA) #2 said Resident #71 used to have a reclining geri chair but was not sure why he/she does not anymore. CNA #2 said she was unaware Resident #71's current standard wheelchair was uncomfortable and that he/she has no open wounds on his/her backside.During an interview on 9/5/25 at 10:01 A.M., Unit Manager #1 and Nurse #1 said all interventions on Resident #71's comprehensive care plan should be implemented or the care plan should be revised if the intervention is no longer appropriate. Unit Manager #1 and Nurse #1 said they were unaware that Resident #71's care plan indicated an intervention for geri chair while up to assist with comfort and positioning or to encourage resident to limit time up in geri chair to promote healthy skin integrity and promote wound healing. Unit Manager #1 and Nurse #1 said Resident #71 no longer has any wounds and has had a standard wheelchair since they had known him/her. Unit Manager #1 and Nurse #1 said at a minimum the care plan should have been updated during the last care plan meeting. Unit Manager #1 and Nurse #1 said they were unaware of Resident #71's current standard wheelchair being uncomfortable. Unit Manager #1 and Nurse #1 said the Director of Rehab (DOR) would have more information about Resident #71's wheelchair because the rehab department is responsible for determining which wheelchair Resident #71 should have.During an interview on 9/5/25 at 10:20 A.M., the Director of Rehab (DOR) said Resident #71 used to have a geri chair but was advanced to a standard wheelchair after his/her pressure wound healed at the beginning of the year (2025). The DOR was unsure of the exact date the standard wheelchair was implemented at the time of the interview but stated he would get the therapy note indicating the date. The DOR said he was unaware nursing had not updated the care plan to reflect that Resident #71 had a standard wheelchair, but they should have since he/she has not had it since shortly after his/her sacral pressure ulcer healed.Review of Resident #71's consultant wound physician progress note, dated 2/5/25, indicated his/her stage four sacral pressure ulcer was healed.Review of Resident #71's therapy progress note, dated 2/24/25, signed by the DOR, indicated:-Pt (patient) to trial a wc (wheelchair) next therapy session.Review of Resident #71's medical record indicated the last quarterly Minimum Data Set (MDS) assessment was dated 4/17/25.Review of Resident #71's social services progress note, dated 4/30/25, indicated a care plan meeting was held and that the care plans were reviewed and interventions remained appropriate.During an interview on 9/5/25 at 11:53 A.M., the Director of Nursing (DON) said care plans should be reviewed and revised to ensure interventions are current and appropriate after every quarterly assessment. The DON said Resident #71's care plan should have been revised because he/she has not required the geri chair in quite some time but was not.

Based on observations, interviews, and record review, the facility failed to ensure that staff accommodated food preferences for one Resident (#66), out of a total sample of 19 residents. Specifically, the facility failed to honor Resident #66's preferences and served the Resident fortified cream of wheat, which he/she disliked, instead of fortified super oatmeal as he/she requested.Findings include:Review of the facility policy titled Meal Rounds/Visits, revised January 2023, indicated:-POLICY: To determine resident's likes/dislikes and overall acceptance of meal service.Resident #66 was admitted to the facility in August 2021 with diagnoses including moderate protein calorie malnutrition.Review of the most recent Minimum Data Set (MDS) assessment, dated 6/5/25, indicated Resident #66 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Review of Resident #66's dietary progress note, dated 9/2/25, indicated:-Honor food preferences. On 9/3/25 at 8:34 A.M., the surveyor observed Resident #66 with a bowl of fortified cream of wheat on his/her breakfast tray. Resident #66 said he/she ordered a new oatmeal because the facility always sends cream of wheat, and he/she hates it. There was a meal slip on his/her meal tray that indicated 2 super oatmeal only, dislikes cream of wheat.On 9/4/25 at 8:17 A.M., the surveyor observed staff deliver Resident #66's meal tray without any discussion regarding cream of wheat or oatmeal. The surveyor observed Resident #66 in bed with two bowls of fortified cream of wheat on his/her breakfast tray untouched. Resident #66 said he/she will not eat them because he/she hates the cream of wheat. Resident #66 said he/she won't ask for the oatmeal again because he/she has told them so many times before and staff don't care. Resident #66 further said he/she is sick of having to ask for the oatmeal and then wait for it to come, if it even does come. During an interview on 9/5/25 at 9:39 A.M., Certified Nurse Assistant (CNA) #1 said she was unaware Resident #66 disliked cream of wheat. CNA #1 said any disliked food items should always be removed from the meal tray because the Resident's food preferences should always be honored.During an interview on 9/5/25 at 9:51 A.M., Unit Manager #1 said the Resident's food preferences should always be honored. Unit Manager #1 said any disliked food items should be removed from the tray unless Resident #66 said he/she wanted the food item.During a follow-up interview on 9/5/25 at 10:24 A.M., Unit Manager #1 said Resident #66 needed to have the type of hot cereal that was on his/her tray because it was fortified super cereal. Unit Manager #1 said she always gives the Resident the type of fortified super cereal that was on Resident #66's tray because it's the only type they have in the facility. Unit Manager #1 was unaware if there was more than one type of super cereal in the facility.During an interview on 9/5/25 at 10:25 A.M., the Food Service Director (FSD) said the facility has two types of super cereals, one is a fortified cream of wheat, and the other is fortified oatmeal called super oatmeal. The FSD said super oatmeal was available on all dates of the survey. The FSD said Resident #66 should have received super oatmeal and not the fortified cream of wheat because the Resident's food preferences should always be honored.During an interview on 9/5/25 at 11:53 A.M., the Director of Nursing (DON) said the Resident's food preferences should always be honored. The DON said if the facility had two types of super cereal than Resident #66 should have received the super oatmeal instead of the fortified cream of wheat.

Based on observation, interview, and record review, the facility failed to ensure that one Resident (#15) was not left with pills to self-administer without first determining if it was safe, out of a total sample of 19 residents. Specifically, staff left pills at Resident #15's bedside for self-administration without completing a self-administration of medication assessment.Findings include:Review of the facility policy titled Self-Administration of Medications, revised January 2023, indicated:-The resident may request to keep medication at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions.-The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident upon request. -In addition to a general evaluation of decision-making capacity, the nurse will perform a more specific skill assessment, this can be accomplished on paper or through the EHR (electronic health record) system.-If this assessment determines that the resident cannot safely administer medications, all medications should be administered by the nurse and stored medication in the med cart. [sic].Resident #15 was admitted to the facility in June 2020 with diagnoses including hypertension and diabetes.Review of the most recent Minimum Data Set (MDS) assessment, dated 7/31/25, indicated Resident #15 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. On 9/3/25 at 7:59 A.M., the surveyor observed Resident #15 in bed with two round brown pills in a medication cup on his/her bedside table. Resident #15 said please hand those to me, the nurse left them last night because I asked to take them later.On 9/3/25 at 8:02 A.M., Unit Manager #1 came into the Resident's room at the surveyor's request. Resident #15 asked Unit Manager #1 if he/she could take the two round brown pills now, because he/she forgot to take them last night. Unit Manager #1 told Resident #15 that he/she could not take these pills because they should have been taken last night and then removed them from the room. Unit Manager #1 further said pills should never have been left at bedside if the Resident was not ready to take them.During a follow-up interview on 9/4/25 at 9:20 A.M., Unit Manager #1 said a self-administration of medication assessment should be completed in the electronic medical record before any medications are left for self-administration. Unit Manager said Resident #15 never had a self-administration of medication assessment completed.Review of Resident #15's medical record failed to indicate a self-administration of medication assessment was completed since his/her admission. During an interview on 9/4/25 at 1:06 P.M., the Director of Nursing (DON) said the two round brown pills should not have been left unattended with Resident #15. The DON further said if pills are left unattended then a self-administration of medication assessment should have been completed but was not.

Based on observation, record review and interviews, the facility failed to ensure food is stored, prepared and distributed in accordance with professional standards in food safety and sanitation to prevent the spread of pathogens, which could result in foodborne illness for the residents. Specifically, 1. food stored in the dry storage area, and walk-in refrigerator were not labeled and dated, and 2. Staff failed to ensure safe food handling during the lunch meal distribution. Findings include: Review of the facility policy titled, Food Storage, not dated indicated Food should be stored and prepared in a clean safe sanitary manner that complies with state and federal guidelines. Purpose: to minimize contamination and bacteria. Review of the facility policy titled, Handling, Serving, and Transporting Foods, not dated indicated: Foods should be handled, served and transported at the proper holding temperatures. Food should be presented attractively, under sanitary conditions, and according to the facility menu. Purpose: to prepare, present, and serve plates safely and attractively. Procedure: 1. Use properly cleaned and sanitized utensils, 2. Use proper utensils according to the menu and standardized recipe. 3. There must be a separate utensil for every item on the tray line. 4. Practice good personal hygiene. 1. During the observation of the kitchen on 4/15/25 at 7:07 A.M., the following was observed: - Dry storage: a large bag of rice was left open, not secure, and was not dated. [NAME] #2 said all items are to be secure and dated when opened. - Walk-in refrigerator: a tray with multiple single serving bowls containing green salad were not dated. The Food Service Director (FSD) said salad is served daily and should be labeled and dated. 2. During observation of the lunch meal distribution tray line on 4/16/25 starting at 11:35 A.M., the surveyor made the following observations: Cook #1 dropped a plate and got a cut on her hand which had a small amount of blood present. [NAME] #1 stopped plating, went and got a Band-Aid, covered the cut and proceeded to put on gloves, when the Food Service Director intervened and asked [NAME] #1 to wash her hands before placing on the gloves. After [NAME] #1 performed hand hygiene and donned gloves on both hands the following was observed: Cook #1 reached into a plastic bag containing hot dog buns and removed the hot dog buns with her gloved hands and plated them on individual plates multiple times. [NAME] #1 did not use utensils to plate the buns. With the same gloved hands [NAME] #1 touched the steam oven door handles and removed a grilled cheese sandwich, then with contaminated gloves continued to reach in the hot dog bun package and removed and plated the buns on multiple individual plates. [NAME] #1 was handed by a dietary aid a dietary paper slip, which she touched with her gloved hands, read it then returned it to the dietary aid. [NAME] #1 between food trucks leaned her gloved hands on the shelf in front and then rested her gloved hands on her back, directly in contact with her clothing. [NAME] #1 resumed plating hot dog buns directly with her contaminated gloved hands. [NAME] #1 touched the utensils for other food including the ladle for macaroni salad. [NAME] #1 touched and removed a hot dog bun with ground hot dog from one plate on to another plate. [NAME] #1 picked up the empty hot dog bun bags, walked from the tray line and threw them into an open trash container, then returned to the tray line. [NAME] #1 with the same gloved hands, touched both handles of the oven and removed a grilled cheese sandwich, removed the foil and plated it directly. [NAME] #1 then left the tray line area and went to the bakery rack and removed a hamburger bun package with the same gloved hands. [NAME] #1 opened the plastic bag of hamburger buns removed the bun, then touched a stack of cheese slices, removed a cheese slice placed it on a hamburger and put it in the streamer. Cook #1 then returned to plating, then returned to the steamer and removed the hamburger bun and placed it directly on a plate. [NAME] #1 continued to touch the sliced cheese, hamburger bun, steam oven door with the same gloved hands a few times during the observation. After touching the ladle for the macaroni salad, the ladle fell into the pan and the handle of the ladle was in direct contact with the macaroni salad. [NAME] #1 continued to remove hot dog buns with her gloved hands and placing them on individual plates. [NAME] #1 removed the ladle from the macaroni salad and used the contaminated ladle to plate the macaroni salad multiple times. At 12:03 P.M., [NAME] #1 removed her gloves, performed hand washing then donned new gloves and proceeded to touch hot dog buns directly to plate. Then [NAME] #1 touched the oven door, removed a grilled cheese, then proceeded to touch the grill cheese directly and resumed to touch hot dog buns directly. The observation ended at 12:13 P.M. During an interview on 4/16/25 at 1:43 P.M., the FSD said [NAME] #1 left and was not available for an interview. The FSD said all utensils were clean before the tray line and that [NAME] #1 should not have touched the food items directly. The FSD said [NAME] #1 should not have touched food directly after touching her clothing, surfaces and the oven doors. The FSD said the dietary tray ticket is handled multiple times by staff and should not have been touched by the Cook. The FSD said the handle of the ladle used for the macaroni salad should not have been in contact with the food. The FSD said the observations made were not what was expected for proper food handling.

Based on record review and interviews, the facility failed to ensure a current hospice care plan was present in the medical record and coordinated with facility staff for one Resident (#71) out of a total sample of 23 residents. Findings include: Review of the facility policy titled 'Hospice Services', last revised January 2023, indicated the following but not limited to: -When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. -The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions, which include: -The facility and hospice will identify the specific services that will be provided by each entity, and this information will be communicated in the plan of care. Based on record review and interviews, the facility failed to ensure a current hospice care plan was present in the medical record and coordinated with facility staff for one Resident (#71) out of a total sample of 23 residents. Findings include: Review of the facility policy titled 'Hospice Services', last revised January 2023, indicated the following but not limited to: -When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. -The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions, which include: -The facility and hospice will identify the specific services that will be provided by each entity, and this information will be communicated in the plan of care. Resident #71 was admitted to the facility in June 2024 with diagnoses including pressure ulcer of sacral region stage 4. Review of Resident #71's Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 10 out of possible 15 on the Brief Interview for Mental Status, indicating he/she had moderate cognitive impairment. The MDS further indicated that the Resident was receiving hospice services. Review of Resident #71's medical record indicated the following: -A physician's order dated 3/20/25, admit to [contracted] hospice services. -A facility care plan: I am receiving hospice services for end-of-life care, dated 3/20/25. Review of the medical record failed to indicate the hospice agency's plan of care was available to the staff at the facility. During an interview on 4/16/25 at 10:15 A.M., Nurse #2 said all hospice communication for Resident #71 was uploaded in the electronic medical record. During an interview on 4/16/25 at 2:04 P.M., the Director of Nursing said hospice had not sent over the plan of care and that the plan of care should be available for staff to review.

Based on observation, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#70) out of a total sample of 23 residents. Specifically, the facility failed to ensure recommendations from behavioral health services were relayed to the physician and implemented for Resident #70. Findings Include: Review of facility policy titled Change in Condition, dated as revised 10/2022, indicated the following: -Our facility shall promptly notify the resident, his or her Attending physician, and representative of changes in the resident's medical, mental condition and/or status. Resident #70 was admitted to the facility in May 2024 with diagnoses including major depressive disorder, post traumatic dress disorder and visual hallucinations. Review of Resident 70's most recent Minimum Data Set (MDS) assessment, dated 2/10/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the resident received antipsychotic medications. Review of Resident #70's Psychiatric Evaluation and Consultation, dated 1/6/25, indicated the following: -Current Assessment/Plan: Patient seen in follow up on hallucinations and delusions. Patient seen at bedside. Patient reports persistent low mood and auditory/visual hallucinations, which [he/she] described as distressing but not commanding or threatening. Tells me [his/her] room is flooded with water and things appears to be jumping from one spot to another. Tells me [he/she] does occasional hear whispers [sic] -I recommend Abilify (an antipsychotic medication) 2.5 mg (milligrams) daily. Review of progress notes indicated a Physician Note, dated 1/7/25, written by Nurse Practitioner (NP) #1 which indicated the following: -Patient was seen yesterday by Psych NP. Patient did report that is having increased hallucinations. Psych NP discuss with patient to start Abilify 2.5 mg QD (daily) and orthostatic BP (blood pressure) x 1 month weekly. Patient is in agreement with this plan. [sic] -Patient will start Abilify 2.5 mg QD. [sic] Review of active and discontinued physician orders failed to indicate that Abilify was initiated on 1/7/25. Review of Resident #70's Psychiatric Evaluation and Consultation, dated 1/13/25, indicated the following: -Current Assessment/Plan: Patient is seen at bedside. [He/she] is endorsing ongoing visual hallucination. These symptoms have been going since the last assessment and has not improved. Patient reports [he/she] is experiencing distress related to these hallucinations especially when [he/she] want to pick up something and it turns to something else . Medication adherence is reported as consistent but has not started the Abilify I made recommendation to initiate. I still believe patient can benefit from Abilify for hallucinations and depression. Patient does not appear to be danger to self or others. I recommend to f/u [follow up] with my las rec [recommendation]. [sic] Review of a Progress note written by NP #1, dated 1/14/25, failed to indicate that Resident #70's Abilify recommendation was not started, and failed to address initiating Abilify. Review of the medical record failed to indicate that the Nurse Practitioner or physician were notified of the recommendations made on 1/13/25 to initiate the previously recommended Abilify. Review of Resident #70's psychological Services Supportive Care Progress note, dated 1/21/25 indicated the following: -The goal of this session was to encourage [the resident] to talk about [his/her] feelings, especially [his/her] sense of depression as well as the hallucinations [he/she] was having. Response: [Resident] reported that [he/she] was still seeing items, bugs, or something of that sort on [his/her] bed when the lights were out, and that disappeared when the lights were on. Review of Resident #70's discontinued physician orders indicated the following: -Abilify 2.5 mg by mouth daily for visual hallucinations, administered 1/29/25 through 2/13/25. -Abilify 5 mg by mouth daily for visual hallucinations, administered 2/14/25 through 2/21/25. Review of the medical record, including the January 2025 Medication Administration Record indicated that Abilify was not initiated until 1/29/25, 23 days after it was initially recommended for the treatment of visual and auditory hallucinations that were distressing to the Resident. Review of Resident #70's Psychiatric Evaluation and Consultation, dated 2/13/25 indicated the following: -I recommend to d/c [discontinue] Abilify 2.5 mg start Abilify 5 mg daily. [sic] During an interview on 4/16/25 at 12:38 P.M., Nurse #1 said that when recommendations are made by consultants such as psych services, the nurses let the NP know, she reviews the recommendations and approves it. She said that sometimes the NP enters the orders directly into the Electronic Medical Record (EMR) and sometimes the nurses enter them. She said most of the time the NP approves the orders and nursing is responsible for ensuring they are entered in the EMR. During an interview on 4/16/25 at 12:51 P.M., Nurse Practitioner #1 said that regarding psych recommendations she typically has a conversation with the psych NP about the recommendations. A copy of the recommendation is provided also to the Director of Nurses. NP #1 said that sometimes she will enter the orders into the EMR, but it is the expectation that nursing enters them or ensures that they are entered. She said that she was aware of the initial recommendation for Resident #70 to start taking Abilify for hallucinations, but was never made aware after the 1/13/25 psych visit that the Abilify was never initiated. She was under the impression that the Resident had been taking it since 1/7/25. She said that if she was notified of the recommendations on the 1/13/25 psych visit note then she would have told nursing staff to initiate the Abilify as recommended. She said she would have expected to be notified of the second recommendation, but she was not. During an interview on 4/16/25 at 2:15 P.M., the Director of Nurses said that since her arrival at the facility two weeks ago, the process is that the psych NP gives their recommendations to the Nursing Supervisor, the NP as well as the Director of Nurses. She said that the nursing supervisor enters the recommendations and that she double checks to make sure they are accurate. She said that when the recommendation and notification that Abilify was not started came through on 1/13/25 someone should have notified the NP or physician that it had not been initiated, but it did not appear that they did.

Based on observations, interviews, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#26 and #42), out of a total sample of 23 residents. Specifically, 1. For Resident #26, the facility failed to administer oxygen appropriately and change oxygen tubing as ordered. 2. For Resident #42, the facility failed to ensure continuous oxygen was provided when the Resident left the facility. Findings include: Review of facility policy titled 'Oxygen Therapy', dated 10/2022, indicated the following but not limited to: -The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. However, oxygen should be regarded as a drug and therefore requires prescribing in all but emergency situations. -Failure to administer oxygen appropriately can result in serious harm to the patient. The safe implementation of oxygen therapy with appropriate monitoring is an integral component of healthcare's professional role. -Oxygen is administered according to the physician order. Oxygen is delivered by wall oxygen, oxygen tank (stationary or portable) or concentrator. Method used on the resident need and concentration required and facility capabilities. -Tubing change, oxygen cannula tubing, without humidification are changed weekly and as needed. 1. Resident #26 was admitted to the facility in February 2021 with diagnoses including chronic obstructive pulmonary disorder. Review of Resident #26's Minimum Data Set (MDS) assessment, dated 4/3/25, indicated the Resident scored 14 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating intact cognition. The MDS further indicated that the Resident was on oxygen therapy. On 4/15/25 at 7:55 A.M., the surveyor observed Resident #26 wearing an oxygen nasal cannula, the oxygen tube was lying on the floor not attached to the concentrator and the tubing was undated. On 4/15/25 at 9:06 A.M., the surveyor observed Resident #26 wearing an oxygen nasal cannula, the oxygen tube was lying on the floor not attached to the concentrator and the tubing was undated. On 4/15/25 at 9:17 A.M., the Surveyor and Nurse #4 observed the Resident's oxygen tubing not connected to the concentrator and the tubing was undated. Nurse #4 said the oxygen tubing should be connected to the concentrator, she said she had been in the room about 25 minutes ago and did not notice the tubing was not connected. She also said the oxygen tubing should be changed weekly and it should have the date and initials of when they were changed and who changed it. Review of the medical record indicated the following: -A physician's order dated 4/13/25 administer oxygen at 3 liter/minute via nasal cannula every shift. -A physician's order dated 10/13/24: Changing oxygen tubing every night shift every Sunday for routine weekly. -Review of the Resident's active respiratory care plan date initiated 5/2/2022 indicated the Resident has diagnosis of chronic respiratory failure and COPD with interventions to Administer oxygen as ordered by provider. During an interview on 4/16/25 at 11:06 A.M., the Director of Nursing said oxygen tubing should be connected to the concentrator and the tubing should be changed weekly and dated to indicate it was changed. 36431 2. Resident #42 was admitted to the facility in August 2023 and has diagnoses that include but are not limited to anxiety disorder and chronic obstructive pulmonary disease. Review the Minimum Data Set assessment dated [DATE] indicated Resident #42 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having intact cognition and requires set-up assistance for daily care. Further review of the MDS indicated Resident #42 uses oxygen. During an interview and observation on 4/15/25 at 7:55 A.M., Resident #42's door to his/her room had a sign that indicated oxygen was in use. Resident #42 was lying on his/her bed. Resident #42 was observed to have a nasal cannula administering oxygen. An oxygen concentrator was next to Resident #42's bed. Resident #42 said he/she was planning to go out today by taxi to go to the store. Resident #42 said he/she does this trip every few weeks. Resident #42 said he/she is not provided with portable oxygen when he/she goes out. Resident #42 said he/she moves slowly and paces him/herself because he/she can get short of breath. Resident #42 said he/she is usually out for a half hour or a little more. Review of Resident #42's physician's orders indicated the following: -May have LOA (leave of absence), order date 8/12/2023. -Oxygen at 2 liters/minute via nasal cannula continuous, every shift, order date 4/24/2024. Review of the leave of absence logbook indicated Resident #42 signed out on 3/21/25 at 6:00 P.M., 3/28/25 at 2:00 P.M., and 4/7/25 at 4:05 [sic]. Review of Resident #42's medical record indicated the following progress notes: -3/21/25 at 23:02, Type: Nurse note: Alert and oriented x 3, LOA this evening come back at 8pm safely [sic]. Further review of the progress notes after 3/21/25 failed to indicate any further documentation regarding Resident #42's LOAs on the above dates. During an interview on 4/16/25 at 10:35 A.M., Nurse #3 said Resident #42 does go out to the store on occasion. Nurse #3 said he typically works on the 3-11 shift and Resident #42 will usually return during his shift. Nurse #3 was asked by the surveyor if Resident #42 returns using portable oxygen. Nurse #3 said it was a good question and said he could not recall but thinks he/she has it sometimes. Nurse #3 reviewed Resident #42's physician's orders and said the order for oxygen is continuous and that would mean he/she needs it when going out. Nurse #3 said Resident #42 will come out to the desk for something without using oxygen for a short time. Nurse #3 said Resident #42 is alert and oriented and it is a good idea for him/her to have portable oxygen. During an interview and observation on 4/16/25 at 10:48 A.M., Resident #42 said I told you yesterday I do not have portable oxygen in my room. No portable oxygen was observed in Resident #42's room. Resident #42 said he/she decided not to go out yesterday. During an interview on 4/16/25 at 3:49 P.M. Certified Nursing Assistant (CNA) #5 said she knows Resident #42 and will assist the Resident as he/she allows. CNA #5 said Resident #42 will sign out, and that she has not seen him/her use portable oxygen and that she has never provided Resident #42 with portable oxygen. During an interview on 4/16/25 at approximately 4:21 P.M., the facility Receptionist said he has assisted Resident #42 in calling a taxi to go to the store. The receptionist said he has seen Resident #42 go out and come back within an hour. The receptionist said he did not recall if Resident #42 had a nasal cannula or portable oxygen. During an interview on 4/17/25 at 8:01 A.M., Unit Manager #1 said Resident #42 does get anxious, and has behaviors of declining or refusing care. Unit Manager #1 said the order for oxygen is continuous and she was not aware that Resident #42 left for LOA without oxygen. Unit Manager #1 said Resident #42 is alert and oriented. Unit Manager #1 said if the order for oxygen is continuous, it means that when a resident goes anywhere like an appointment or LOA, the resident should have oxygen. Unit Manager #1 said Resident #42 will tell the nursing staff what he/she needs and when he/she is going out. Unit Manager #1 said Resident #42 does not go out a lot but should have portable oxygen. During an interview on 4/17/25 at 8:41 A.M., the Director of Nursing (DON) said if a Resident is on continuous oxygen, it is implied that if they leave the facility, they should have portable oxygen available. The DON said if Resident #42 refused to use the portable oxygen it would be documented in the nurse progress notes.

Based on observations, record review, and interviews, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (a tube surgically inserted through the abdominal wall directly into the stomach with the purpose of delivering food, typically in the form of liquid formula) was provided according to professional standards for one Resident (#36) out of a total sample of 23 Residents. Specifically, the facility failed to ensure a tube feeding was running according to physician orders for Resident #36. Findings include: Review of the facility policy titled Enteral Feedings, dated and revised January 2022, indicated the following: - Continuous Feeding: Enteral feeding delivered around the clock, Feedings are only stopped for medication administration and routine tube flushes. This type of feeding may or may not use an electronic pump; but typically, a pump is used. -Procedure: 1. Verify physician order 2. Document all assessments, findings and interventions in the medical record. Resident #36 was admitted to the facility in September, 2017 with diagnoses including traumatic brain injury and quadriplegia. Review of Resident #36's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident was unable to participate in the Brief Interview for Mental Status exam indicating severe cognitive impairment. Further review of the MDS indicated that Resident #36 requires a feeding tube. The surveyor made the following observations: - On 4/16/25 at 6:48 A.M., Resident #36 was awake and laying in bed. Next to the Resident was a pole consisting of a tube feeding pump, tube feeding formula in a gravity bag as well as a water bag. The tube feeding pump was off and the tube feeding formula was not connected to the Resident's abdomen. - On 4/16/25 at 7:44 A.M., 8:31 A.M., 9:11 A.M. and 9:47 A.M., Resident #38 was sleeping in bed. Next to the Resident was a pole consisting of a tube feeding pump, tube feeding formula in a gravity bag as well as a water bag. The tube feeding pump was off and the tube feeding formula was not connected to the Resident's abdomen. The surveyor observed Resident #36 not receiving his/her tube feeding formula for just under three hours. Review of Resident #36's physician's order dated 10/21/24 indicated the following: - Enteral feed every shift Vivonex RTF (a ready-to-feed enteral tube feeding formula) @ 85cc/hr x 24 hours continuous. [sic] Further review of Resident #36's physician's orders failed to indicate an order to hold/stop tube feeding. Review of Resident #36's Nutrition/tube feeding care plan indicated the following intervention revised and dated 10/9/24: - Enteral Nutrition Order: Vivonex via GT (gastric tube) @ 85ml x 24 hours - may be off for care. [sic] During an interview on 4/16/25 at 10:36 A.M., Nurse #1 said Resident #36's tube feeding is continuous, and he/she should always be receiving it. Nurse #1 was not sure why Resident #36's tube feeding was not running in the morning, Nurse #1 said she restarted the tube feeding within the past hour. During an interview on 4/16/25 at 10:55 A.M., the Director of Nursing (DON) said she realized Resident #36 had increased oral secretions, so she wanted to hold the Resident's tube feeding. The DON then said she forgot to transcribe a physician's order to stop the tube feeding and all physician's orders should be followed as written.

Based on observation, record review and interviews, the facility failed to ensure for one Resident (#37), out of a total sample of 23 resident, interventions related to fall, and injury prevention were implemented in accordance with the medical plan of care. Specifically, the facility staff failed to ensure bedside fall mats were in place. Findings include: Review of the policy titled, Fall Preventions and Management, last date revised 1/2023 indicated The Fall Risk Evaluation will determine risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Resident #37 was admitted to the facility in January 2023 and has diagnoses that include but are not limited to atherosclerotic heart disease, unspecified fracture of right pubis, repeated falls, low back pain and depression. Review of the most recent Minimum Data Set assessment, dated 1/27/25 indicated Resident #37 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating he/she as having moderately intact cognition, was dependent on staff for toileting and required substantial maximum assistance for bathing. Further review of the MDS indicated Resident #37 had a fall in the last month before admission and the Care Areas Summary for falls was triggered and a care plan would be developed. On 4/15/25 at 8:31 A.M., Resident #37 was observed in bed. A fall mat was on his/her right side of the bed. Review of Resident #37's medical record indicated the following: -A physician's order dated 1/28/2025, floor mats to both sides of bed, every shift. -A care plan focus: Falls: Resident is at risk for fall related injuries related to recent decline in function, recent fall prior to admission with R (right) hip fracture repair, requires staff assistance for mobility dated as initiated 1/23/2025, revision on 4/2/2025. Interventions: Fall mats to both sides of residents (sic) bed. Date initiated: 1/28/25. On 4/16/25 at 7:20 A.M., Resident #37 was observed sitting on the edge of his/her bed on his/her left side of the bed. A fall mat was on his/her right side of the bed. There was no mat on his/her left side of the bed. There was no second fall mat located in the room. At 7:24 A.M., a nurse entered the room and said he would get someone to assist him/her. Resident #37 was sitting close to the edge of the bed and was looking at the doorway. At 7:29 A.M., the Director of Rehabilitation entered and assisted Resident #37 to walk to the bathroom. On 4/16/25 at 7:57 A.M., Resident #37 was observed sitting up in a wheelchair next to the left side of his/her bed. A mat is on the floor on the right side of the resident's bed. There was no second fall mat in the vicinity of the room. On 04/16/25 at 3:44 P.M., Resident #37 was observed in his/her bed. A fall mat was on his/her right side. There was no fall mat on his/her left side of the bed and no second mat in the room. On 4/17/25 at 7:34 A.M., Resident #37 was observed in his/her bed with a fall mat on his/her right side. There was no fall mat located on the left side of the bed, as indicated by the fall care plan and physician's order. During an observation and interview on 4/17/25 at 7:32 A.M., Nurse #4 said he worked the 11-7 shift. Nurse #4 said Resident #37 had a history of falls, requires his/her bed to be low. Nurse #4 reviewed Resident #37's physician's orders and said Resident #37 has an order for fall mats on both sides of his/her bed. Nurse #4 went with the surveyor to Resident #37's room and said there was no fall mat on his/her left side and there should be. During an interview on 4/17/25 at 7:42 A.M., Unit Manager #1 said she started as the Unit Manager about two weeks ago. Unit Manager #1 said she knew Resident #37. Unit Manager #1 reviewed Resident #37's medical record and said he/she was assessed to be a high fall risk. Unit Manager #1 said there was an order and a fall care plan to have falls mats on both sides of Resident #37's bed. Unit Manager #1 said all staff are responsible for making sure the mats are present. Unit Manager #1 said the fall mats should be present and in place per the order and care plan. During an interview on 4/17/25 at 8:38 A.M., the Director of Nursing said the fall interventions should be implemented per the order and care plan. Review of an incident report dated 1/28/25 at 00:28 hours (12:28 A.M.) indicated Resident found on floor beside the bed. No obvious injury noted. Resident description try to get to the bathroom as verbalized by patient (sic).

Based on observation, record review and interview, the facility failed to ensure that for two Residents (#10 and #1) who are unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal and oral hygiene out of a total sample of 23 Residents. Specifically, 1. For Resident #10, the facility failed to ensure incontinence care was provided timely and in accordance with the standards of care and the Resident care plan. 2. For Resident #1, the facility failed to remove unwanted facial hair. Findings include: Review of the facility policy, titled, ADL (Activities of Daily Living-Personal Hygiene) Last Date Revised 10/2022 included but was not limited to the following: Policy: The purpose of this procedure is to direct the Nursing Staff and meet Residents individual needs per the plan of care and Kardex on a daily basis. Facial hair will be groomed as needed Toileting/incontinence care for a Resident will be provided as needed for each individual Resident per care plan and Kardex. 1. Resident #10 was admitted to the facility in February 2022 and has diagnoses that include but are not limited to unspecified dementia with other behavioral disturbance, type 2 diabetes mellitus, and cerebral infarction. Review of Resident #10's Minimum Data Set (MDS) assessment, dated 3/16/25, indicated the staff assessment for mental status determined severe cognitive impairment for daily decision making, is dependent on staff for toileting hygiene and is always incontinent of bladder and bowel. Further review of the MDS indicated Resident #10 is assessed as high risk for developing pressure ulcers/injuries. Review of the KARDEX (a written summary to guide daily care tasks) dated as of 4/17/2025 indicated: ADL/Personal Hygiene: Max Assist. Bladder/Bowel/Toileting, Toilet Hygiene: Dependent. Review of Resident #10's care plans indicated the following: -A care plan with the focus: Potential alteration in skin integrity: r/t (related to) incontinence of bowel and bladder. Dependence upon staff for care/needs and hx (history) of resolved pressure ulcer R (right) heel, date initiated 2/16/2022, Revision on: 2/23/2025. Interventions included: Protect skin with incontinent care, dated 2/16/2022, Toileting assistance on toileting schedule or routine, dated 2/16/2022. -A care plan focus Self-Care, Resident requires assist with ADLs (activities of daily living) cognitive loss, Generalized weakness increased safety risk, lack of balance, unable to follow simple directions. Would not initiate of follow through d/t (due to) dementia, date initiated 5/7/2024. Interventions included Toilet Hygiene: Dependent. -A care plan focus: Activities of Daily Living Resident will not initiate and unable to follow through with care needs d/t impaired cognition and s/p (status post) stroke, and Dementia (sic), date initiated: 2/16/2022, Revision on 3/8/2025. Goal: Resident will receive assistance with needed in ADL Activities, date initiated: 2/16/2022 revision on 3/22/2025 and target date 6/22/2025. Interventions: Encourage and assist with reposition every 2-3 hours prn (as needed) as resident allows date 2/16/2022. On 4/15/25 at 8:18 A.M., Resident #10 was observed in bed on his/her back. The entrance to the room and area around the room had an odor detected consistent with urine. On 4/15/25 at 8:45 A.M., Resident #10 was resting on his/her back with his/her eyes closed. An odor consistent with urine was detected in and around the room. On 4/15/25 at 9:01 A.M., Resident #10 was set up with his/her breakfast tray and made eye contact but did not respond to the surveyors greeting. Resident #10 continued to have a tray in front of him/her until 9:18 A.M. During an observation and interview on 4/15/25 at 12:24 P.M., Resident #10 was out of bed. An odor was detected consistent with urine was in and around the room/area. Resident #10's bedsheets were observed to be wet. Certified Nursing Assistant (CNA) #2 said the bed was soaked, that she just changed the Resident about 15 minutes ago, that she was assigned to the Resident, and it was the first change since she came in at 7 this morning. CNA #2 said she could not say when the Resident was last changed. During an interview on 4/16/25 at 7:00 A.M., CNA #3 said she worked the 11:00 P.M.-7:00 A.M., shift. CNA #3 said incontinence care is provided about every two hours. CNA #3 said she checks her residents upon coming on her shift, then will do rounds, check to see if changing is required and will change residents. CNA #3 said the last rounds and incontinence care for residents is done between 5:00 A.M and 6:00 A.M. On 4/16/25 the following continuous observations were made: -At 7:02 A.M., Resident #10 was in bed on his/her back. -At 7:36 A.M., Resident # 10 was in bed on his/her back and eyes were closed. -At 7:53 A.M., the MDS (Minimum Data Set) nurse entered Resident #10's room, pulled out blue protective boots and asked the Resident if he/she would let her place them on his/her feet and did so. -At 8:22 A.M., Resident #10 was in bed with the room dark. -At 8:29 A.M., Resident #10 was sitting up in bed, light on and his/her breakfast tray was in front of him/her, and he/she was eating. -At 9:23 A.M., Housekeeping entered Resident #10's room and emptied the trash. -At 9:24 A.M., a doctor entered the room and observed both residents. -At 9:38 A.M., CNA #4 entered Resident #10's room, stood at the end of the bed and asked Resident #10 do you want to get up now or later? CNA #4 then exited the room and did not check to see if Resident #10 needed to be changed. -At 10:18 A.M., Resident #10 remained in bed wearing a johnny and did not respond to the surveyors greeting. -At 10:31 A.M., CNA #4 was passing snacks and gave Resident #10 a pudding snack. During an interview on 4/16/25 at 11:03 A.M., four hours into her shift, CNA #4 said she did not yet provide care to Resident #10 today. CNA #4 said when she worked the night shift the last change would be around six in the morning. CNA #4 said Resident #10 is incontinent and needs to be changed every few hours. During an interview on 4/16/25 at 11:07 A.M., Nurse #3 said the Nursing staff supervise the CNA staff and trust they are providing care as a resident requires. Nurse #3 said he was not aware that Resident #10 had not been provided with care until now. Nurse #3 said he would expect the CNAs to round and provide incontinent care by now. Nurse #3 said incontinence care including checking and changing residents should be done every two hours and not more than three hours. Nurse #3 said by not changing timely Resident #10 is at risk for pressure ulcers, urinary tract infection, and dignity. During an interview on 4/16/25 at 2:46 P.M., Unit Manger #1 said she detected an odor of urine on 4/15/2025, from Resident #10's and his/her roommates' room, and was not sure of the source and requested a deep clean. Unit Manager #1 said incontinence care should be provided every two hours and as needed. Unit Manger #1 said the CNA staff should physically check to see if a resident needs to be changed. Unit Manager #1 said she was in Resident #10's room around 6:30 A.M. and said he/she was dry at that time. Unit Manager #1 said not changing Resident #10 until after 11:00 A.M., would increase his/her risk for skin breakdown, and urinary tract infection. During an interview on 4/17/2025 at 8:22 A.M., and 9:42 A.M., the Director of Nursing said she had seen Resident #10 on 4/15/25 to check his/her skin on his/her abdomen and at the time said he/she was not incontinent. The Director of Nursing said the aim is to keep a resident's skin clean, clear and dry, to follow the care plan and optimally change an incontinent resident every two hours. 49880 2. Resident #1 was admitted to the facility in July 2022 with diagnoses that include parkinsonism, dysarthria and chronic pain. Review of Resident #1's most recent Minimum Data Set (MDS) assessment, dated 4/3/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that for personal hygiene, defined as the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands, the Resident requires substantial/ maximal assistance. The MDS failed to indicate any behaviors for refusal of care. -On 4/15/25 at 7:47 A.M., the surveyor observed Resident #1 sitting up in his/her wheelchair. He/she said that they have been assisted with getting washed and dressed this morning. There was facial hair present on the Resident's face. -On 4/16/25 at 8:22 A.M., the surveyor observed Resident #1 sitting up in his/her wheelchair eating breakfast. Resident #1 said that he/she has been assisted with washing and dressing this morning. There was facial hair present on the Resident's face. -On 4/16/25 at 1:44 P.M., the surveyor observed Resident #1 sitting up in his/her wheelchair. There was facial hair present on the Resident's face. Review of Resident #1's active care plan for self-care, dated as revised 5/6/24, indicated personal hygiene: max assist. [sic] Resident #1's care plan failed to indicate any refusal of care. During an interview on 4/16/25 at 1:44 P.M., Resident #1 said that it is his/her preference is to have facial hair removed, but no one has offered recently. He/she said that in the past they have shaved it. During an interview on 4/16/25 at 1:52 P.M., Certified Nurse's Aide (CNA) #1 said that if staff notice facial hair on a resident, they should offer to remove it, for both men and women. She said that Resident #1 does sometimes want the facial hair removed and sometimes doesn't but that it should be offered regardless. During an interview on 4/16/25 at 2:12 P.M., the Director of Nurses said that CNA's should be observing for facial hair and removing it as the resident wishes as part of daily activities of daily living care.

Based on observation, record review and interview, the facility failed to ensure three Residents (#39, #25 and #38) received care in accordance with professional standards of practice, out of a total sample of 23 residents. Specifically, 1. For Resident #39, the facility failed to ensure a physician's order was developed for the use of a hand orthotic before it was in use. 2. For Resident #25, the facility failed to ensure a wound physician recommendation was implemented. 3. For Resident #38, the facility failed to implement physician's orders for daily dressing changes to the left elbow. Findings include: 1. Resident #39 was admitted to the facility in August 2023 with diagnoses including encephalopathy and Parkinson's Disease. Review of Resident #39's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. During an observation on 4/15/25 at 8:40 A.M., Resident #39 was awake in bed eating his/her breakfast. On the Resident's bedside table was a hand carrot orthotic device (a hand-held orthotic that positions the fingers away from the palm in the shape of a carrot) that was not being used. Resident #39 said staff do not check in with him/her on using the hand orthotic. During an interview on 4/15/25 at 11:09 A.M., Resident #39 said he/she would like to see physical therapy for his/her hands and using his/her hand orthotic. The Resident continued to say that staff do not check in about using the hand orthotic. During an observation on 4/15/25 at 1:58 P.M., Resident #39 was sleeping in bed, no hand orthotic was observed. Review of Resident #39's current and discontinued physician's orders failed to indicate the use of a hand carrot orthotic. Review of Resident #39's active care plans failed to indicate the use of a hand carrot orthotic. Review of Resident #39's Occupational Therapy Discharge Summary dated from 11/7/24 through 2/12/25 failed to indicate the recommendation or use of any hand orthotic. Review of Resident #39's Medication and Treatment Administration Records for April 2025 failed to indicate the use of a hand orthotic. During an interview on 4/16/25 at 11:44 A.M., the Director of Rehab (DOR) said Resident #39 has some weakness in his/her hands. The DOR continued to say he just provided the Resident a hand carrot orthotic to ease his/her anxiety and he/she was never evaluated for it. The DOR said a physician's order should be developed for the use of a hand orthotic. During an interview on 4/16/25 at 1:43 P.M., Nurse #5 said Resident #39 is dependent on staff for all care and the Resident has a hard time moving his/her hands. Nurse #5 said she has no knowledge of Resident #38 using a hand carrot orthotic. During an interview on 4/16/25 at 1:49 P.M., Nursing Supervisor #1 said Resident #39 is dependent on staff for most activities of daily living. Nursing Supervisor #1 said she was not aware of Resident #39 having a hand carrot orthotic, she continued to say there should be a physician's order for it so staff know how to monitor its use. 46339 2. Resident #25 was admitted to the facility in June 2018 with diagnoses including dementia and adult failure to thrive. Review of Resident #25's Minimum Data Set (MDS) Assessment, dated 3/15/25, indicated the Resident scored a 4 out of a total possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS further indicated that the Resident had skin impairment. On 4/15/25 at 8:00 A.M., the surveyor observed Resident #25 lying in bed wearing prevalon boots on his/her feet. On 4/16/25 at 7:04 A.M., the surveyor observed Resident #25 lying in bed wearing prevalon boots on his/her feet. Review of the medical record indicated the following: -Physician order dated 2/27/25: Prevalon boots while in bed as tolerated/accepted every shift. -Physician order dated 4/3/25: Cleanse 2nd digit on right foot with normal saline, pat dry, apply betadine twice a day, leave open to air. Review of wound physician recommendations dated 3/5/25, 3/12/25, 3/19/25, 3/26/25, 4/2/25 and 4/9/25 in the electronic medical record indicated the following: -Bed cradle to keep weight of blankets off toes. Review of the medical record failed to indicate the wound physician's recommendations had been addressed. Review of Resident #25's care plan indicated the following: -Focus: The Resident has actual impairment to skin integrity related to abrasion top of 2nd and 3rd digits on right foot upon return from hospital. -Intervention: Keep the pressure off Resident's feet. During an interview on 4/16/25 at 10:04 A.M., Unit Manager #1 said they were using prevalon boots as a substitute for a bed cradle. During an interview on 4/16/25 at 10:05 A.M., Wound Physician #1 said the Resident requires a foot cradle, he said he had indicated this in the recommendations that he writes to the facility multiple times and that the prevalon boots are not a substitute for the bed cradle. During an interview on 4/16/25 at 11:11 A.M., the Director of Nursing said the bed cradle should be in place if it was recommended by the Wound Physician. She then returned with a physician wound recommendation dated 3/19/25 indicating the following (not appropriate as patient will not keep feet in cradle) and said the nurse practitioner said no to the bed cradle. During an interview on 4/16/25 at 1:40 P.M., Nurse Practitioner #1 said she declined the recommendation as she did not think the Resident would be able to keep his/her feet in the bed cradle. When asked if the facility had attempted to provide the bed cradle and if the Resident was unable to keep feet in it, she said that she was not aware of it. When asked if the decline of the bed cradle recommendation was communicated to the wound physician, she said no. 49880 3. Resident #38 was admitted to the facility in January 2024 with diagnoses that include type 2 diabetes and dysphagia. Review of Resident 38's most recent Minimum Data Set (MDS) assessment, dated 3/27/25, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the Resident has intact cognition. -On 4/15/25 at 7:52 A.M., the surveyor observed the Resident up in his/her wheelchair. The Resident had a dressing on his/her left elbow dated 4/13/25. He/she said they have a wound on their elbow. Review of Resident 38's active physician orders indicated the following: -Wash wound with wound wash or NS, pat dry, apply skin prep to peri wound (skin surrounding the wound), apply Bacitracin to wound bed and cover with gauze island DSG, every day shift for 30 days dated 4/11/25. [sic] Review of the wound consultant note, dated 4/9/25, indicated that Resident #38 had a skin tear wound of the left elbow, full thickness. Review of Resident 38's active care plan indicated the following: -Resident has a new *skin tear* due to repositioning self in wheelchair, initiated 4/3/25, with interventions that included apply treatment a/o (as ordered) by MD (Medical Doctor). [sic] Review of the April 2025 Treatment Administration Record (TAR) indicated that the dressing was changed to the left elbow on 4/14/25. Review of the Progress notes failed to indicate that the dressing was changed to the left elbow on 4/14/25. Review of Resident #38's most recent weekly skin check assessment, dated 4/14/25, failed to indicate the wound to the left elbow. During an interview on 4/16/25 at 12:38 P.M., Nurse #1 said that she worked on 4/14/25 and took care of Resident #38. She said that she can't remember for sure if she changed the dressing to the left elbow. During an interview on 4/16/25 at 2:08 P.M. the Director of Nurses said that she would expect that nurses would implement physician orders and that if they sign off it is complete, that they have completed the order.

Based on interview, record review, and observation the facility failed to ensure seven residents maintained acceptable parameters of nutritional status out of a total sample of 39 residents. Specifically, the facility failed to: 1) For Resident #85 the facility failed to assess the nutritional status of and implement pertinent interventions for the Resident who developed a necrotic skin area which worsened to two unstageable wounds and experienced significant weight loss. 2) For Resident #68 the facility failed to address a significant weight loss in a timely manner. 3) For Resident #16 the facility failed to obtain weights as ordered, and address a significant weight loss for in a timely manner. 4) For Resident #24 the facility failed to implement a therapeutic diet as ordered by the physician, failed to identify, and address a potential significant weight loss, and failed to implement recommendations by the Dietitian. 5) For Resident #42, the facility failed to implement dietitian recommendations for prosource (a liquid protein supplement), zinc, vitamin c, and weekly weights. 6) For Resident #50, the facility failed to implement dietitian recommendations for prosource (a liquid protein supplement), zinc, vitamin c. 7) For Resident #35, the facility failed to assess the nutritional status in a timely manner, obtain weights as ordered by the physician and assess for a potential weight loss. Findings include: Review of the facility policy, titled Weighing the Resident revised January 2023, indicated, but was not limited to, the following: 1. Each resident/patient will be weighed within 24 hours of admission. 2. Weights will be obtained and recorded: - Upon admission - Weekly for the first four weeks, - Then either monthly or more frequently if clinical condition warrants or as ordered by the physician. 3. Any unplanned weight loss/gain is to be reported to the physician, family/responsible party, dietitian, nursing supervisor and addressed at the weekly at risk meeting. 4. Re-weigh of resident/patient is required with fluctuation of 3 lbs. from previous weight, with licensed nurse observation/validation. Also with: a. 5% loss or gain in one month b. 7.5% loss or gain in three months c. 10% loss or gain in six months Review of the facility policy, titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: Poor Nutrition 1. Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. 2. Monitor nutrition and hydration status. 3. Monitor laboratory values, notify physician when appropriate. 4. Encourage proper dietary and fluid intake. 5. If a normal diet is not possible, talk to physician about supplements. 6. Administer vitamins, mineral and protein supplements in accordance with physician orders and dietitian recommendations. Pressure ulcers can diminish global life quality, contribute to rapid mortality in some patients and pose a significant cost to health-care organizations. Accordingly, their prevention and management are highly important. Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing. Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development. Suboptimal nutrition interferes with the function of the immune system, collagen synthesis, and tensile strength. Nutritional status plays a central role in the process of wound healing. Malnutrition accompanies a poor outcome and brings about higher morbidity and mortality. Malnutrition should be recognized rapidly and treated accordingly in all patients suffering from pressure ulcers. Malnutrition impedes pressure ulcer healing. Although the ideal nutrient intake to encourage wound healing is unknown, increased needs for energy, protein, zinc, and Vitamins A, C, and E have been documented. High-protein oral nutritional supplements are effective in reducing the incidence of pressure ulcers by 25% in patients at risk. Energy, protein, arginine, and micronutrients (Vitamins A, C, and zinc) are all vital in the wound healing. Proteins are the most important macronutrients since it is indispensable for the repair of tissues. Pressure Ulcer and Nutrition NIH 2018 Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, revised 4/29/24, indicated the Resident had potential for further alteration in skin integrity, with the following interventions: - Dietary intervention/evaluation, initiated 3/8/23 Review of Resident #85's Nutrition care plan, initiated 3/10/23 and revised 7/1/24, indicated the Resident was at risk for weight loss secondary to esophageal dysmotility, pressure wounds, and mechanically altered diet with a goal for the Resident to remain greater than 190 lbs. (pounds). The following interventions were listed: - Diet consult PRN (as needed), initiated 3/10/23 - Monitor weight per facility policy as ordered, initiated 3/10/23 -Diet as ordered Regular diet, Puree texture, initiated 3/10/23 Review of Resident #85's Self-care care plan, initiated 3/6/24 and revised 5/17/24, indicated the Resident required assistance with activities of daily living related to right side hemiplegia, decreased endurance and fatigues easy. Further review of the care plan indicated the Resident was dependent on staff assistance with eating. Review of Resident #85's most recent comprehensive nutrition assessment, dated 11/14/23, indicated the following: - The Resident did not meet criteria for malnutrition. - A goal for the Resident was to maintain his/her weight. - The Resident's skin was intact. - An intervention to monitor and evaluate the Resident's weight, diet, intakes, skin, labs, mood, and food preferences. On 07/31/24 at 03:17 P.M. the surveyor observed Resident #85 in bed. The Resident appeared cachectic (physical wasting with loss of weight and muscle mass due to disease) as evidence by protruding clavicles, scooping/hallowing temporal region, and thin quadriceps with prominent bones in the patellar region. Review of Resident #85's skin check, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's skin check, dated 3/11/24, indicated Resident #85 had a new necrotic wound on the left buttock, medial area, and that the wound did not have an odor. Review Resident #85's progress note, written by Nurse Practitioner #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM (morning) of 3/26. They will now follow his/her wounds which are pressure related. Review of Resident #85's wound evaluation and management summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement. Review of the hospital discharge paperwork indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement on 3/29, 3/31, 4/5, and 4/21, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/25 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis (an infection in the bone caused by bacteria) with the sacrum/coccyx exposed in the wound. Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated that malnutrition was a factor complicating wound healing. Further review of Resident #85's medical record failed to indicate any nutritional evaluation or recommendations/orders were implemented for the Resident. Review of Resident #85's weight and vitals summary indicated the following weight readings: 3/7/23 - 199.3 lbs. 6/19/23 - 204 lbs. 11/14/23 - 203.4 lbs. 2/2/24 - 200.4 lbs. 3/7/24 - 200.8 lbs. 4/22/24 - 189 lbs. 5/14/24 - 185.4 lbs. 7/20/24 - 141 lbs. Review of the Certified Nursing Assistant (CNA) assignment sheet, dated 6/3/24, indicated Resident #85 weighed 181.2 lbs. Further review of Resident #85's recorded weights indicated that Resident #85 had lost 11.8 lbs. of body weight during hospitalization between 3/7/24 and 4/22/234, and then continued to lose weight. Review of the recorded weights indicated that Resident #85's weight loss reached clinical significance on 5/14/24, indicating the Resident had lost a total of 7.6% of his/her total body weight within 2 months. The weight recorded in the CNA assignment book confirms a trend of weight loss, and review of the weight records indicated the Resident had lost an additional 40 lbs. of body weight on 7/20/24, indicating an additional, clinical significant loss of 22.2% of his/her total body weight lost in a month, 25.4% of his/her total body weight lost in three months, or 29.2% of his/her total body weight lost in six months. Review of Resident #85's recorded weights failed to indicate that a reweight was obtained for the weight taken on 4/22/24 until 22 days later, for the weight taken on 5/14/24 until 20 days later, for the weight taken on 6/3/34 until 47 days later, and that a reweight was never obtained to confirm the weight reading on 7/20/24. Review of Resident #85's medical record indicated the Resident was hospitalized again on 5/9/24, 5/22/24, and 7/10/24 for wound-related reasons. Review of the hospital discharge paperwork, dated 5/9/24, indicated the Resident met criteria for severe calorie-protein malnutrition, required enteral nutrition via a nasogastric tube (a tube placed through the nose terminating directly in the stomach used to provide nutrition formula) during the hospitalization , and the hospital recommended to continue supplemental nutrition at the long-term care facility. Review of the hospital discharge paperwork, dated 7/10/24, indicated the Resident appeared cachectic and that the Resident had presented with severe sepsis secondary to his/her sacral wound requiring admission to the ICU (intensive care unit). Further review of Resident #85's medical record failed to indicate any nutritional evaluation or recommendations/orders were implemented for the Resident. Review of Resident #85's medical record indicated he/she was evaluated by the Registered Dietitian (RD) on 7/1/24, 112 days after the necrotic skin condition was first identified, and 48 days after Resident #85's weight loss reached clinical significance. Review of the RD's progress note, dated 7/1/24, indicated the Resident had lost weight and recommended Proheal (a liquid protein supplement) 30cc tid (three times a day) (providing 45 gm elemental protein), Vitamin C 500mg bid, Zinc 220mg x 30 days, and weekly weights. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended house supplements. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 was at risk for developing pressure ulcers and that the Resident had an unhealed Stage IV pressure ulcer. Review of Resident #85's medical record indicated that the Wound Physician recommended house supplements on 3/12/24, 3/19/24, 3/26/24, 4/23/24, 4/30/24, 5/14/24, 5/21/24, 5/28/24, 6/4/24, 6/11/24, 6/18/24, 6/25/24, 7/2/24, 7/9/24 and 7/23/24. Review of Resident #85's physician orders, dining manager change history report, and care plans failed to indicate that any nutrition interventions were ever initiated for Resident #85, including the house shakes recommended by the Wound Physician or the Proheal, Vitamin C , Zinc, and weekly weights recommended by the RD. Review of the At Risk documentation indicated that meetings were held on 5/8 and 7/8 but failed to indicate nutrition interventions for Resident #85's weight loss or wounds. Review of the Requested Dietician Information documentation, provided by the facility Administrator, indicated the facility did not have a Registered Dietitian from 1/18/24 to 6/4/24. During an interview on 7/25/24 at 10:12 A.M., the Nurse Supervisor said cardiac residents are weighed every day, and every other resident is weighed monthly and as needed. The Nurse Supervisor said that the nurse will review the weights and enter them into the electronic medical record, and that the nurse should immediately obtain a reweight if there had been a change of three lbs. or more. The Nurse Supervisor said that if the reweight confirms a big change that the physician and RD should be notified, who would be expected to review the weights and address weight changes. During an interview on 7/30/24 at 11:13 A.M., the Wound Physician said that it is always good to have a dietitian involved in wound care and that protein is good for wound healing; she said she tries to get a dietitian involved. The Wound Physician said lack of nutrition interventions will slow down wound healing, increase risk for infection and wound deterioration which can lead to hospitalization . The Wound Physician was not aware that a dietitian was not involved with Resident #85's care. During an interview on 7/25/24 at 1:17 P.M., the RD said that Certified Nursing Aides (CNA's) take weights and give them to nurses, and that if there was a change of three pounds or more from the previous weight that she would expect a reweight to occur within 24 hours. The RD said she would expect to be notified of any confirmed weight changes. The RD said all residents should be assessed quarterly and high risk residents would be assessed monthly; the RD said that an assessment would include weight history, supplement usage, dental status, skin status, past medical history, ideal body weight, feeding status, and past nutrition interventions. During a follow-up interview on 7/30/24 at 12:22 P.M., the RD said she would expect to evaluate a Resident who had returned from the hospital. The RD said that Residents with wounds have elevated protein needs, and that all wounds require a nutrition assessment and intervention even before they progress to stage III or IV pressure wounds; the RD said that protein is important for wound healing. The RD said she would expect to be notified of significant weight loss or a new wound immediately and would assess the Resident within seven days. The RD said that Resident #85 has a wound and has experienced weight loss; the RD said the Resident requires extra protein and that he/she would not be able to meet his/her protein needs by meals alone. The RD said that the risk of nutrition interventions not being implemented for Resident #85 would be further skin breakdown, and that a Resident can't heal a wound and lose weight at the same time. The RD said the NP was aware of her recommendations and that she had not disagreed with them. The RD said that her recommendations for proheal, vitamin C, zinc, and weekly weights were to promote wound healing. The RD said that house supplements would require a physician order. The RD said she had not been notified of the weight loss recorded on 7/20/24 and she should have. Review of Resident #85's medical record failed to indicate that a comprehensive nutrition assessment was completed for the Resident during a regularly scheduled quarterly MDS assessment on 2/27/24, during significant change MDS assessments on 3/12/24, 4/28/24, or 5/15/24, or when the Resident returned from the hospital on 4/22/24, 5/9/24, 5/24/24 or 7/20/24. During an interview on 7/30/24 at 2:02 P.M., the Food Service Director (FSD) said there have been no interventions for weight loss or wound healing initiated by the kitchen for Resident #85. During an interview on 8/1/24 at 9:17 A.M., NP #1 said she would not have disagreed with the RD's recommendation to implement proheal, vitamin C, zinc, or weekly weights for Resident #85 and that she does not recall if she was notified of the Resident's most recent weight loss on 7/20/24. NP #1 said she was not aware of any nutrition interventions in place for Resident #85, and that she had not initiated any nutrition interventions. During a follow-up interview on 7/31/24 at 12:18 P.M., the Wound Physician said she had recommended Resident #85 receive house shakes to help meet calorie needs to help with wound healing and that she was not aware that her recommendations were not implemented. During an interview on 7/31/24 at 8:09 A.M., the Director of Nursing (DON) said she would expect a Resident who had experienced weight loss to be assessed by an RD as soon as possible, as weight loss would compromise the Resident's health. The DON also said that a change in skin condition should be reported to the Dietitian, as the wound could get worse if untreated. During an interview on 8/12/24 at 10:05 A.M., the Speech Language Pathologist (SLP) said that she had worked with Resident #85 to reduce the risk of aspiration, to trial textures, consistencies, and to strengthen swallowing function. The SLP said that she had not been consulted to address Resident #85's weight loss, and that the speech therapy was to address safety with swallowing. During an interview on 8/12/24 at 19:17 A.M., RD #2 said that the she would not consider the Minimum Data Set (MDS) assessment a comprehensive nutrition assessment, and that a comprehensive nutrition assessment would include height, weight, intake, weight changes, wounds, and a review of medications, vitamins and minerals. 2) Resident #68 was admitted to the facility in March 2023 with a diagnosis of Dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #68 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #68's Potential Skin care plan, revised 4/29/24, indicated the Resident had potential for further alteration in skin integrity, with the following interventions: - Dietary intervention/evaluation Review of Resident #68's Nutrition care plan, initiated 3/22/23 and revised 7/8/24, indicated the Resident was at risk for weight loss secondary to poor PO (per os/by mouth) intake associated with dementia with a goal for the Resident to remain greater than 106 lbs and the following interventions: - Diet consult PRN (as needed) Review of Resident #68's active physician orders indicated the following order: Weight monthly, initiated on 1/1/24. Review of Resident #68's weights and vitals summary indicated the following weight readings: 11/9/23 - 127 lbs. 12/1/23 - 127.4 lbs. 2/2/24 - 128 lbs. 3/7/24 - 129 lbs. 6/13/24 - 110 lbs. 7/8/24 - 106 lbs. 7/8/24 - 106 lbs. Further review of Resident #68's recorded weights indicated Resident #68 had lost 19 lbs. between 3/7/24 and 6/13/24, which is a clinically significant 14.7% of the Resident's total body weight lost in three months. Further review of the recorded weights indicated that a reweight to confirm the 6/13/24 weight loss did not occur until 25 days later. Review of the recorded weights failed to indicate that Resident #68's weight had been recorded in April. Review of the CNA assignment sheet indicated that Resident #68 weighed 86.2 lbs. on 5/14/24 but failed to indicate that a reweight was completed until 6/13/23, 30 days later. Review of the risk meeting progress note, dated 7/8/24, indicated that Resident #68 was noted with a significant weight loss and that his/her supplement was changed to hi-cal (a calorically concentrated oral nutrition supplement) to increase caloric intake with decreased fluid intake. Review of the dietary progress note, dated 7/8/24, indicated Resident #68 had experienced a weight loss and had recommended to change the Resident's supplement from a house shake to a hi-cal supplement. Review of Resident #68's medical record indicated the first time the Resident's weight loss was first addressed was on 7/8/24, 25 days after the weight loss was initially identified. Review of the dining manager change history failed to indicate the implementation of any nutrition interventions to address Resident #68's weight loss. During an interview on 7/31/24 at 3:20 P.M., CNA #10 said she feels that Resident #68 had lost weight, and that the Resident typically eats 50% of his/her meals. During an interview on 7/25/24 at 10:12 A.M., the Nurse Supervisor said cardiac residents are weighed every day, and every other resident is weighed monthly and as needed. The Nurse Supervisor said that the nurse will review the weights and enter them into the electronic medical record, and that the nurse should immediately obtain a reweight if there had been a change of three lbs. or more. The Nurse Supervisor said that if the reweight confirms a big change that the physician and RD should be notified, who would be expected to review the weights and address weight changes. During an interview on 7/25/24 at 1:17 P.M., the RD said that CNA's obtain weights and give them to nurses, and that if there was a change of three pounds or more from the previous weight that she would expect a reweight to occur within 24 hours. The RD said she would expect to be notified of any confirmed weight changes. During a follow-up interview on 7/30/24 the RD said that Resident #68 had lost weight, and that she is unable to review weights not recorded in the electronic medical record. During an interview on 7/31/24 at 8:09 A.M., the Director of Nursing (DON) said she would expect a Resident who had experienced weight loss to be assessed by an RD as soon as possible, as weight loss would compromise the Resident's health. 3) Resident #16 was admitted to the facility in February 2022 with diagnoses Dementia and malnutrition. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #16 scored a 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Review of Resident #16's care plans indicated that the Resident was at nutritional risk given a past medical history of weight loss and dysphagia, with the goal that the Resident will maintain a weight of 165 lbs. Review of Resident #16's weights and vitals summary indicated the following weight readings: 7/3/23 - 178.2 lbs. 9/28/23 - 177.4 lbs. 10/12/23 - 164.4 lbs. 11/9/23 - 172.8 lbs. 12/1/23 - 168.4 lbs. 2/27/24 - 172.4 lbs. 3/7/24 - 158.6 lbs. 5/14/24 - 158.8 lbs. Review of the CNA assignment sheets indicated that Resident #16 weighed 157 lbs. on 7/1/24. Review of Resident #16's recorded weights indicate that the Resident had experienced a clinically significant weight loss of 13.8 lbs., or 8% of the Resident's total body weight within a month between 2/27/24 and 3/7/24. Further review of the recorded weights failed to indicate that a weight was taken in April as ordered by the physician, and that a reweight confirming the 3/7/24 weight loss was completed on 5/14/24, 68 days later. Review of the dining manager change history and physician's orders failed to indicate the implementation of any nutrition interventions to address Resident #16's weight loss. Review of the nurse progress note, dated 7/26/24, indicated the NP was updated regarding Resident #16's fluctuating weights with a new order to monitor the Resident's weight daily for five days. Further review of the progress note indicated that the NP had reported Resident #16 was at risk for unavoidable weight loss due to disease state. Review of Resident #68's medical record indicated the first time the Resident's weight loss was first addressed or acknowledged was on 7/26/24, 141 days after the weight loss was initially recorded. During an interview on 7/25/24 at 10:12 A.M., the Nurse Supervisor said cardiac residents are weighed every day, and every other resident is weighed monthly and as needed. The Nurse Supervisor said that the nurse will review the weights and enter them into the electronic medical record, and that the nurse should immediately obtain a reweight if there had been a change of three lbs. or more. The Nurse Supervisor said that if the reweight confirms a big change that the physician and RD should be notified, who would be expected to review the weights and address weight changes. During an interview on 7/25/24 at 1:17 P.M., the RD said that CNA's obtain weights and give them to nurses, and that if there was a change of three pounds or more from the previous weight that she would expect a reweight to occur within 24 hours. The RD said she would expect to be notified of any confirmed weight changes. The RD said she had not yet assessed Resident #16. During a follow-up interview on 7/25/24 at 2:58 P.M. the RD said she would have expected a Dietitian to intervene when the weight loss was identified, and that interventions should have been initiated to slow down the rate of weight loss. The RD said a Dietitian should have assessed Resident #16 at the time of the weight loss to rule out unavoidable weight loss, as there could have been other reasons why a resident lost weight other than progressing dementia. During a follow-up interview on 7/30/24 the RD said that she is unable to review weights that are not recorded in the electronic medical record. During an interview on 7/31/24 at 8:09 A.M., the Director of Nursing (DON) said she would expect a Resident who had experienced weight loss to be assessed by an RD as soon as possible, as weight loss would compromise the Resident's health. 44095 4.) For Resident #24 the facility failed to implement a therapeutic diet as ordered by the physician, failed to identify, and address a potential significant weight loss, and failed to implement recommendations by the Dietitian. Resident #24 was admitted to the facility in August 2022 with diagnoses including multiple sclerosis, quadriplegia, dysphagia, and protein malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/21/24, indicated that Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #24 was dependent on staff for eating. Review of the Minimum Data Set (MDS) assessments, dated 10/12/23, 1/4/24, 3/21/24, and 6/21/24, indicated that Resident #24 was coded as the following: K0300. Weight Loss, Loss of 5% or more in the last month or loss of 10% or more in last 6 month Coded: No or unknown. On 7/23/24 at 8:10 A.M., 7/23/24 at 12:10 P.M., 7/25/24 at 8:34 A.M., 7/25/24 at 11:54 A.M., and on 7/26/24 at 12:31 P.M., the surveyor observed Resident #24 being fed by a Certified Nurse Assistant (CNA) a puree diet. During an interview on 7/25/24 at 8:34 A.M., Resident #24 said he/she did not like the puree eggs, and he/she continued to say he/she was not sure why the eggs were now pureed. During an interview on 7/31/24 at 8:24 A.M., Certified Nursing Assistant (CNA) #1 said Resident #24 has lost weight, CNA #1 said that she obtains his/her weights and gives them to nursing and CNA #1 said that Resident #24 has been eating a puree diet for about 6 months. CNA #1 said that Resident #1 does not like the pureed eggs. Review of Resident #24's physician's order dated, 5/3/24, indicated: - No Added Salt (NAS) diet, mechanical soft texture, thin liquids consistency, sodium restriction, high protein, and low fat. Review of Resident #24's diet slip, dated as current on 7/30/24, indicated the following: - NAS Pureed. Further review of the diet slip failed to include the physician's order for mechanical soft texture, high protein, and low fat. Review of Resident #24's plan of care related to nutrition indicated that Resident #24 is at nutritional risk related to increased need for protein and multiple vitamins with minerals to aid in skin integrity. Risk for weight flux with diagnosis of multiple sclerosis and functional quadriplegia, dated as revised 1/4/24, and included the following interventions: - Fortified foods as ordered, initiated on 8/19/22. - Monitor weight per facility policy as ordered, initiated on 8/19/22. - Supplements as ordered; magic cup twice daily, house shake twice daily, and pro source twice daily, initiated on 1/4/24. Review of Resident #24's physician's order, dated 5/23/23, indicated: - Weight monthly one time a day every 25 day(s) Review of Resident #24's Treatment Administration Recorded (TAR), indicated that nursing implemented the physician's order and obtained Resident #24's weight on the following dates: 12/10/23, 1/4/24, 1/29/24, 2/23/24, 3/19/24, 4/13/24, 5/8/24, 6/2/24, 6/27/24, 7/22/24. Further review of the weight tab in the electronic medical record failed to support nursing documented the weights that were obtained as ordered by the physician for the above dates. Review of Resident #24's weight tab in the electronic medical record included the following weights: - 3/8/23 196.6 pounds (lbs) - 11/9/23 186.2 lbs, - 12/1/23 187.0 lbs, - 3/7/24 167.0 lbs, on 12/1/23, the resident weighed 187 lbs. On 3/7/24, the resident weighed 167 pounds which is a -10.70 % Loss. - 5/3/24 167.0 lbs, - 7/25/24 161.2 lbs. Review of Resident #24's dietitian note, dated 11/9/23, indicated: -Significant weight change, reweight requested. Review of the medical record failed to include that Resident #24 was reweighed as requested by the dietitian. Review of Resident #24's dietitian note, dated 1/4/24, indicated: - A comprehensive nutrition assessment has been completed for Resident. - Weight is stable. - Type of Wounds: significant sacrum/coccyx pressure injuries - Significant weight loss is not noted. The resident does not have a low body mass index (BMI). - The resident does not meet criteria for active malnutrition diagnosis (2 characteristics). Review of Resident #24's physician note, dated 3/3/24, indicated the following: - His/her most recent weight is 187 pounds taken on 12/1/23. Review of Resident #24's nurse practitioner note, dated 5/30/24, failed to document weight loss. Review of Resident #24's physician note, dated 6/10/24, failed to docu[TRUNCATED]

Based on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically: 1.) The facility failed to ensure licensed nursing staff were trained and demonstrated competency related to wound care, treatment administration, transcribing orders, pressure ulcer prevention, change in condition, and communication. For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 2.) The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure competencies were completed and documented for 5 out of 5 certified nursing assistants (CNAs), and 12 out of 12 licensed nurses whose education records were reviewed. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 1.) Review of the facility policy titled Ulcer/skin Breakdown Clinical Protocol, created January 2023, indicated, but was not limited to, the following: - All caregivers are responsible for preventing, care of, and providing treatment for Skin Ulcerations. Review of the Facility Assessment Tool, dated 5/24/24, included but was not limited to the following: - Commonly admitted diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management: Integumentary System (the body system consisting of skin, hair, nails and glands): Skin Ulcers, Injuries, surgical wounds. Facility utilizes Wound Physicians: MD (medical doctor)/NP (nurse practitioner), Nursing, Registered Dietician, Regularly scheduled skin Assessments, Wound care supplies, Consultation with specialist as needed for wound management. - Services and Care we Offer based on our Resident's Needs: Skin Integrity: Pressure injury prevention and care, skin care, wound care, (surgical, other skin wounds). - Staff training/education and competencies: Competencies by department. - Licensed Nurses Competencies on hire and PRN (as needed): Skin Prevention/Wound Program, Transcribing order, Change in Condition, Communication - Licensed Nurses Annual Competencies: Treatment Administration - Certified Nurse Assistant (CNA) Annual Competencies: Preventative skin care. During a tour of the facility on 7/23/24 at 8:11 A.M., the surveyor interviewed residents and the following statements regarding staff competencies were reported: - One resident on the [NAME] Unit said, I'm concerned my nurses weren't trained to care for my wounds. - Another resident on the [NAME] Unit said, sometimes my wound dressing isn't changed every day like it should be because the nurses said they don't know how. Throughout the Recertification Survey (7/23/24 through 7/26/24 and 7/29/24 through 8/1/24) the surveyors identified multiple concerns regarding the repeated failure to implement wound care recommendations, notify the physician of wound care recommendations, and failure to transcribe the physician's orders related to wound care. For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD (medical doctor). Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said aides had been using house barrier cream to Resident #85 buttocks region, which was not a new treatment for the newly identified wound in March. During an interview on 7/30/24 at 11:13 A.M., The Wound Physician said she was initially consulted on 3/12/24 to evaluate a rash on Resident #85's frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of Resident #85's entire medical record indicated a wound treatment was not ordered until 3/23/24, 12 days after Nurse #17 had initially identified the necrotic wound. Following this initial failure to notify the physician of the change in condition (the new necrotic skin condition), failure to implement wound care recommendations for a skin condition, failure to notify the physician of the wound care recommendations, and failure to transcribe the physician's orders related to wound care, there continued to be repeated failures, including, but not limited to: - On 3/26/24, the Wound Physician recommended alginate calcium (a gel that promotes wound healing), or santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue) for Resident #85's unstageable sacral ulcer, which was first identified by nursing on 3/11/24. The physician's orders for alginate calcium and santyl were never implemented before Resident #85 was emergently hospitalized on [DATE]. Review of Resident #85's hospital discharge summary indicated he/she was admitted with a diagnosis of sepsis with the presumed source of the infected sacral ulcer. During this hospitalization , the status of the sacral ulcer, with osteomyelitis, necessitated the creation of a fecal-diverting colostomy. - On 3/26/24, the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs). This house supplement was never implemented. - On 4/23/24, the Wound Physician recommended a negative pressure wound therapy (NPWT) to be applied and to be changed three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously, the nurses failed to transcribe the order for the correct frequency. As a result, this NPWT was never changed at the correctly ordered frequency. - On 4/23/24, the Wound Physician recommended a foley catheter (a medical device that helps drain urine from the bladder) as urine will cause wound vac to lose suction. A foley catheter was not implemented until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter, when Resident #85 was admitted to the hospital for severe sepsis secondary to a sacral wound infection. During an interview on 7/31/24 at 3:58 P.M., Nurse #17 said she was the nurse who first identified Resident #85's new necrotic area. Nurse #17 said she never had any wound competencies completed at the facility since she was hired on 9/29/22. The surveyor reviewed Nurse #17's education file which failed to indicate any evidence of the required competencies for skin prevention/wound program, treatment administration, transcribing order, change in condition, or communication. During an interview on 7/31/24 at 7:39 A.M., Nurse #2 said she never had any wound competencies completed at the facility since she was hired on 3/8/24. Nurse #2 said she never had any competencies completed since she was hired, including topics such as treatment administration, transcribing orders, skin prevention/wound program, change in condition, or communication. On 7/29/24 1:51 P.M., the surveyor observed Nurse #14 provide wound care on a different resident, during which infection control concerns were noted with failing to perform hand hygiene. Nurse #14 said she had never had any wound competencies completed at the facility since she was hired on 9/6/23. Nurse #14 said she never had any competencies completed since she was hired, including topics such as treatment administration, transcribing orders, skin prevention/wound program, change in condition, or communication. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he expected that nurses providing wound care would have training completed specific for wound care. During an interview on 8/1/24 at 11:31 A.M., CNA #8 said she had never had any skin prevention competencies completed at the facility since she was hired on 6/27/22. The surveyor requested staff education files with all competencies for 5 Certified Nurse Assistants (CNA) and 12 Licensed Nurses on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 12 Licensed Nurses education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12 Licensed Nurses had competencies completed for skin prevention/wound program - 0 out of 12 Licensed Nurses had competencies completed for transcribing orders. - 0 out of 12 Licensed Nurses had competencies completed for treatment administration - 0 out of 12 Licensed Nurses had competencies completed for colostomy care. - 0 out of 12 Licensed Nurses had competencies completed for change in condition. - 0 out of 12 Licensed Nurses had competencies completed for communication. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNA's had competencies completed for preventative skin care. 2.) Throughout the Recertification Survey (7/23/24 through 7/26/24 and 7/29/24 through 8/1/24) the surveyors identified concerns across multiple care areas including but not limited to: - Medication administration - IV (intravenous) administration - Documentation - CPAP (continuous positive airway pressure) - Restraints - Weights - Psychotropic medication consents - Resident Rights - Advanced Directives Review of the Facility Assessment Tool, dated 5/24/24, indicated the following competencies should be completed for licensed nurses on hire and PRN: - CPAP/BIPAP (bilevel positive airway pressure) - Side rails/restraint policy and procedure - Weights - Nutritional Program - Psychotropic medication consents - IV Therapy - programming pump, peripheral, central lines - DNR (do not resuscitate) Order - Consents, DNR, Advanced Directives, Psychotropic medication Review of the Facility Assessment Tool, dated 5/24/24, indicated the following competencies should be completed for licensed nurses annually: - Medication administration - IV administration - Documentation Review of the Facility Assessment Tool, dated 5/24/24, indicated the following competencies should be completed for CNA's on hire and annually: - Preventative Skin Care - Weights - Resident Rights - Restraint and Ambulation The surveyor requested staff education files with all competencies for 5 Certified Nurse Assistants (CNA) and 12 Licensed Nurses on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 12 Licensed Nurses education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12 Licensed Nurses had competencies completed for CPAP/BIPAP. - 0 out of 12 Licensed Nurses had competencies completed for side rails/restraint policy and procedure. - 0 out of 12 Licensed Nurses had competencies completed for weights. - 0 out of 12 Licensed Nurses had competencies completed for Nutritional Program - 0 out of 12 Licensed Nurses had competencies completed for Psychotropic medication consents - 0 out of 12 Licensed Nurses had competencies completed for IV administration. - 0 out of 12 Licensed Nurses had competencies completed for IV Therapy - programming pump, peripheral, central lines - 0 out of 12 Licensed Nurses had competencies completed for DNR Order - 0 out of 12 Licensed Nurses had competencies completed for Consents, DNR, Advanced Directives, Psychotropic medication. - 0 out of 12 Licensed Nurses had competencies completed for Medication administration. - 0 out of 12 Licensed Nurses had competencies completed for documentation. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNA's had competencies completed for weights. - 0 out of 5 CNA's had competencies completed for resident rights. - 0 out of 5 CNA's had competencies completed for restraint and ambulation. During an interview on 7/29/24 1:51 P.M., Nurse #14 said she never had any nursing competencies completed at the facility since she was hired. During an interview on 7/31/24 at 3:58 P.M., Nurse #17 said she never had any nursing competencies completed at the facility since she was hired. During an interview on 7/31/24 at 7:39 A.M., Nurse #2 said she never had any nursing competencies completed at the facility since she was hired. During an interview on 8/1/24 at 11:31 A.M., CNA #8 said she had never had CNA specific competencies completed since she was hired, including restraints or resident rights. During an interview on 8/1/24 at 1:01 P.M., Nurse #19 said she used to be the Staff Development Nurse a few months ago. Nurse #19 said nursing competencies were not being completed for nurses or CNA's. During an interview on 8/1/24 at 7:40 A.M., The Staff Development Nurse said nursing competencies haven't been completed in years. The Staff Development Nurse said she knew these should have been done, but they had not had the time or a consistent person in the position. During an interview on 7/31/24 at 11:10 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said nursing competencies such as medication administration, IV administration, and documentation, should have been completed based on the facility assessment for all nurses upon hire, annually and as needed to prove their competency for these skills before providing care to Residents in the facility. The DON and ADON said these competencies should be documented and readily available but were not. The DON and ADON said all nursing competencies were not being completed because they had trouble filling the staff development nurse position. The DON and ADON said they knew these should have been done, but they had not had the time or resources. The DON and ADON further said that the position had been vacant for a long time and then had multiple turnovers recently. Ref to F835

Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: 1.) The facility failed to provide nursing staff education and training to provide competent, safe, and effective wound care management. As a result the facility failed to notify the physician, implement treatments recommended by the consulting wound physician, assess the nutritional status and implement pertinent nutrition interventions for a Resident (#85) resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection), significant weight loss, and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 2.) The facility failed to allocate resources to meet the nutritional needs of residents in the absence of a Dietitian. Findings include: 1.) According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Review of the Facility Assessment Tool, dated 5/24/24, included but was not limited to the following: - Commonly admitted diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management: Integumentary System: Skin Ulcers, Injuries, surgical wounds. Facility utilizes Wound Physicians: MD/NP, Nursing, Registered Dietician, regularly scheduled skin Assessments, Wound care supplies, Consultation with specialist as needed for wound management. - Services and Care we offer based on our Resident's Needs: Skin Integrity: Pressure injury prevention and care, skin care, wound care, (surgical, other skin wounds). - Staff training/education and competencies: Competencies by department. - Licensed Nurses Annual Competencies: Treatment Administration, Colostomy Care. - Licensed Nurses Competencies on hire and PRN: Transcribing order, Skin Prevention/Wound Program. - Certified Nurse Assistant (CNA) Annual Competencies: Preventative skin care. Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD (medical doctor). Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the left buttock, medical area; Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said aides had been using house barrier cream to Resident #85 buttocks region, which was not a new treatment for the newly identified wound in March. During an interview on 7/30/24 at 11:13 A.M., The Wound Physician said she was initially consulted on 3/12/24 to evaluate a rash on Resident #85's frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of Resident #85's entire medical record indicated a wound treatment was not ordered until 3/23/24, 12 days after Nurse #17 had initially identified the necrotic wound. Following this initial failure to notify the physician of the change in condition (the new necrotic skin condition), failure to implement wound care recommendations for a skin condition, failure to notify the physician of the wound care recommendations, and failure to transcribe the physician's orders related to wound care, there continued to be repeated failures, including, but not limited to: - On 3/26/24, the Wound Physician recommended alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue) for Resident #85's unstageable sacral ulcer. The physician's orders for alginate calcium and santyl were never implemented before Resident #85 was emergently hospitalized on [DATE]. Review Resident #85's hospital paperwork, dated 4/22/24, indicated he/she was admitted with a diagnosis of sepsis with the presumed source the infected sacral ulcer. Resident #85 underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; and on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. - On 3/26/24, the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs). This house supplement continued to be documented in Wound Physician written recommendations on 4/23/24, 4/30/24, 5/14/24, 5/21/24, 6/4/24, and 7/23/24. This house supplement was never implemented. - On 4/23/24, the Wound Physician recommended negative pressure wound therapy (wound vac) to be applied and to be changed three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously, the nurses failed to transcribe the order for the correct frequency. The Wound Physician continued to document written recommendations to have the wound vac changed three times a week on 4/23/24, 4/30/34, and 5/14/24. As a result, the nurses only changed the wound vac two times a week (instead of three times a week) since it was initially applied on 4/23/24. This wound vac was never changed at the correctly ordered frequency. - On 4/23/24, the Wound Physician recommended a foley catheter (a medical device that helps drain urine from the bladder) as urine will cause wound vac to lose suction. A foley catheter was not implemented until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter. During an interview on 7/31/24 at 3:58 P.M., Nurse #17 said she was the nurse who first identified Resident #85's new necrotic area. Nurse #17 said she never had any wound competencies completed at the facility since she was hired on 9/29/22. The surveyor reviewed Nurse #17's education file which failed to indicate any evidence of the required competencies for skin prevention/wound program, treatment administration, transcribing orders, change in condition, or communication. During an interview on 7/31/24 at 7:39 A.M., Nurse #2 said she never had any wound competencies completed at the facility since she was hired on 3/8/24. Nurse #2 said she never had any competencies completed since she was hired, including topics such as treatment administration, transcribing orders, skin prevention/wound program, change in condition, or communication. The surveyor requested staff education files with all competencies for 5 Certified Nurse Assistants (CNA) and 12 Licensed Nurses on 7/30/24 at 9:07 A.M., 7/30/24 at 12:20 P.M., 7/31/24 at 8:07 A.M., 7/31/24 at 12:32 P.M., and 8/1/24 at 7:47 A.M. Review of 12 Licensed Nurses education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12 Licensed Nurses had competencies completed for skin prevention/wound program - 0 out of 12 Licensed Nurses had competencies completed for transcribing orders. - 0 out of 12 Licensed Nurses had competencies completed for treatment administration - 0 out of 12 Licensed Nurses had competencies completed for colostomy care. - 0 out of 12 Licensed Nurses had competencies completed for change in condition. - 0 out of 12 Licensed Nurses had competencies completed for communication. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNA's had competencies completed for preventative skin care. 2.) Further review of the Facility Assessment Tool indicated the facility required a dietitian for 24 hours a week and that a dietitian was a necessary resource in managing the following complex medical care: - Integumentary System (skin ulcers, injuries, surgical wounds) - Nutritional Disorder (failure to thrive)Neurological system - Neoplasm - Metabolic Disorders - Respiratory System - Genitourinary system - Diseases of Blood - Digestive System - Infectious Diseases - Covid-19 virus Review of the Dietitian job description indicated, but was not limited to, the following: Position summary: -Provides consultation concerning nutritional services to the Administrator of the facility and works in advisory capacity to the Food Service Director in accordance with current generally accepted professional practices. - Provides consultation to allied staff, consultants and physicians regarding diet, nutritional problems, and management, including patient visitation, nutritional assessment, patient nutritional care plans, and diet reviews. - Updates nutritional care plans on a timely basis. - Will review diets and nutritional status on residents' chart and make recommendation to the physician for changes as necessary. - Will visit each nurse's station weekly and check with the charge nurse and/or the dietary communication book for any comments and/or dietary concerns on that particular unit. Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's weight and vitals summary indicated the following weight readings: 3/7/23 - 199.3 lbs. 6/19/23 - 204 lbs. 11/14/23 - 203.4 lbs. 2/2/24 - 200.4 lbs. 3/7/24 - 200.8 lbs. 4/22/24 - 189 lbs. 5/14/24 - 185.4 lbs. 7/20/24 - 141 lbs. Review of the Certified Nursing Assistant (CNA) assignment sheet, dated 6/3/24, indicated Resident #85 weighed 181.2 lbs. Further review of Resident #85's recorded weights indicated that Resident #85 had lost 11.8 lbs. of body weight during hospitalization between 3/7/24 and 4/22/234, and then continued to lose weight. Review of the recorded weights indicated that Resident #85's weight loss reached clinical significance on 5/14/24, indicating the Resident had lost a total of 7.6% of his/her total body weight within 2 months. The weight recorded in the CNA assignment book confirms a trend of weight loss, and review of the weight records indicated the Resident had lost an additional 40 lbs. of body weight on 7/20/24, indicating an additional, clinical significant loss of 22.2% of his/her total body weight lost in a month, 25.4% of his/her total body weight lost in three months, or 29.2% of his/her total body weight lost in six months. Review of Resident #85's recorded weights failed to indicate that a reweight was obtained for the weight taken on 4/22/24 until 22 days later, for the weight taken on 5/14/24 until 20 days later, for the weight taken on 6/3/34 until 47 days later, and that a reweight was never obtained to confirm the weight reading on 7/20/24. Review of Resident #85's medical record indicated the Resident was hospitalized again on 5/9/24, 5/22/24, and 7/10/24 for wound-related reasons. Review of the hospital discharge paperwork, dated 5/9/24, indicated the Resident met criteria for severe calorie-protein malnutrition, required enteral nutrition via a nasogastric tube (a tube placed through the nose terminating directly in the stomach used to provide nutrition formula) during the hospitalization , and the hospital recommended to continue supplemental nutrition at the long-term care facility. Review of the hospital discharge paperwork, dated 7/10/24, indicated the Resident appeared cachectic and that the Resident had presented with severe sepsis secondary to his/her sacral wound requiring admission to the ICU (intensive care unit). Further review of Resident #85's medical record failed to indicate any nutritional evaluation or recommendations/orders were implemented for the Resident. Review of Resident #85's medical record indicated he/she was evaluated by the Registered Dietitian (RD) on 7/1/24, 112 days after the necrotic skin condition was first identified, and 48 days after Resident #85's weight loss reached clinical significance. Review of the RD's progress note, dated 7/1/24, indicated the Resident had lost weight and recommended Proheal (a liquid protein supplement) 30cc tid (three times a day) (providing 45 gm elemental protein), Vitamin C 500mg bid, Zinc 220mg x 30 days, and weekly weights. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended house supplements. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 was at risk for developing pressure ulcers and that the Resident had an unhealed Stage IV pressure ulcer. On 7/30/24 at 8:01 A.M., the surveyor observed the Wound Physician and the Unit Supervisor performing wound care on Resident #85. The wound was larger in diameter than a cantaloupe with a bright red wound bed and some yellow-colored tissue. Review of Resident #85's medical record indicated that the Wound Physician recommended house supplements on 3/12/24, 3/19/24, 3/26/24, 4/23/24, 4/30/24, 5/14/24, 5/21/24, 5/28/24, 6/4/24, 6/11/24, 6/18/24, 6/25/24, 7/2/24, 7/9/24 and 7/23/24. Review of Resident #85's physician orders, dining manager change history report, and care plans failed to indicate that any nutrition interventions were ever initiated for Resident #85, including the house shakes recommended by the Wound Physician or the Proheal, Vitamin C, Zinc, and weekly weights recommended by the RD. During an interview on 7/25/24 at 1:17 P.M., the Registered Dietitian (RD) said that she had started in her role six weeks ago, and that the first two weeks were spent in orientation. The RD said that the last RD had left around last December, and that during the interim there had been nothing in place to compensate, and no consulting Dietitians. The RD said that the Food Service Director does not have the expertise to replace the Dietitian and had not been conducting nutrition assessments. The RD said that there have been some assessments that have not been done in the absence of a Dietitian, and that she would expect the facility to have employed a Dietitian. The RD said she had initially agreed to work 10 hours a week but would need more hours than that. During an interview on 7/25/24 at 11:32 A.M. the Food Service Director (FSD) said the previous Dietitian had resigned in January and that there were no consulting Dietitians during the interim. The FSD said he had not been completing nutrition assessments or reviewing weights. During an interview on 7/25/24 at 2:41 P.M. the Administrator said that the previous Dietitian had left in January of 2024, and that there had not been a qualified nutrition professional to cover during the interim. The Administrator said that the facility had not employed a Dietitian from 1/18/24 until 6/4/24. During a follow-up interview on 7/31/24 at 7:40 A.M. the Administrator said that Dietitian responsibilities would have been delegated by the Director of Nursing (DON), that the speech therapist would adjust diets, and that the medical director and Nurse Practitioner (NP) would be implementing nutrition interventions. During an interview on 7/31/24 at 2:59 P.M., the DON said that nothing had been delegated to her to compensate for the lack of a Dietitian. During an interview on 8/1/24 at 9:17 A.M., NP #1 said there was a time when the facility did not have a Dietitian, which was an issue. During a follow-up interview at 7/31/24 at 8:04 A.M., the Administrator said that he would rely on clinical staff to make him aware of a critical need for a Dietitian. During a follow-up interview on 8/1/24 at 9:17 A.M. NP #1 said that no additional responsibilities were delegated to her to compensate for the missing Dietitian. During an interview on 8/1/24 at 1:01 P.M., the Occupational Therapist (OT) said that she was not aware of any additional responsibilities delegated to the therapy department to compensate for the lack of a Dietitian. During an interview on 8/1/24 at 10:18 A.M., the Medical Director said that nothing had changed regarding his practice in the absence of a Dietitian, that typically he would defer to the Dietitian to meet the nutritional needs of residents but in the absence of a Dietitian would defer to weights for monitoring. During an interview on 8/12/24 at 10:05 A.M., the Speech Language Pathologist (SLP) said that she was aware that the facility did not have a Dietitian, but that no additional responsibilities were delegated to her to compensate for the lack of a dietitian. During an interview on 8/12/24 at 10:05 A.M., the Regional Director of Operations said that a contract has been in place for clinical consulting since January 1, 2024 but has not been utilized at the facility. She said that it could have been utilized if the Director of Nursing or Administrator brought concerns within the center forward to regional directors- they would have had the ability to bring a consultant in but no concerns were brought forward until this survey. She said she would have expected the facility administration and clinical leadership to recognize and bring forward concerns. Review of the consulting agreement, with an effective date of January 1, 2024 and an end date of December 31, 2026, indicated an agreement between the governing body and a consultant. Further review of the agreement indicated that the consultant duties included consulting services related to the clinical, operations, and regulatory matters related to the operation of the Facilities, as requested by the governing body. 48990 refer to F940

Based on interview, record review and the Facility Assessment, the facility failed to ensure the Governing Body provided oversight and accountability for effective operational management and quality of care related to the clinical status of residents. Specifically: 1.) The governing body failed to ensure the facility provided consistent and effective nursing staff education and training to provide competent quality of care and effective wound care management, as per the Facility Assessment. 2.) The governing body failed to allocate resources and obtain a Dietitian for the facility, as per the Facility Assessment. Findings include: Review of the facility policy titled, Governing Body, dated as initiated 11/2017, indicated to ensure that the facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. Governing Body Members include: Regional VP (vice president) of Operations, Administrator, Assistant Administrator (if applicable), Director of Nursing, Assistant Director of Nursing (if applicable), Quality Assurance Nurse (if applicable). Administrator and/or designee will communicate day to day operation information to the Regional VP of Operations. Day to Day operation information may include survey results, abuse & neglect allegations, complaint surveys. Review of the facility policy titled, QAPI Plan, dated as reviewed 2/18/22, included but was not limited to the following: - (The Company) shall ensure that the Governing Body, Administration, Medical Director, Director of Nursing, clinical and non-clinical staff demonstrate a consistent endeavor to deliver safe, effective, optimal resident care and services in an environment of minimal risk. - This facility shall develop, implement, and maintain an effective, comprehensive, data-driven Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. - As resident care is a coordinated and collaborative effort, the approach to improving performance shall involve multiple departments and disciplines in establishing the plans, processes and mechanisms that comprise the performance improvement activities at this facility. Organization: - To achieve fulfillment of the objectives, goals and scope of the organizational Performance Improvement Plan, the organizational structure of the program shall be designed to facilitate an effective system of monitoring, assessment and evaluation of the care and services provided throughout the facility. - The Governing Body shall be responsible for the quality of resident care provided. - The Governing Body shall require quality assurance and performance improvement mandatory training that outlines and informs staff of the elements and goals of the facility's Performance Improvement Program. - The Governing Body shall set clear expectations around safety, quality, rights, choice, and respect. - The Governing Body shall require the Medical Director to implement and report on the activities and the mechanisms for monitoring, assessing, and evaluating resident safety practices and the quality of resident care, for identifying and resolving problems and for identifying opportunities to improve resident care and services or performance throughout the facility. This process addresses those departments/disciplines that have direct or indirect effect on resident care, including management, administrative functions, and contracted services. 1.) During an interview on 7/31/24 at 11:10 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said all nursing competencies were not being completed because they had trouble filling the Staff Development Nurse position. The DON and ADON said they knew these should have been done, but they had not had the time or resources. The DON and ADON further said that the position had been vacant for a long time and then had multiple turnovers recently. Review of the Facility Assessment Tool, dated 5/24/24, included but was not limited to the following: - Facility utilizes wound physicians: MD (medical doctor)/NP (nurse practitioner), nursing, registered dietician, regularly scheduled skin assessments, wound care supplies, consultation with specialist as needed for wound management. - Services and Care we Offer based on our Resident's Needs: Skin Integrity: Pressure injury prevention and care, skin care, wound care, (surgical, other skin wounds). - Staff training/education and competencies: - Licensed Nurses Competencies on hire and PRN (as needed): Skin Prevention/Wound Program, Transcribing order, Change in Condition, Communication, Treatment Administration, weights, and nutritional program. - Certified Nurse Assistant (CNA) Annual Competencies: Preventative skin care. During the survey the survey team identified 5 Residents (#85, #24, #88, #103, and #3) with concerns including the failure to implement wound care recommendations, notify the physician of wound care recommendations, and the failure to transcribe the physician's orders related to wound care. Review of 12 Licensed Nurse education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 12, Licensed Nurses had competencies completed for skin prevention/wound, competencies completed for transcribing orders, competencies completed for treatment administration, competencies completed for change in condition, competencies completed for communication, competencies for weights and the nutritional program. Review of 5 Certified Nurse Assistant (CNA) education files indicated the following competencies completed as applicable on hire, annually, or as needed: - 0 out of 5 CNAs had competencies completed for preventative skin care and weights. During an interview on 8/1/24 at 1:01 P.M., Nurse #19 said she used to be the Staff Development Nurse a few months ago. Nurse #19 said nursing competencies were not being completed for Nurses or CNA's. During an interview on 8/1/24 at 7:40 A.M., The Staff Development Nurse said she just started the position a week prior to the start of survey, and she said she had worked in the facility as the MDS Nurse prior. The Staff Development Nurse said nursing competencies haven't been completed in years. The Staff Development Nurse said she knew these should have been done, but they had not had the time or a consistent person in the position. Review of the Staff Development role indicated between January, 2024 to present, the facility had 6 different individuals covering the responsibilities. During an interview on 8/12/24 at 10:05 A.M., the Regional Director of Operations (Governing Body, representative), said that a contract has been in place for clinical consulting since January 1, 2024, but has not been utilized at the facility. During an interview on 8/20/24 at 12:19 P.M., the Director of Nursing (DON) said that she started in January of 2024 and that she had clinical support who called and hired her, and she said she never saw that person in the facility. The DON continued to say there was a new Regional Clinical Director who started back a few months ago but she has not been to the facility. The DON said that she has been without a stable Staff Development Nurse to complete competencies with facility staff and she could have used help. During an interview on 8/21/24 at 1:22 P.M., the Regional Clinical Director said that she provided clinical oversight to the Director of Nursing, and she was in the facility on 5/16/24, 5/20/24, 6/5/24, 6/12/24, 6/24/24, 6/26/24, and 7/3/24. The Regional Clinical Director said she would attend Medicare meetings and review reportable events. The Regional Clinical Director said she was aware of the facilities need for a Staff Development Nurse. Review of the consulting agreement, with an effective date of January 1, 2024, and an end date of December 31, 2026, indicated an agreement between the governing body and a consultant. Further review of the agreement indicated that the consultant duties included consulting services related to the clinical, operations, and regulatory matters related to the operation of the Facilities, as requested by the governing body. Review of the job description titled, Regional Director of Clinical Services, undated, included but not limited to the following: the Regional Director of Clinical Services (RDCS) will be responsible for assessment and evaluation of clinical services in an assigned geographic service region of the corporation. The RDCS will provide routine consultation services to the facilities in the assigned region. Consultation services include, but not limited to, the areas of resident care, state and federals surveys, regulator compliance, staffing and, MDS reimbursement or case management issues, and clinical services. The RDCS is responsible for driving clinical outcomes, mentoring staff, implementing corporate clinical services policies and procedures and ensuring compliance with state and federal laws, rules and regulations. The RDCS will occasionally be assigned to function as the interim Director of Nursing (DON) in a local facility in times of transition or on an as needed basis short term basis by the VP of Clinical Operations. Review of the job description failed to indicate scope and frequency of visits. 2.) Review of the Facility assessment, updated 5/24/24, indicated the facility required a dietitian for 24 hours a week. Further review of the facility assessment indicated that a dietitian was a necessary resource in managing the following complex medical including: - Integumentary System (skin ulcers, injuries, surgical wounds) - Nutritional Disorder (failure to thrive) Neurological system During the recertification survey there were seven Residents (#85, #68, #16, #24, #42, #50, and #35) identified by the survey team that the facility failed to ensure these Residents maintained acceptable parameters of nutritional status. During an interview on 7/25/24 at 2:41 P.M. the Administrator said that the previous Dietitian had left in January of 2024, and that there had not been a qualified nutrition professional to cover during the interim. The Administrator said that the facility had not employed a Dietitian from 1/18/24 until 6/4/24. During a follow-up interview on 7/31/24 at 8:04 A.M., the Director of Operations (Governing Body, representative) and the Administrator (Governing Body, representative) were present. The Administrator said that he would rely on clinical staff to make him aware of a critical need for a Dietitian, and that cycling Dietitians from other buildings would have to be something directed by the governing body. The Director of Operations said she had started in April and was aware that the facility did not have a Dietitian. The Director of Operations said that if there was ever a need, and things were dire, that they could cycle a Dietitian from another building owned by the company, but that she didn't feel there was a need. During an interview on 8/21/24 at 11:50 A.M., the Director of Operations said that there was a Director of Operations in the facility on the following dates 1/25/24, 2/12/24, 2/28/24. The Director of Operations said she was in the facility on 4/20/24, 5/17/24, 5/30/24, 6/20/24, 6/26/24, and on 7/8/24. Review of the job description titled, Director of Operations, undated, included but not limited to the following: the Regional Director of Operations is responsible for ensuring that the assigned region ensures a high level of quality care based on established nursing standards and resident rights while supporting and assisting with the implementation of facility policy and state regulations. Also includes formulating policies, monitoring budgets, overseeing programs and assessing patient satisfaction. They set and meet financial goals and strive to satisfy all federal and state laws and mandates. 48990

Based on observations, interviews and record review, the facility failed to notify the physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and/or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for five Residents (# 85, #24, #88, #103 and #3) out of a total sample of 39 residents. Specifically: 1) For Resident #85, the facility failed to notify the physician of a new necrotic skin condition or of the Wound Physician's recommendations for wound care treatment leading to the skin condition progressing to an wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 2.) For Resident #24, who had four stage 4 pressure ulcers and one unstageable pressure ulcer, the facility failed to notify the provider of the consultant wound physician's recommendations and subsequently nursing did not obtain new physician's orders for wound care based on these recommendations. 3) For Resident #88, the facility failed to notify the provider of the change in wound condition and need to alter wound treatment. 4) For Resident #103, the facility failed notify the physician of new recommendations from the consultant wound practitioner for treatment of a stage IV pressure ulcer. 5) For Resident #3, the facility failed to notify physician of the change in wound condition and need to initiate wound treatment. Findings include: Review of the facility policy titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: Monitoring 1. Evaluate, report and document potential changes in the skin. 1) Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, initiated 3/8/23, indicated the Resident had potential for alteration in skin integrity, with the following interventions: - Complete skin condition checks weekly. - Dietary interventions/evaluation. - Follow MD (Medical Doctor/physician) orders for skin care and treatments (utilize best practice guidelines). Review of Resident #85's Norton Scale for predicting risk for pressure ulcer, dated 2/27/24, indicated the Resident scored an eight, placing the Resident in the high risk category. Review of Resident #85's Skin Only Evaluation, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD (medical doctor). Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the middle of the coccyx and a wound on the left buttocks; Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said she did not apply lotrisone, and that the aides have been using house barrier cream which was not a new treatment for the newly identified wound in March. During a follow-up interview on 7/30/24 at 8:19 A.M., Nurse #17 said that communication with the physician would be included in a progress note, and in the communication book. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of the Nurse practitioner (NP) progress note, dated 3/13/24, failed to indicate that the NP was aware of, evaluated, or initiated treatments for Resident #85's necrotic wound. Review of Resident #85's wound evaluation and management summary, dated 3/19/24, indicated the Wound Physician evaluated the Resident's rash. The Wound Physician recommended lotrisone cream for the diaper dermatitis. During an interview on 7/30/24 at 11:13 A.M., the Wound Physician said that when she is consulted, she does not do a full skin check due to time constraints. The Wound Physician said she was initially consulted for Resident #85 to evaluate a rash on the frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of Resident #85's Treatment Administration Records (TAR) failed to indicate that the lotrisone cream was implemented. Review of Resident #85's medical record failed to indicate a nursing skin evaluation was completed the week of 3/18/24. Review of Resident #85's physician orders indicated the following discontinued orders: - Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Wound, initiated 3/23/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Left butt wound wash with normal saline cover with silicone bordered form dressing every day shift left butt wound, initiated 3/22/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Wound Consult for left butt wound, initiated 3/25/24, 15 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 4/25/24. Review Resident #85's progress note, written by NP #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He/she had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM of 3/26. They will now follow his/her wounds which are pressure related. Further review of Resident #85's progress note, written by Nurse Practitioner (NP) #2, dated 3/26/24, indicated that the consult for the Resident's wound was initiated 15 days after nursing had initially identified the necrotic area. Further review of the progress note indicated that the wound team requested multi-interventions in addition to wound care. During an interview on 7/30/24 at 11:42 A.M., NP #2 said she would expect to be notified of a new skin condition. NP #2 said that her review of systems includes communication with the nurses, and that she does not do a full-skin check as part of her regular evaluation; the NP said that she would only look at skin if a concern is brought to her attention. NP #2 said a staff member will follow the Wound Physician to communicate the recommendations to her, and that she would expect the recommendations to be implemented. NP #2 said that the risk of not implementing the Wound Physician recommendations would be that the wound could get worse, and that the wound could get infected and develop osteomyelitis. NP #2 said she was first notified of the wound on 3/26/24, when nursing reported to her that the wound had developed an odor, and that when she had evaluated the Resident on 3/13/24 she had not been aware of the wound. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he would expect nursing to notify himself or an NP of a change in skin condition. Physician #2 said a facility nurse should be following the Wound Physician for recommendations, and that the risk of Wound Physician recommendations not being followed would be that the wound would probably get worse if the Resident was not receiving treatment. Review of Resident #85's Wound Evaluation and Management Summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs) alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue). Review of the nursing progress note, dated 3/27/24, indicated Resident #85 was being transferred to emergency room for evaluation as the resident was very week [sic]. And oxygen of at 58% at room air. Review of Resident #85's Treatment Administration Record (TAR) failed to indicate that alginate calcium, or santyl were implemented prior to the Resident's hospitalization on [DATE]. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the hospital discharge paperwork, dated 4/22/24, indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. Review of the nursing progress note, dated 4/22/24, indicated that Resident #85 had returned from the hospital with a sacral ulcer with underlying osteomyelitis status post multiple debridement's and the creation of a diverting loop colostomy. Further review of the progress note indicated that the Wound Physician would evaluate the Resident on 4/23/24 to provide guideline on wound vac (a treatment that uses suction to help wounds heal) use [sic]. Review of the Minimum Data Set (MDS) assessment, dated 4/28/24, indicated that Resident #85 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #85 had a new Stage IV and a new Stage III pressure ulcer and was at risk for developing pressure ulcers. According to the Mayo Clinic, complications and outcomes of Stage IV pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement, foley catheter (a medical device that helps drain urine from the bladder) and negative pressure wound therapy (wound vac) to be applied three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 17 x 16.8 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for 23 days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress notes indicated the Resident was transferred to the emergency roiagnom on [DATE]. Review of the hospital discharge paperwork, dated 5/9/24, indicated Resident #85 presented to the hospital with lethargy, anorexia (abnormal loss of appetite for food), hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and worsening wound drainage. Further review of the hospital paperwork indicated the Resident required intravenous antibiotics for sepsis during hospitalization , and was discharged back to the facility with the recommendation to change the wound vac three times per week. Review of the Wound Evaluation and Management Summary, dated 5/14/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 16.8 x 16.5 x 4.5 cm and a stage IV pressure wound on the left ischium measuring 2 x 1 x .4 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for nine days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 5/21/24, indicated that Resident #85 had a stage IV pressure wound measuring 16.8 x 16.7 x 4.8 cm, and that the wound progress was exacerbated due to infection; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 30 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 1 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's Nurse Practitioner progress note, dated 5/22/24, indicated that the Resident had been seen on 5/21/24 by the Wound Physician who found bone chips in the Resident's wound. Further review of the progress note indicated that the Resident was transferred to the hospital on 5/21/24 for sacral wound for IV antibiotics or hospice. Review of the hospital discharge paperwork, dated 5/24/24, indicated Resident #85 had presented to the hospital after the facility had noticed bone chips in his/her wound. Review of the Wound Evaluation and Management Summary, dated 5/28/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 16.8 x 4.8 cm, and that the wound continues to deteriorate; the Wound Physician recommended sodium hypochlorite solution (dakins) twice daily for 23 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 0.9 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 6/4/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 17 x 4.8 cm, and that the wound was exacerbated by acute osteomyelitis; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 16 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress note, dated 7/10/24, indicated the Resident was sent to the hospital as the resident was shaking and pale. Review of the hospital discharge paperwork, dated 7/20/24, indicated Resident #85 presented to the hospital on 7/10/24 with severe sepsis secondary to sacral wound infection requiring admission to the ICU (intensive care unit) for pressor support. Further review of the hospital discharge paperwork indicated the Resident's wound was debrided on 7/11/24, the Resident required IV antibiotics for sepsis, a urinary foley catheter was placed on 7/11, 80 days after the Wound Physician initially recommended the placement of the foley catheter, and a wound vac was placed on 7/13 with instructions to be changed on Monday, Wednesday, and Friday. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended a house supplement and to change the wound vac three times per week. Review of Resident #85's physician orders indicated the following discontinued orders: - Change (wound vac) dressing every 3 days and PRN (as needed), initiated on 4/22/24 and discontinued on 5/24/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's physician orders indicated the following active orders: - Change Negative pressure wound therapy (wound vac) dressing every 3 days and PRN, initiated 7/20/24. - Change foley catheter as needed, initiated 7/20/24. Review of Resident #85's TAR indicated that foley care was initiated on 7/20/24. Further review of Resident #85's physician orders, hospital discharge orders, diet manager change history, and TAR indicated that the lotrisone cream, and house supplement recommended by the Wound Physician were never initiated, a wound treatment was not ordered until 3/23/24, 12 days after nursing had initially identified the necrotic wound, and that a foley catheter was not placed until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter. Review of Resident #85's MAR failed to indicate that the wound vac was ever changed three times a week as recommended by the Wound Physician. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/23/24, indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 had an unhealed Stage IV pressure ulcer and was at risk for developing pressure. On 7/30/24 at 8:01 A.M., the surveyor observed the Wound Physician and the Unit Supervisor performing wound care on Resident #85. The wound was larger in diameter than a cantaloupe with a bright red wound bed and some yellow-colored tissue. During an interview on 7/29/24 at 2:52 P.M., the Nurse Supervisor said that if a Resident is noted with a change in skin condition that a skin assessment will be done, that the change would be reported to the physician, and that a treatment order would be placed. The Nurse Supervisor said that he accompanies the Wound Physician during her wound rounds on Tuesdays. The Nurse Supervisor said that it was his responsibility to print the Wound Physician recommendations and to present them to the NP and that the signed recommendations will be placed in the physical chart. The Nurse Supervisor said that he never has the time to follow this process because he is always working on a cart, as a result the Wound Physician's recommendations for treatment changes don't get implemented. Review of Resident #85's medical chart failed to indicate that the Wound Physician's recommendations for lotrisone, a house supplement, foley catheter placement, or a three day a week wound vac change were reviewed by the NP or MD. During an interview on 7/31/24 at 3:05 P.M., NP #1 said she would not disagree with the Wound Physician recommendations and that the recommendations sound reasonable, but cant recall if she was aware of them. During an interview on 7/3024 at 7:36 A.M., the Wound Physician said her expectation was that the nurse rounding with her should print, review and implement her recommendations. The Wound physician said she was not aware that her recommendation for lotrisone was not implemented. The Wound physician said the wound vac should have been changed three times a week, she was not aware that it was ordered for two times a week and that was not the correct order. The Wound Physician said she had recommended a foley catheter but that it wasn't implemented by the facility. 44095 2. Resident #24 was admitted to the facility in August 2022 with diagnoses including multiple sclerosis, quadriplegia, and protein malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/21/24, indicated that Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #24 required total dependence for toileting and bed mobility and he/she had functional limitations in range of motion on both sides of his/her upper and lower extremities. The MDS indicated Resident #24 had four stage 4 pressure ulcers and one unstageable ulcer. Review of Resident #24's consultant wound evaluation and summary, dated 7/2/24, indicated the following: -Site 7: Stage 4 Pressure Wound of the right ischium. Continue: Alginate calcium apply once weekly for 9 days. -Site 10: Stage 4 Pressure Wound of the left ischium. Continue: Alginate calcium apply once daily for 9 days; Skin sub application (restorigin, is a placental tissue allograft that is used as a protective barrier in wound care applications. The natural properties of amniotic tissue provide mechanical protection and growth factors to aid in the management of acute and chronic wounds) apply once weekly for 7 days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit. Foam silicone boarder apply once daily for 9 days. -Site 12: Stage 4 Pressure Wound Sacrum. Continue: Alginate calcium apply once daily for 9 days; Skin sub application (restorigin) apply once weekly for 7 days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit. Foam silicone boarder & faced apply once daily for 30 days. -Site 13: Stage 4 Pressure Wound of the left, lateral ankle. Continue: Santyl apply once daily for 23 days; Alginate calcium apply once daily for 23 days. -Site 15: Unstageable (due to necrosis) Pressure Wound of the right buttock., Continue: Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Wound Size: 0.9 cm x 0.9 cm x unmeasured in centimeters (cm) Review of Resident #24's consultant wound evaluation and summary, dated 7/9/24, indicated the following: -Site 15: Unstageable (due to necrosis) Pressure Wound of the right buttock., Continue: Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Wound Size: 2 cm x 6 cm x unmeasured in centimeters (cm) Review of Resident #24's consultant wound evaluation and summary, dated 7/15/24, indicated the following: -Site 15: Unstageable (due to necrosis) Pressure Wound of the right buttock., Continue: Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days. Wound Size: 2 cm x 5.9 x unmeasured in centimeters (cm) Review of Resident #24's consultant wound evaluation and summary, dated 7/23/24, indicated the following: -Site 7: Stage 4 Pressure Wound of the right ischium. Continue: Alginate calcium apply once daily for 22 days. -Site 10: Stage 4 Pressure Wound of the left ischium. Continue: Alginate calcium apply once daily for 22 days; Skin sub application (restorigin) apply once weekly for 7 days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit. -Site 12: Stage 4 Pressure Wound Sacrum. Continue: Alginate calcium apply once daily for 16 days. -Site 13: Stage 4 Pressure Wound of the left, lateral ankle. Continue: Alginate calcium apply once daily for 9 days; Santyl apply once daily for 9 days. -Site 15: Stage 4 Pressure Wound of the right buttock. Continue: Alginate calcium apply once daily for 16 days; Santyl apply once daily for 16 days. Wound Size: 2 cm x 5.9 x unmeasured in centimeters (cm), post-debridement assessment of this previously unstageable necrotic area wound has revealed the underlying deep tissue at the at the muscle/fascia level, which had previously been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure ulcer. On 7/25/24, the surveyor reviewed Resident #24's active physician's orders for wound care which indicated the following orders were being implemented and documented on the Treatment Administration Record (TAR) by nursing staff during the recertification survey: - Sacral wounds, cleanse with vashe (antimicrobial wound cleanser) or (a similar antibacterial wound cleanser) pat dry, apply alginate (a dressing, highly absorbent wound care product from natural seaweed extract) and eclipse (absorbent dressing), alginate foam dressing daily and PRN, one time a day, initiated on 10/18/22. Further review of this treatment order failed to correspond with the Wound Physician's recommendations, dated 7/23/24, for wound sites 7, 10, 12, or 15. - Alginate calcium apply once daily for 30 days, foam with boarder (silicone sacrum) apply once daily for 30 days), Skin prep apply once daily 30 days, one time a day, initiated on 5/22/23. Further review of this treatment order failed to include a location. - Skin prep apply once daily for 16 days, one time a day, initiated on 5/24/23. Further review of this treatment order failed to include the location. - Skin prep apply once daily for 16 days, one time a day, initiated on 6/22/23. Further review of this treatment order failed to include the location. - Right buttock-antifungal prescription, apply twice daily for 13 days: lotrisone (prescription medication used to treat fungal skin infections) cream to bilateral buttocks and groin, two times a day, initiated on 7/10/23. Further review of this order, indicated the treatment was for 13 days and the order should have been discontinued and this order failed to correspond with the Wound Physician's recommendations, dated 7/23/24, for wound sites 7, 10, 12, or 15. - Right buttock-alginate calcium, apply once daily for 30 days; foam with border (silicone-sacrum) apply once daily for 30 days; one time a day, initiated on 7/10/23. Further review of this treatment order failed to correspond with the Wound Physician's recommendations, dated 7/23/24, for wound sites 7, 10, 12, or 15. - Santyl (a medication that helps remove dead skin tissue and aid in wound healing) External Ointment 250 units/gram (Collagenase), Apply to right buttock area topically, two times a day for wound care. Wash with normal saline pat dry, apply santyl to wound daily and PRN, initiated on 2/26/24. Further review of this physician's order indicated the frequency was documented as both daily and twice daily. Further review of this treatment order failed to correspond with the Wound Physician's recommendations, dated 7/23/24, for wound sites 7, 10, 12, or 15. - Left lateral ankle- cleanse with saline. Apply Medihoney (a hydrocolloidal suspension, helps removal of necrotic tissue and aids in wound healing) gel to wound, cover with bordered foam. Change 3x/week and as needed (PRN). Off -load with pillow or prevalon boots, every day shift every on Mon, Wed, Fri related to pressure ulcer of the left heel, initiated on 5/3/24. Further review of this treatment order failed to correspond with the Wound Physician's recommendations, dated 7/23/24, for wound site 13. - Medihoney Wound/Burn Dressing External Gel (Wound Dressings), apply to left ankle topically every day shift, on every Mon, Wed, Fri related to pressure ulcer of the left heel, initiated on 5/3/24. Further review of this treatment order failed to correspond with the Wound Physician's recommendations, dated 7/23/24, for wound site 13. - Sodium Hypochlorite External Solution 0.125 % (Sodium Hypochlorite, form of bleach for wound cleaning that has been diluted), apply to sacral ischial wounds topically every day and evening shift related to pressure ulcer of the sacral region, initiated on 5/3/24. Further review of this treatment order failed to correspond with the Wound Physician's recommendations, dated 7/23/24, for wound sites 7, 10, 12, or 15. During an interview on 8/1/24 at 4:17 P.M., Nurse #13 said Resident #24 has multiple wounds on his/her buttocks. Nurse #13 said he performs wound care on the evening shift to the sacral wounds and the buttocks wounds. Nurse #13 said that Resident #24's wound orders are messy and difficult to follow, and we try to do our best. Nurse #13 said he has not notified the provider about the wound care orders or the consultant wound physician's reco [TRUNCATED]

Based on observations, interviews and record review, the facility failed to protect five residents, out of a total sample of 39 residents, from neglect. Specifically: 1a) For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 1b) For Resident #85, the facility failed to ensure that an air mattress was set at the appropriate setting to promote wound healing in the presence of a stage IV pressure wound (defined as deep wounds that may impact muscle, tendons, ligaments, and bone). 2a) For Resident #24, the facility failed to implement the physician's order for air mattress settings, in the presence of four stage four pressure ulcers and one unstageable pressure ulcer. 2b) For Resident #24, the facility failed to implement dietician recommendations for wound healing. 2c) For Resident #24, the facility failed to implement wound physician's recommendations for wound care. 3) For Resident #88, the facility failed to implement treatment recommendations from the wound consultant physician for a right third amputated toe surgical wound. 4) For Resident #3, the facility failed to implement wound physician's recommendations for wound care. 5) For Resident #103, the facility failed to implement treatment recommendations by the consultant wound practitioner for a stage IV pressure ulcer. Findings include: The Centers for Medicare and Medicaid Services defines neglect as the failure to provide goods and services necessary to avoid physical harm or mental anguish. Review of the facility policy titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: - Inspect the skin on a daily basis when performing or assisting with personal care or ADLS (activities of daily living). - Evaluate, report and document potential changes in the skin. - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility policy titled Ulcer/skin Breakdown Clinical Protocol, created January 2023, indicated, but was not limited to, the following: - The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; - The interdisciplinary team should collectively complete Route Cause Analysis for any newly identified in-house acquired pressure injury. - The wound care specialist/medical provider will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 1a) Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, initiated 3/8/23, indicated the Resident had potential for alteration in skin integrity, with the following interventions: - Complete skin condition checks weekly - Dietary interventions/evaluation - Follow MD (Medical Doctor/physician) orders for skin care and treatments (utilize best practice guidelines) Review of Resident #85's Norton Scale for predicting risk for pressure ulcer, dated 2/27/24, indicated the Resident scored an eight, placing the Resident in the high risk category. Review of Resident #85's Skin Only Evaluation, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended Lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD. Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the middle of the coccyx and a wound on the left buttocks. Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said she did not apply lotrisone, and that the aides have been using house barrier cream which was not a new treatment for the newly identified wound in March. During a follow-up interview on 7/30/24 at 8:19 A.M., Nurse #17 said that communication with the physician would be included in a progress note, and in the communication book. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of the Nurse practitioner (NP) progress note, dated 3/13/24, failed to indicate that the NP was aware of, evaluated, or initiated treatments for Resident #85's necrotic wound. Review of Resident #85's wound evaluation and management summary, dated 3/19/24, indicated the Wound Physician evaluated the Resident's rash. The Wound Physician recommended lotrisone cream for the diaper dermatitis. Review of Resident #85's Treatment Administration Records (TAR) failed to indicate that the lotrisone cream was implemented. Review of Resident #85's medical record failed to indicate a nursing skin evaluation was completed the week of 3/18/24. Review of Resident #85's physician orders indicated the following discontinued orders: - Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Wound, initiated 3/23/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Left butt wound wash with normal saline cover with silicone bordered form dressing every day shift left butt wound, initiated 3/22/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Wound Consult for left butt wound, initiated 3/25/24, 15 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 4/25/24. Review Resident #85's progress note, written by NP #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He/she had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM of 3/26. They will now follow his/her wounds which are pressure related. Further review of Resident #85's progress note, written by Nurse Practitioner (NP) #2, dated 3/26/24, indicated that the consult for the Resident's wound was initiated 15 days after nursing had initially identified the necrotic area. Further review of the progress note indicated that the wound team requested multi-interventions in addition to wound care. During an interview on 7/30/24 at 11:42 A.M., NP #2 said she would expect to be notified of a new skin condition. NP #2 said that her review of systems includes communication with the nurses, and that she does not do a full-skin check as part of her regular evaluation; the NP said that she would only look at skin if a concern is brought to her attention. NP #2 said a staff member will follow the Wound Physician to communicate the recommendations to her, and that she would expect the recommendations to be implemented. NP #2 said that the risk of not implementing the Wound Physician recommendations would be that the wound could get worse, and that the wound could get infected and develop osteomyelitis. NP #2 said she was first notified of the wound on 3/26/24, when nursing reported to her that the wound had developed an odor, and that when she had evaluated the Resident on 3/13/24 she had not been aware of the wound. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he would expect nursing to notify himself or an NP of a change in skin condition. Physician #2 said a facility nurse should be following the Wound Physician for recommendations, and that the risk of Wound Physician recommendations not being followed would be that the wound would probably get worse if the Resident was not receiving treatment. Review of Resident #85's Wound Evaluation and Management Summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs) alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue). Review of the nursing progress note, dated 3/27/24, indicated Resident #85 was being transferred to emergency room for evaluation as the resident was very week [sic]. And oxygen of at 58% at room air. Review of Resident #85's TAR failed to indicate that alginate calcium, or santyl were implemented prior to the Resident's hospitalization on [DATE]. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the hospital discharge paperwork, dated 4/22/24, indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. Review of the nursing progress note, dated 4/22/24, indicated that Resident #85 had returned from the hospital with a sacral ulcer with underlying osteomyelitis status post multiple debridement's and the creation of a diverting loop colostomy. Further review of the progress note indicated that the Wound Physician would evaluate the Resident on 4/23/24 to provide guideline on wound vac (a treatment that uses suction to help wounds heal) use [sic]. Review of the Minimum Data Set (MDS) assessment, dated 4/28/24, indicated that Resident #85 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #85 had a new Stage IV and a new Stage III pressure ulcer and was at risk for developing pressure ulcers. According to the Mayo Clinic, complications and outcomes of Stage IV pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement, foley catheter (a medical device that helps drain urine from the bladder) and negative pressure wound therapy (wound vac) to be applied three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 17 x 16.8 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for 23 days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress notes indicated the Resident was transferred to the emergency roiagnom on [DATE]. Review of the hospital discharge paperwork, dated 5/9/24, indicated Resident #85 presented to the hospital with lethargy, anorexia (abnormal loss of appetite for food), hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and worsening wound drainage. Further review of the hospital paperwork indicated the Resident required intravenous antibiotics for sepsis during hospitalization , and was discharged back to the facility with the recommendation to change the wound vac three times per week. Review of the Wound Evaluation and Management Summary, dated 5/14/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 16.8 x 16.5 x 4.5 cm and a stage IV pressure wound on the left ischium measuring 2 x 1 x .4 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for nine days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 5/21/24, indicated that Resident #85 had a stage IV pressure wound measuring 16.8 x 16.7 x 4.8 cm, and that the wound progress was exacerbated due to infection; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 30 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 1 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's Nurse Practitioner progress note, dated 5/22/24, indicated that the Resident had been seen on 5/21/24 by the Wound Physician who found bone chips in the Resident's wound. Further review of the progress note indicated that the Resident was transferred to the hospital on 5/21/24 for sacral wound for IV antibiotics or hospice. Review of the hospital discharge paperwork, dated 5/24/24, indicated Resident #85 had presented to the hospital after the facility had noticed bone chips in his/her wound. Review of the Wound Evaluation and Management Summary, dated 5/28/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 16.8 x 4.8 cm, and that the wound continues to deteriorate; the Wound Physician recommended sodium hypochlorite solution (dakins) twice daily for 23 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 0.9 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 6/4/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 17 x 4.8 cm, and that the wound was exacerbated by acute osteomyelitis; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 16 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress note, dated 7/10/24, indicated the Resident was sent to the hospital as the resident was shaking and pale. Review of the hospital discharge paperwork, dated 7/20/24, indicated Resident #85 presented to the hospital on 7/10/24 with severe sepsis secondary to sacral wound infection requiring admission to the ICU (intensive care unit) for pressor support. Further review of the hospital discharge paperwork indicated the Resident's wound was debrided on 7/11/24, the Resident required IV antibiotics for sepsis, a urinary foley catheter was placed on 7/11, 80 days after the Wound Physician initially recommended the placement of the foley catheter, and a wound vac was placed on 7/13 with instructions to be changed on Monday, Wednesday, and Friday. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended a house supplement and to change the wound vac three times per week. Review of Resident #85's physician orders indicated the following discontinued orders: - Change (wound vac) dressing every 3 days and PRN (as needed), initiated on 4/22/24 and discontinued on 5/24/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's physician orders indicated the following active orders: - Change Negative pressure wound therapy (wound vac) dressing every 3 days and PRN, initiated 7/20/24. - Change foley catheter as needed, initiated 7/20/24. Review of Resident #85's TAR indicated that foley care was initiated on 7/20/24. Further review of Resident #85's physician orders, hospital discharge orders, diet manager change history, and TAR indicated that the lotrisone cream, and house supplement recommended by the Wound Physician were never initiated, a wound treatment was not ordered until 3/23/24, 12 days after nursing had initially identified the necrotic wound, and that a foley catheter was not placed until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter. Review of Resident #85's MAR failed to indicate that the wound vac was ever changed three times a week as recommended by the Wound Physician. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/23/24, indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 had an unhealed Stage IV pressure ulcer and was at risk for developing pressure. On 7/30/24 at 8:01 A.M., the surveyor observed the Wound Physician and the Unit Supervisor performing wound care on Resident #85. The wound was larger in diameter than a cantaloupe with a bright red wound bed and some yellow-colored tissue. During an interview on 7/29/24 at 2:52 P.M., the Nurse Supervisor said that if a Resident is noted with a change in skin condition a skin assessment will be done, that the change would be reported to the physician, and that a treatment order would be placed. The Nurse Supervisor said that he accompanies the Wound Physician during her wound rounds on Tuesdays. The Nurse Supervisor said that it was his responsibility to print the Wound Physician recommendations and to present them to the NP and that the signed recommendations will be placed in the physical chart. The Nurse Supervisor said that he never has the time to follow this process because he is always working on a cart, as a result the Wound Physician's recommendations for treatment changes don't get implemented. Review of Resident #85's medical chart failed to indicate that the Wound Physician's recommendations for lotrisone, a house supplement, foley catheter placement, or a three day a week wound vac change were reviewed by the NP or MD. During an interview on 7/31/24 at 3:05 P.M., NP #1 said she would not disagree with the Wound Physician recommendations and that the recommendations sound reasonable, but can't recall if she was aware of them. During an interview on 7/30/24 at 7:36 A.M., the Wound Physician said her expectation was that the nurse rounding with her should print, review and implement her recommendations. The Wound physician said she was not aware that her recommendation for lotrisone was not implemented. The Wound physician said the wound vac should have been changed three times a week, she was not aware that it was ordered for two times a week and that was not the correct order. The Wound Physician said she had recommended a foley catheter but that it wasn't implemented by the facility. During a follow-up interview on 7/30/24 at 11:13 A.M., the Wound Physician said that when she is consulted, she does not do a full skin check due to time constraints. The Wound Physician said she was initially consulted for Resident #85 to evaluate a rash on the frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. During an interview on 7/31/24 at 11:46 A.M., the Director of Nursing said she would consider it neglectful to not provide services or treatments that are needed, and that she would consider it neglectful for a nurse to identify a wound but fail to notify the physician or initiate treatments. 1b) Review of the facility policy, titled Supportive surfaces - air mattress, indicated, but was not limited to, the following: Low air mattress use is indicated as follows: - To assist in the treatment and/or prevention of pressure ulcers as part of the holistic program of pressure ulcer management - As part of a pain management program when indicated for resident comfort Settings: - The patient weight indication is a close approximation of the correct setting. If the mattress is too soft or firm, simply press the up or down arrows to adjust, as necessary. - It may be necessary to alter weight setting to get optimal comfort setting for patients. If patient feels that the bed is too firm/soft, lower or increase weight setting one increment at a time and wait for stabilization before evaluating. Review of Resident #85's physician orders indicated the following active order: - Air Mattress to be for pressure relief. Set to manufacturers recommendations check functionality every shift Review of Resident #85's most recent weight reading, dated 7/20.24, indicated the Resident weighed 141 lbs. On 7/23/24 at 9:15 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. (pounds). On 7/25/24 at 9:42 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. On 7/25/24 at 12:01 P.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. On 7/26/24 at 7:56 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. On 7/29/24 at 10:32 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. During an observation and interview on 7/31/24 at 3:17 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. Resident #85 said his/her bed was not comfortable, and that it was too firm. During an observation and interview on 7/31/24 at 3:22 P.M., Nurse #8 said the air mattress should be set to Resident #85's weight, and that the risk of an air mattress being too firm is that it would delay wound healing. The surveyor and Nurse #8 observed Resident #85 in bed, his/her air mattress was set to 9. Nurse #8 said the air mattress should not be set to nine because the Resident did not weight 350 lbs., and that the air mattress was too firm. 44095 2. Resident #24 was admitted to the facility in August 2022 with diagnoses including multiple sclerosis, quadriplegia, and protein malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/21/24, indicated that Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #24 required total dependence for toileting and bed mobility and he/she had functional limitations in range of motion on both sides of his/her upper and lower extremities. The MDS indicated Resident #24 had four stage 4 pressure ulcers and one unstageable ulcer. Review of Resident #24's ADV - LN: Norton Scale for Predicting Risk of Pressure Ulcer, dated 1/30/24, 5/24/24, and 7/23/24, indicated Resident #24 was at high risk for skin breakdown as evidenced by a score of 5. Review of Resident #24's ADV - LN: Norton Scale for Predicting Risk of Pressure Ulcer, dated 4/26/24, indicated Resident #24 was at high risk for skin breakdown as evidenced by a score of 7. 2a. On 7/23/24 at 8:10 A.M., 7/23/24 at 9:55 A.M., 7/23/24 at 12:10 P.M., 7/23/24 at 3:21 P.M., 7/24/24 3:05 A.M., 7/24/24 at 7:23 A.M., 7/24/24 at 10:03 A.M., 7/25/24 at 6:42 A.M., 7/25/24 at 8:34 A.M., 7/25/24 at 11:54 A.M., 7/25/24 at 12:50 P.M., 7/25/24 at 4:06 P.M., 7/26/24 at 6:50 A.M., 7/26/24 at 12:31 P.M., and on 7/29/24 at 6:56 A.M., the surveyor observed Resident #24 in his/her bed on an air mattress set to 325. Review of the Resident #24's most recent weights in the electronic medical record indicated the following: - 5/3/24 - 167.0 pounds (lbs) - 7/25/24 - 161.2 lbs Review of Resident #24's physician's order, dated 11/8/22, indicated: - Low Air Mattress - setting 250. Check setting and function every shift. Review of Resident #24's plan of care related to actual skin breakdown, dated as revised 5/9/24, indicated: - Low Loss Air Mattress in place. Check for proper function and ensure proper setting, every shift and as needed. Review of Resident #24's Treatment Administration Record (TAR), dated July 2024, indicated nursing implemented air mattresses setting (set to 250) as ordered on 7/23/24, 7/24/24, 7/25/24, 7/26/24, and 7/29/24. However, based on observations of Resident #24's air mattress was not set to the correct setting. During an interview on 7/29/24 at 7:08 A.M., Certified Nurse Assistant (CNA) #1 said CNAs do not adjust air mattress settings and she said Resident #24 has skin wounds. During an interview on 7/29/24 at 7:10 A.M., Nurse #11 (who had just completed her overnight shift 11:00 P.M., to 7: 00A.M.) said Resident #24 has multiple wounds and he/she uses an air mattress for wound healing. Nurse #11 said air mattress settings are set according to physician's order based on the Resident's weight and CNAs do not adjust air mattress settings. Nurse #11 said she is supposed to verify physician's orders every shift and the orders are documented on the TAR. 2b. Review of Resident #24's dietitian's note, dated 6/30/24, indicated: - Suggest Vitamin C 500 mg twice daily, Zinc 220 mg x 30 days, MVI (multivitamin) with minerals for wound healing. Discussed with nursing. Further Review of Resident #24's medical record failed to include documentation to support nursing implemented the dietitian's recommendations. Review of Resident #24's risk meeting note, dated 7/8/24, indicated: - Resident reviewed by interdisciplinary team (IDT) at Risk meeting. Resident bedbound by preference/discomfort, wounds, weights. During an interview on 7/30/24 at 1:50 P.M., the Dietician said her recommendations for weekly weights, vitamin C and zinc 220 were not implemented by nursing but should have been. 2c. Review of Resident #24's consultant wound evaluation and summary, dated 7/2/24, indicated the following: -Site 7: Stage 4 Pressure Wound of the right ischium. Continue: Alginate calcium apply once weekly for 9 days. -Site 10: Stage 4 Pressure Wound of the left ischium. Continue: Alginate calcium apply once daily for 9 days; Skin sub application (restorigin, is a placental tissue allograft that is used as a protective barrier in wound care applications. The natural properties of amniotic tissue provide mechanical protection and growth factors to aid in the management of acute and chronic wounds) apply once weekly for 7 days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit. Foam silicone boarder apply once daily for 9 days. -Site 12: Stage 4 Pressure Wound Sacrum. Continue: Alginate calcium apply once daily for 9 days; Skin sub application (restorigin) apply once weekly for 7 days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations[TRUNCATED]

Based on observations, interviews, policy review, and record review, the facility failed to provide care and treatment to prevent the development of pressure ulcers (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) for 4 out of a total sample of 39 residents. Specifically: 1a) For Resident #85, the facility failed to implement treatments and physician orders recommended by the consulting wound physician resulting in a new necrotic skin condition progressing to an unstageable wound leading to osteomyelitis (a bone infection) and sepsis (a life-threatening response to infection) requiring hospitalization and need for a fecal-diverting colostomy (a surgical procedure that creates an opening in the abdomen, called a stoma, that allows digested food to pass out of the body through an external pouch system). 1b) For Resident #85, the facility failed to ensure that an air mattress was set at the appropriate setting to promote wound healing in the presence of a stage IV pressure wound (defined as deep wounds that may impact muscle, tendons, ligaments, and bone). 2a) For Resident #24, the facility failed to implement the physician's order for air mattress settings. 2b) For Resident #24, the facility failed to implement dietician recommendations for wound healing. 2c) For Resident #24, the facility failed to implement wound physician's recommendations for wound care. 3) For Resident #42, the facility failed to ensure nursing accurately transcribed the frequency of a physician ordered topical medication for a stage four pressure ulcer. 4) For Resident #103, the facility failed to implement treatment recommendations by the consultant wound practitioner for a stage IV pressure ulcer. Findings include: Review of the facility policy, titled Pressure Wound Prevention, revised January 2023, indicated, but was not limited to, the following: - Inspect the skin on a daily basis when performing or assisting with personal care or ADLS (activities of daily living). - Evaluate, report and document potential changes in the skin. - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility policy, titled Ulcer/skin Breakdown Clinical Protocol, created January 2023, indicated, but was not limited to, the following: - The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; - The interdisciplinary team should collectively complete Route Cause Analysis for any newly identified in-house acquired pressure injury. - The wound care specialist/medical provider will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 1a) Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 2/27/24, indicated that Resident #85 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 did not have any pressure ulcers but was at risk for developing pressure ulcers. Review of Resident #85's Potential Skin care plan, initiated 3/8/23, indicated the Resident had potential for alteration in skin integrity, with the following interventions: - Complete skin condition checks weekly - Dietary interventions/evaluation - Follow MD (Medical Doctor/physician) orders for skin care and treatments (utilize best practice guidelines) Review of Resident #85's Norton Scale for predicting risk for pressure ulcer, dated 2/27/24, indicated the Resident scored an eight, placing the Resident in the high risk category. Review of Resident #85's Skin Only Evaluation, dated 3/6/24, indicated Resident #85 had no skin issues. Review of Resident #85's Skin Only Evaluation, dated 3/11/24, indicated Resident #85 had a new necrotic (the death of body tissue or an organ due to a lack of blood supply) wound on the left buttock, medial area, and that the wound did not have an odor. Review of Resident #85's initial Wound Evaluation and Management Summary, dated 3/12/24, indicated the Wound Physician evaluated the Resident for a rash. The Wound Physician diagnosed Resident #85 with diaper dermatitis and recommended Lotrisone cream (an anti-fungal cream) to be applied twice daily to the affected area and prn (as needed). Review of Resident #85's Treatment Administration Records failed to indicate that the lotrisone cream was implemented. During an interview on 7/29/24 at 10:03 A.M., Nurse #17 said that when changes in skin are identified they should be reported to the NP (Nurse Practitioner)/MD. Nurse #17 said that the Wound Physician will give recommendations to the staff member accompanying her during wound rounds every Tuesday. Nurse #17 said that a Certified Nursing Assistant had initially reported the wound to her, and that the Resident had a wound on the middle of the coccyx and a wound on the left buttocks; Nurse #17 said she had not reported the wound to the physician because the wound did not need the physicians' attention because of how small it was. Nurse #17 said she did not apply lotrisone, and that the aides have been using house barrier cream which was not a new treatment for the newly identified wound in March. During a follow-up interview on 7/30/24 at 8:19 A.M., Nurse #17 said that communication with the physician would be included in a progress note, and in the communication book. Review of the communication book and Resident #85's progress notes failed to indicate that the physician was notified of the new necrotic skin condition identified on 3/11/24. Review of the Nurse practitioner (NP) progress note, dated 3/13/24, failed to indicate that the NP was aware of, evaluated, or initiated treatments for Resident #85's necrotic wound. Review of Resident #85's wound evaluation and management summary, dated 3/19/24, indicated the Wound Physician evaluated the Resident's rash. The Wound Physician recommended lotrisone cream for the diaper dermatitis. During an interview on 7/30/24 at 11:13 A.M., the Wound Physician said that when she is consulted, she does not do a full skin check due to time constraints. The Wound Physician said she was initially consulted for Resident #85 to evaluate a rash on the frontal groin area, and nothing else; as the rash was on the front she may not have evaluated the backside and she was not aware of a necrotic wound when she evaluated the rash. The Wound Physician said this may have been a result of bad communication. Review of Resident #85's Treatment Administration Records (TAR) failed to indicate that the lotrisone cream was implemented. Review of Resident #85's medical record failed to indicate a nursing skin evaluation was completed the week of 3/18/24. Review of Resident #85's physician orders indicated the following discontinued orders: - Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Wound, initiated 3/23/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Left butt wound wash with normal saline cover with silicone bordered form dressing every day shift left butt wound, initiated 3/22/24, 12 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 5/24/24. - Wound Consult for left butt wound, initiated 3/25/24, 15 days after nursing had initially identified the Resident's necrotic wound, and discontinued on 4/25/24. Review Resident #85's progress note, written by NP #2, dated 3/26/24, indicated the following: I was asked to see this pt (patient) because of worsening wounds. Nursing reports they had started as superficial, but now were open and deeper. He/she had not been followed by the wound care team. Consult initiated and wound team saw this resident the AM of 3/26. They will now follow his/her wounds which are pressure related. Further review of Resident #85's progress note, written by Nurse Practitioner (NP), dated 3/26/24, indicated that the consult for the Resident's wound was initiated 15 days after nursing had initially identified the necrotic area. Further review of the progress note indicated that the wound team requested multi-interventions in addition to wound care. During an interview on 7/30/24 at 11:42 A.M., NP #2 said she would expect to be notified of a new skin condition. NP #2 said that her review of systems includes communication with the nurses, and that she does not do a full-skin check as part of her regular evaluation; the NP said that she would only look at skin if a concern is brought to her attention. NP #2 said a staff member will follow the Wound Physician to communicate the recommendations to her, and that she would expect the recommendations to be implemented. NP #2 said that the risk of not implementing the Wound Physician recommendations would be that the wound could get worse, and that the wound could get infected and develop osteomyelitis. NP #2 said she was first notified of the wound on 3/26/24, when nursing reported to her that the wound had developed an odor, and that when she had evaluated the Resident on 3/13/24 she had not been aware of the wound. During an interview on 7/31/24 at 9:16 A.M., Physician #2 said he would expect nursing to notify himself or an NP of a change in skin condition. Physician #2 said a facility nurse should be following the Wound Physician for recommendations, and that the risk of Wound Physician recommendations not being followed would be that the wound would probably get worse if the Resident was not receiving treatment. Review of Resident #85's Wound Evaluation and Management Summary, dated 3/26/24, indicated Resident #85 had an unstageable (due to necrosis) pressure injury on his/her left ischium measuring 2.5 x 2.4 cm (centimeters), and an unstageable (due to necrosis) pressure injury on his/her sacrum measuring 3.9 x 3.7 cm. Further review of the wound evaluation indicated that the duration of both wounds was greater than six days, and that the Wound Physician recommended a house supplement (a calorically and nutritionally fortified drink typically utilized to address weight loss and/or meet assist in meeting nutrient, such as protein, needs) alginate calcium (a gel that promotes wound healing), and santyl (an ointment used to promote the healing of skin ulcers by removing damaged tissue). Review of the nursing progress note, dated 3/27/24, indicated Resident #85 was being transferred to emergency room for evaluation as the resident was very week sic. And oxygen of at 58% at room air. Review of Resident #85's TAR failed to indicate that alginate calcium, or santyl were implemented prior to the Resident's hospitalization on [DATE]. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the hospital discharge paperwork, dated 4/22/24, indicated that Resident #85 presented to the hospital on 3/27/24 with encephalopathy (a broad term for any brain disease that alters brain function), found to be in sepsis with an infected sacral ulcer as the presumed source. Further review of the hospital paperwork indicated that the Resident underwent wound debridement (a procedure that removes unhealthy or dead tissue from a wound to promote healing and prevent infection) on 3/29/24, 3/31/24, 4/5/24, and 4/21/24, and that fecal diversion was indicated to allow for the wound to heal due to the wound's proximity to the anus; on 4/5/24 the Resident underwent a diverting loop sigmoid colostomy creation. The hospital paperwork indicated there was clinical and imaging evidence of osteomyelitis with the sacrum/coccyx bones exposed in the wound. Review of the nursing progress note, dated 4/22/24, indicated that Resident #85 had returned from the hospital with a sacral ulcer with underlying osteomyelitis status post multiple debridement's and the creation of a diverting loop colostomy. Further review of the progress note indicated that the Wound Physician would evaluate the Resident on 4/23/24 to provide guideline on wound vac (a treatment that uses suction to help wounds heal) use [sic]. Review of the Minimum Data Set (MDS) assessment, dated 4/28/24, indicated that Resident #85 scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #85 had a new Stage IV and a new Stage III pressure ulcer and was at risk for developing pressure ulcers. According to the Mayo Clinic, complications and outcomes of Stage IV pressure ulcers include: - Osteomyelitis, which is characterized by a mixture of inflammatory cells, fibrosis, bone necrosis, and new bone formation. It is associated with nonhealing wounds, surgical flap complications, and an increased length of hospitalization . It may develop within the first 2 weeks of pressure ulcer formation and despite treatment may require amputation in lower extremity cases. - Joint infections (septic arthritis) can damage cartilage and tissue. - Bone infections (osteomyelitis) can reduce the function of joints and limbs. - Long-term, nonhealing wounds can develop into a type of squamous cell carcinoma. - Sepsis (blood infection). Review of the Wound Evaluation and Management Summary, dated 4/23/24, indicated that Resident #85 had a stage IV sacral pressure wound (Stage IV pressure wounds are defined as deep wounds that may impact muscle, tendons, ligaments, and bone) measuring 17 x 17 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement, foley catheter (a medical device that helps drain urine from the bladder) as urine will cause wound vac to lose suction and negative pressure wound therapy to be applied three times per week for 30 days at 125 mmHg (millimeter of mercury, a manometric unit of pressure) continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 4/30/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 17 x 16.8 x 4.5 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for 23 days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated on 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress notes indicated the Resident was transferred to the emergency roiagnom on [DATE]. Review of the hospital discharge paperwork, dated 5/9/24, indicated Resident #85 presented to the hospital with lethargy, anorexia (abnormal loss of appetite for food), hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and worsening wound drainage. Further review of the hospital paperwork indicated the Resident required intravenous antibiotics for sepsis during hospitalization , and was discharged back to the facility with the recommendation to change the wound vac three times per week. Review of the Wound Evaluation and Management Summary, dated 5/14/24, indicated that Resident #85 had a stage IV sacral pressure wound measuring 16.8 x 16.5 x 4.5 cm and a stage IV pressure wound on the left ischium measuring 2 x 1 x .4 cm. Further review of the Wound Evaluation and Management Summary indicated the Wound Physician recommended a house supplement and negative pressure wound therapy to be applied three times per week for nine days at 125 mmHg continuously. Review of Resident #85's TAR indicated that the wound vac was scheduled to be changed twice a week, initiated 4/22/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 5/21/24, indicated that Resident #85 had a stage IV pressure wound measuring 16.8 x 16.7 x 4.8 cm, and that the wound progress was exacerbated due to infection; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 30 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 1 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's Nurse Practitioner progress note, dated 5/22/24, indicated that the Resident had been seen on 5/21/24 by the Wound Physician who found bone chips in the Resident's wound. Further review of the progress note indicated that the Resident was transferred to the hospital on 5/21/24 for sacral wound for IV antibiotics or hospice. Review of the hospital discharge paperwork, dated 5/24/24, indicated Resident #85 had presented to the hospital after the facility had noticed bone chips in his/her wound. Review of the Wound Evaluation and Management Summary, dated 5/28/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 16.8 x 4.8 cm, and that the wound continues to deteriorate; the Wound Physician recommended sodium hypochlorite solution (dakins) twice daily for 23 days. Further review of the Wound Evaluation and Management summary indicated the Resident had a stage 4 pressure injury of the left ischium measuring 1 x 0.9 x 0.2 cm, and that the Wound Physician recommended alginate calcium once daily for 23 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of the Wound Evaluation and Management Summary, dated 6/4/24, indicated that Resident #85 had a stage IV pressure wound measuring 17 x 17 x 4.8 cm, and that the wound was exacerbated by acute osteomyelitis; the Wound Physician recommended a house supplement and sodium hypochlorite solution (dakins) twice daily for 16 days. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's progress note, dated 7/10/24, indicated the Resident was sent to the hospital as the resident was shaking and pale. Review of the hospital discharge paperwork, dated 7/20/24, indicated Resident #85 presented to the hospital on 7/10/24 with severe sepsis secondary to sacral wound infection requiring admission to the ICU (intensive care unit) for pressor support. Further review of the hospital discharge paperwork indicated the Resident's wound was debrided on 7/11/24, the Resident required IV antibiotics for sepsis, a urinary foley catheter was placed on 7/11, 80 days after the Wound Physician initially recommended the placement of the foley catheter, and a wound vac was placed on 7/13 with instructions to be changed on Monday, Wednesday, and Friday. Review of the most recent Wound Evaluation and Management Summary, dated 7/23/24, indicated that Resident #85 had a stage IV pressure wound measuring 16 x 15.5 x 4.8 cm, and that the wound was not at goal; the Wound Physician recommended a house supplement and to change the wound vac three times per week. Review of Resident #85's physician orders indicated the following discontinued orders: - Change (wound vac) dressing every 3 days and PRN (as needed), initiated on 4/22/24 and discontinued on 5/24/24. Review of Resident #85's physician orders and diet manager change history failed to indicate that a house supplement was implemented. Review of Resident #85's physician orders indicated the following active orders: - Change Negative pressure wound therapy (wound vac) dressing every 3 days and PRN, initiated 7/20/24. - Change foley catheter as needed, initiated 7/20/24. Review of Resident #85's TAR indicated that foley care was initiated on 7/20/24. Further review of Resident #85's physician orders, hospital discharge orders, diet manager change history, and TAR indicated that the lotrisone cream, and house supplement recommended by the Wound Physician were never initiated, a wound treatment was not ordered until 3/23/24, 12 days after nursing had initially identified the necrotic wound, and that a foley catheter was not placed until 7/11/24, 80 days after the Wound Physician initially recommended the placement of a foley catheter. Review of Resident #85's MAR failed to indicate that the wound vac was ever changed three times a week as recommended by the Wound Physician. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/23/24, indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 had an unhealed Stage IV pressure ulcer and was at risk for developing pressure. On 7/30/24 at 8:01 A.M., the surveyor observed the Wound Physician and the Unit Supervisor performing wound care on Resident #85. The wound was larger in diameter than a cantaloupe with a bright red wound bed and some yellow-colored tissue. During an interview on 7/29/24 at 2:52 P.M., the Nurse Supervisor said that if a Resident is noted with a change in skin condition that a skin assessment will be done, that the change would be reported to the physician, and that a treatment order would be placed. The Nurse Supervisor said that he accompanies the Wound Physician during her wound rounds on Tuesdays. The Nurse Supervisor said that it was his responsibility to print the Wound Physician recommendations and to present them to the NP and that the signed recommendations will be placed in the physical chart. The Nurse Supervisor said that he never has the time to follow this process because he is always working on a cart, as a result the Wound Physician's recommendations for treatment changes don't get implemented. Review of Resident #85's medical chart failed to indicate that the Wound Physician's recommendations for lotrisone, a house supplement, foley catheter placement, or a three day a week wound vac change were reviewed by the NP or MD. During an interview on 7/31/24 at 3:05 P.M., NP #1 said she would not disagree with the Wound Physician recommendations and that the recommendations sound reasonable, but cant recall if she was aware of them. During an interview on 7/3024 at 7:36 A.M., the Wound Physician said her expectation was that the nurse rounding with her should print, review and implement her recommendations. The Wound physician said she was not aware that her recommendation for lotrisone was not implemented. The Wound physician said the wound vac should have been changed three times a week, she was not aware that it was ordered for two times a week and that was not the correct order. The Wound Physician said she had recommended a foley catheter but that it wasn't implemented by the facility. 1b) Review of the facility policy, titled Supportive surfaces - air mattress, indicated, but was not limited to, the following: Low air mattress use is indicated as follows: - To assist in the treatment and/or prevention of pressure ulcers as part of the holistic program of pressure ulcer management - As part of a pain management program when indicated for resident comfort Settings: - The patient weight indication is a close approximation of the correct setting. If the mattress is too soft or firm, simply press the up or down arrows to adjust, as necessary. - It may be necessary to alter weight setting to get optimal comfort setting for patients. If patient feels that the bed is too firm/soft, lower or increase weight setting one increment at a time and wait for stabilization before evaluating. Review of Resident #85's physician orders indicated the following active order: - Air Mattress to be for pressure relief. Set to manufacturers recommendations check functionality every shift Review of Resident #85's most recent weight reading, dated 7/20.24, indicated the Resident weighed 141 lbs. On 7/23/24 at 9:15 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. (pounds). On 7/25/24 at 9:42 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. On 7/25/24 at 12:01 P.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. On 7/26/24 at 7:56 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. On 7/29/24 at 10:32 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. During an observation and interview on 7/31/24 at 3:17 A.M., the surveyor observed Resident #85 in bed, his/her air mattress was set to nine, which was the highest setting denoted by 350 lbs. Resident #85 said his/her bed was not comfortable, and that it was too firm. During an observation and interview on 7/31/24 at 3:22 P.M., Nurse #8 said the air mattress should be set to Resident #85's weight, and that the risk of an air mattress being too firm is that it would delay wound healing. The surveyor and Nurse #8 observed Resident #85 in bed, his/her air mattress was set to 9. Nurse #8 said the air mattress should not be set to nine because the Resident did not weight 350 lbs., and that the air mattress was too firm. 44095 2. Resident #24 was admitted to the facility in August 2022 with diagnoses including multiple sclerosis, quadriplegia, and protein malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/21/24, indicated that Resident #24 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS indicated Resident #24 required total dependence for toileting and bed mobility and he/she had functional limitations in range of motion on both sides of his/her upper and lower extremities. The MDS indicated Resident #24 had four stage 4 pressure ulcers and one unstageable ulcer. Review of Resident #24's ADV - LN: Norton Scale for Predicting Risk of Pressure Ulcer, dated 1/30/24, 5/24/24, and 7/23/24, indicated Resident #24 was at high risk for skin breakdown as evidenced by a score of 5. Review of Resident #24's ADV - LN: Norton Scale for Predicting Risk of Pressure Ulcer, dated 4/26/24, indicated Resident #24 was at high risk for skin breakdown as evidenced by a score of 7. 2a. On 7/23/24 at 8:10 A.M., 7/23/24 at 9:55 A.M., 7/23/24 at 12:10 P.M., 7/23/24 at 3:21 P.M., 7/24/24 3:05 A.M., 7/24/24 at 7:23 A.M., 7/24/24 at 10:03 A.M., 7/25/24 at 6:42 A.M., 7/25/24 at 8:34 A.M., 7/25/24 at 11:54 A.M., 7/25/24 at 12:50 P.M., 7/25/24 at 4:06 P.M., 7/26/24 at 6:50 A.M., 7/26/24 at 12:31 P.M., and on 7/29/24 at 6:56 A.M., the surveyor observed Resident #24 in his/her bed on an air mattress set to 325. Review of the Resident #24's most recent weights in the electronic medical record indicated the following: - 5/3/24 - 167.0 pounds (lbs) - 7/25/24 - 161.2 lbs Review of Resident #24's physician's order, dated 11/8/22, indicated: - Low Air Mattress - setting 250. Check setting and function every shift. Review of Resident #24's plan of care related to actual skin breakdown, dated as revised 5/9/24, indicated: - Low Loss Air Mattress in place. Check for proper function and ensure proper setting, every shift and as needed. Review of Resident #24's Treatment Administration Record (TAR), dated July 2024, indicated nursing implemented air mattresses setting (set to 250) as ordered on 7/23/24, 7/24/24, 7/25/24, 7/26/24, and 7/29/24. However, based on observations of Resident #24's air mattress was not set to the correct setting. During an interview on 7/29/24 at 7:08 A.M., Certified Nurse Assistant (CNA) #1 said CNAs do not adjust air mattress settings and she said Resident #24 has skin wounds. During an interview on 7/29/24 at 7:10 A.M., Nurse #11 (who had just completed her overnight shift 11:00 P.M., to 7: 00A.M.) said Resident #24 has multiple wounds and he/she uses an air mattress for wound healing. Nurse #11 said air mattress settings are set according to physician's order based on the Resident's weight and CNAs do not adjust air mattress settings. Nurse #11 said she is supposed to verify physician's orders every shift and the orders are documented on the TAR. 2b. Review of Resident #24's dietitian's note, dated 6/30/24, indicated: - Suggest Vitamin C 500 mg twice daily, Zinc 220 mg x 30 days, MVI (multivitamin) with minerals for wound healing. Discussed with nursing. Further Review of Resident #24's medical record failed to include documentation to support nursing implemented the dietitian's recommendations. Review of Resident #24's risk meeting note, dated 7/8/24, indicated: - Resident reviewed by interdisciplinary team (IDT) at Risk meeting. Resident bedbound by preference/discomfort, wounds, weights. During an interview on 7/30/24 at 1:50 P.M., the Dietician said her recommendations for weekly weights, vitamin C and zinc 220 were not implemented by nursing but should have been. 2c. Review of Resident #24's consultant wound evaluation and summary, dated 7/2/24, indicated the following: -Site 7: Stage 4 Pressure Wound of the right ischium. Continue: Alginate calcium apply once weekly for 9 days. -Site 10: Stage 4 Pressure Wound of the left ischium. Continue: Alginate calcium apply once daily for 9 days; Skin sub application (restorigin, is a placental tissue allograft that is used as a protective barrier in wound care applications. The natural properties of amniotic tissue provide mechanical protection and growth factors to aid in the management of acute and chronic wounds) apply once weekly for 7 days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit. Foam silicone boarder apply once daily for 9 days. -Site 12: Stage 4 Pressure Wound Sacrum. Continue: Alginate calcium apply once daily for 9 days; Skin sub application (restorigin) apply once weekly for 7 days: DO NOT REMOVE or disturb the wound bed. Change the secondary dressing(s) with care as per the recommendations. The skin substitute graft will be re-evaluated by the wound physician during the indicated next visit. Foam silicone boarder & faced apply once daily for 30 days. -Site 13: Stage 4 Pressure Wound of the left, lateral ankle. Continue: Santyl apply once daily for 23 days; Alginate calcium apply once daily for 23 days. -Site 15: Unstageable (due to necrosis) Pressure Wound of the right buttock., Continue: Alginate

Based on interview and record review, the facility failed to ensure that pain management, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences was provided for two Residents out of a total sample of 39 residents. Specifically: 1) For Resident #85, the facility failed to utilize as-needed (PRN) pain medication for breakthrough pain and wound dressing changes as directed by the physician. 2) For Resident #75, the facility failed to ensure nursing provided pain management in accordance with professional standards of practices. Specifically for Resident #75 the facility failed consistently administer his/her physician's ordered pain medication on time. Findings include: Review of the facility policy, titled Pain Management, revised in October 2022, indicated, but was not limited to, the following: - The facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. - The facility promotes resident self-reporting as the most reliable indicator of pain. Facility clinicians use objective pain scales when caring for residents that are able to assist in determining the severity of pain and effectiveness of interventions. Residents with a cognitive impairment will be assessed for pain based on objective clinical evaluation using the PAINAD pain scale (a tool used to assess pain in people with dementia by observing five behaviors: Breathing, Negative vocalization, Facial expression, Body language, Consolability.) Procedure: - Review interdisciplinary assessments and documentation. - Identify potential causes for resident pain. Evaluate alleviating and/or exacerbating factors. Review effectiveness of past and current treatment. - Determine appropriate interventions to manage pain and side effects. Appropriate interventions may include pharmacologic as well as non-pharmacologic interventions. - Develop and revise the resident's plan of care. - Communicate interventions to staff. - Evaluate effectiveness of pain management intervention(s) within 30-60 minutes. - Notify the physician if interventions are not effective in achieving resident comfort and/or functional goals. - Re-assess resident status indicated including, but not limited to: o Level of pain relief o Side effect management o Effectiveness of interventions o Need for increasing/decreasing amount of medication due to tolerance or side effects. - Review and revise plan of care as necessary. 1. Resident #85 was admitted to the facility in March 2023 with diagnoses including Alzheimer's Disease, cerebral infarction, diabetes, hemiplegia (muscle weakness or paralysis on one side of the body that can affect arms, legs, and facial muscles), and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #85 scored a 2 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had severe cognitive impairment. Further review of the MDS indicated that Resident #85 was at risk for developing pressure ulcers and that the Resident had an unhealed Stage IV pressure ulcer. Review of the MDS also indicated that the Resident had not received PRN pain medications or non-medication interventions for pain. Review of Resident #85's Pain care plan, initiated 3/8/23, indicated the Resident had an alteration in comfort related to chronic pain and existing pressure ulcers with the following interventions: - Administer and monitor for effectiveness and for possible side effects from: Routine pain medication. - Monitor and report to nurse: sign and symptoms of pain, worsening of pain. - Pain assessment to be completed prior to initiating wound care. - Report changes in pain location/type frequency/intensity to physician. Review of Resident #85's physician's orders indicated the following active orders: - Pain evaluation Q (every) shift, use pain scale for verbal and nonverbal signs of pain, initiated 5/10/24. - Lidocaine External Patch 4%, apply to low back topically one time a day for back pain every 24 hours, initiated 3/7/23. - Morphine sulfate 100 mg/5mL (milligram/milliliters), give 0.25 mL by mouth every 4 hours as needed for pain, initiated 5/17/24. - Suboxone (a narcotic) sublingual film 4-1Mg, give 1 film sublingually two times a day, initiated 5/1/24. - Acetaminophen tablet 325 mg. give 2 tablets by mouth every 2 hours as needed for pain, initiated 3/7/23. - Review of Resident #85's physician's orders indicated the following discontinued orders: - Suboxone sublingual film 4-1Mg, give 1 film sublingually three times a day, initiated 4/22/24 and discontinued 4/30/24. - Sacrum - irrigate with NS (normal Saline) liquid barrier film to periwound skin, pack with 1 continue PC kerlix moistened with 1/4 Dakins change 2x/day, initiated 5/24/24 and discontinued on 7/22/24. Review of the Nurse Practitioner (NP) progress note, dated 5/13/24, indicated that Resident #85's suboxone had been gradually reduced to twice a day. Review of the Nurse Practitioner (NP) progress note, dated 5/13/24, indicated that Resident #85 was visited by palliative care who recommended to schedule morphine instead of PRN, and that the Resident continued to endorse pain in his/her sacral wound and lower back. Review Resident #85's progress note, dated 5/16/24, indicated that the Resident was seen by NP#1 for pain management. Review of the progress note indicated that the Resident had a chronic sacral decubitus ulcer and was in pain when having his/her wound vac changed. NP #1's progress note indicated that Today patient states that his/her pain is severe especially during dressing changes and that orders are in for morphine 0.25ml Q4H PRN (every four hours as needed). Will continue to monitor patient's pain while in rehab. Review of Resident #85's physician orders and Medication Administration Record (MAR) failed to indicate that morphine was ever scheduled. Review of NP #1's progress note, dated 6/14/24, indicated Resident #85 Continues to state he/she has pain at sacral area. Will continue to monitor and have patient receive morphine prior to dressing changes. Review of Resident #85's progress notes indicated that NP #1 had noted painful movement during the Residents physical examination on 5/13/24, 5/16/24, 5/22/24, 5/24/24, 5/29/24, 6/3/24, 6/13/24, 6/14/24, 6/25/24, and 7/24/24. Review of the skin only evaluation, dated 7/9/24, indicated Resident #85 was in constant pain. Review of Resident #85's vitals summary indicated the following pain readings on a 0 to 10 pain scale: - 4/23/24 at 15:12: 2 out of 10 pain. - 4/23/24 at 21:18: 3 out of 10 pain. - 4/25/24 at 20:28: 5 out of 10 pain. - 4/28/24 at 10:00: 10 out of 10 pain. - 5/11/24 at 12:13: 3 out of 10 pain. - 5/11/24 at 13:47: 2 out of 10 pain. - 5/31/24 at 21:43: 7 out of 10 pain. - 6/2/24 at 13:54: 4 out of 10 pain. - 6/22/24 at 12:57: 3 out of 10 pain. - 6/22/24 at 15:16: 5 out of 10 pain. - 6/25/24 at 9:57: 4 out of 10 pain. - 6/25/24 at 10:08: 5 out of 10 pain. - 6/25/24 at 13:43: 5 out of 10 pain. - 6/29/24 at 13:08: 10 out of 10 pain. Review of Resident #85's Medication Administration Record (MAR) indicated the following pain levels on a scale of 0 to 10 recorded during administration of suboxone: - 3/11/24: 3 out of 10 pain at 8 A.M, and 3 again at 10 P.M. - 3/20/24: 3 out of 10 pain at 8 A.M., and 3 again at 10 P.M. - 4/24/24: 3 out of 10 pain at 8 A.M., 3 at 2 P.M., and 3 at 8 P.M. - 4/26/24: 5 out of 10 pain at 8 A.M., 5 at 2 P.M., and 5 at 8 P.M. - 4/26/24: 10 out of 10 pain at 8 P.M. - 5/11/24: 3 out of 10 pain at 8 A.M., and 2 at 2 P.M. - 5/27/24: 3 out of 10 pain at 8 A.M., and 3 at 2 P.M. - 6/3/24: 4 out of 10 pain at 8 A.M., and 4 at 2 P.M. - 6/4/24: 4 out of 10 pain at 8 A.M., and 4 at 2 P.M. - 6/5/24: 4 out of 10 pain at 8 A.M., and 4 at 2 P.M. - 6/22/24: 3 out of 10 pain at 8 A.M., and 5 at 2 P.M. - 6/23/24: 5 out of 10 pain at 8 A.M., and 5 at 2 P.M. - 6/24/24: 5 out of 10 pain at 8 A.M., and 5 at 2 P.M. - 6/25/24: 5 out of 10 pain at 8 A.M., and 5 at 2 P.M. - 6/26/24: 5 out of 10 pain at 8 A.M., and 5 at 2 P.M. - 6/27/24: 10 out of 10 pain at 4 at P.M. Review of Resident #85's Treatment Administration Record (TAR) indicated that the Resident's wound dressing was changed 60 times since the NP instructed to provide morphine with dressing changes on 6/14/24. Review of the Resident #85's MAR failed to indicate that the PRN morphine was ever administered in June or July of 2024, and that the PRN morphine was only administered once in May, on 5/17/24, the day the order was initiated. Further review of the MAR failed to indicate acetaminophen was ever administered in May, June, or July. During an interview on 7/29/24 at 10:32 A.M., Resident #85 said that he/she was currently in pain, and that he/she does not feel that his/her pain medication helps. During an interview on 7/31/24 at 10:03 A.M., Certified Nursing Assistant (CNA) #11 said Resident #85 complains of pain when being repositioned. During an interview on 7/31/24 the Unit Supervisor said that if a Resident experiences breakthrough pain (a transitory flare of pain that occurs on a background of relatively well-controlled baseline pain) that nurses are expected to administer PRN pain medication. The Unit Supervisor said Resident #85 is in pain a lot of the time. During an interview on 7/31/24 at 10:14 A.M., Nurse Practitioner (NP) #1 said the goal for Resident #85 would be to decrease pain, and that if pain can't be decreased and a Resident is requesting more pain medication that the Resident would be evaluated by palliative care and the facility will follow up on palliative care recommendations. NP #1 said that the expectation was that if a Resident reports pain after his/her regularly scheduled pain medication that the nurse would administer PRN pain medication. NP #1 said that every time she has met with Resident #85 he/she had complained of pain, and that she would expect nursing to provide morphine with dressing changes and when the Resident complains of pain. 44095 2.) Resident #75 was admitted to the facility in October 2023 with diagnoses including dementia, low back pain, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/4/24, indicated that Resident #75 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS indicated the following: Ask resident: Have you had pain or hurting at any time in the last 5 days? - Yes. Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? - Almost Constantly. Ask resident: Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? - Almost Constantly. Ask resident: Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? - Almost Constantly Ask resident: Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine. (Show resident 00-10 pain scale) - 8 of 10. Review of Resident #75's plan of care related to pain, dated as revised 7/5/24, indicated the following: - Administer and monitor for effectiveness and for possible side effects from gabapentin. - Monitor and report to the nurse: signs and symptoms of pain, worsening of pain. Review of Resident #75's physician's order, dated 10/17/23, indicated: - Pain Evaluation every shift, use pain scale for verbal and nonverbal signs of pain. Review of Resident #75's physician's order, dated 10/17/23, indicated: - Gabapentin Oral Capsule 100 mg (Gabapentin), give 100 mg by mouth three times a day for chronic pain. Scheduled three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M. Review of Resident #75's physician's order, dated 2/6/24, indicated: - Baclofen Oral Tablet 10 mg (milligrams), give 10 mg by mouth three times a day related to wedge compression fracture of the second lumbar vertebra, scheduled three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M. Review of Resident #75's physician's order, dated 3/13/24, indicated: - Ibuprofen Oral Tablet 200 mg (Ibuprofen), give 2 tablets by mouth every 8 hours as needed for pain related to muscle weakness. On 7/23/24 at 10:10 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #75 including the following: - baclofen 10 mg, 1 tablet, 2 hours and 10 minutes after the scheduled time - gabapentin 100 mg, 1 capsule, 2 hours and 10 minutes after the scheduled time On 7/23/24 at 10:11 A.M., Resident #75 said he/she has 8 out of 10 pain in his/her hip and leg. On 7/23/24 at 10:12 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #75 including the following: - ibuprofen 200 mg, 2 tablets as needed. During an interview on 7/23/24 at 10:15 A.M., Nurse #1 said she was late administering medications to Resident #75 and medications should be administered within one hour of the scheduled time. On 7/25/24 at 8:26 A.M., the surveyor was seated at the nurse's station and observed Resident #75 complaining about 8 out of 10 back pain to the Unit Supervisor. The Unit Supervisor said to Resident #75 you will have to wait until after breakfast for your medication. Review of Resident #75's Medication Administration Audit Report, dated July 2024, indicated nursing administered his/her physician's ordered 8:00 A.M. gabapentin and baclofen doses (which are scheduled three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M.) were administered after the prescribed time on the following dates and times: 7/1/24 administered at 9:24 A.M., 1 hour and 24 minutes after the scheduled time, 7/2/24 administered at 3:55 P.M., 1 hour and 55 minutes after the scheduled time, 7/3/24 administered at 12:31 P.M., 4 hours and 31 minutes after the scheduled time, 7/4/24 administered at 9:34 A.M., 1 hour and 34 minutes after the scheduled time, 7/5/24 administered at 5:27 P.M., 9 hours and 27 minutes after the scheduled time, 7/6/24 administered at 11:29 A.M., 3 hours and 29 minutes after the scheduled time, 7/8/24 administered at 10:10 A.M., 2 hours and 10 minutes after the scheduled time, 7/10/24 administered at 11:46 A.M., 3 hours and 36 minutes after the scheduled time, 7/11/24 administered at 1:35 P.M., 5 hours and 35 minutes after the scheduled time, 7/15/24 administered at 1:56 P.M., 5 hours and 56 minutes after the scheduled time, 7/17/24 administered at 10:21 A.M., 2 hours and 21 minutes after the scheduled time, 7/19/24 administered at 9:47 A.M., 1 hour and 47 minutes after the scheduled time, 7/20/24 administered at 11:44 A.M., 3 hours and 44 minutes after the scheduled time, 7/22/24 administered at 11:43 A.M., 3 hours and 43 minutes after the scheduled time, 7/23/24 administered at 10:11 A.M., 2 hours and 11 minutes after the scheduled time, 7/24/24 administered at 9:39 A.M., 1 hour and 39 minutes after the scheduled time, 7/30/24 administered at 9:51 A.M., 1 hour and 51 minutes after the scheduled time. Review of Resident #75's Medication Administration Audit Report, dated July 2024, indicated nursing administered his/her physician's ordered 8:00 P.M. gabapentin and baclofen doses (which are scheduled three times daily at 8:00 A.M., 2:00 P.M., and 8:00 P.M.) were administered after the prescribed time on the following dates and times: 7/2/24 administered at 10:16 P.M., 2 hours and 16 minutes after the scheduled time, 7/3/24 administered at 9:13 P.M., 1 hour and 13 minutes after the scheduled time, 7/6/24 administered at 9:12 P.M., 1 hour and 12 minutes after the scheduled time, 7/14/23 administered at 10:11 P.M., 2 hours and 11 minutes after the scheduled time, 7/16/24 administered at 10:23 PM., 2 hours and 23 minutes after the scheduled time, 7/23/24 administered at 9:19 P.M., 1 hour and 19 minutes after the scheduled time, 7/24/24 administered at 9:30 P.M., 1 hour and 30 minutes after the scheduled time, 7/26/24 administered at 9:41 P.M., 1 hour and 41 minutes after the scheduled time. Review of Resident #75's nurse practitioner progress note, dated 7/17/24 and 7/19/24, indicated: - chronic back pain with history of compression fracture and back spasms - has history of traumatic compression fractures as well as fractures related to falls. - currently takes gabapentin and baclofen. - M54.59 - Other low back pain: Patient has a history of traumatic compression fractures as well as fractures related to falls. He/she currently takes gabapentin 100 mg every 6 hours (Q6H) as needed (PRN) and baclofen 10 mg three times daily (TID). Patient does ambulate with walker in the long-term care facility. Review of Resident #75's physician progress note, dated 7/24/24, indicated: - Patient is requesting tramadol for back pain. Family Member reports that he/she will always ask a new nurse if he/she is getting tramadol. The older nurses that know him/her tell him/her yes he/she is getting tramadol. Family Member encourages this and would like us to continue doing this with the patient as he/she gets worked up and agitated when he/she finds that he/she is not getting tramadol. There is a new nurse today who referred him/her to me. Did review the patient's medications with the Family Member and appears that he/she is on 2 different muscle relaxers. I will stop the baclofen at this. Patient has had behavior agitation past related to his/her dementia but none currently. On exam patient is able to bend and back without problem able to bend his right leg without problem. No objective signs of pain. [sic] During an interview on 7/29/24 at 4:40 P.M., the Director of Nursing (DON) said medications should be administered within one hour of the scheduled times and pain management medications should be given on time.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Comprehensive Plan of Care indicated he/she was dependent on two staff for transfers, the Facility failed to ensure nursing staff implemented and followed interventions from his/her Plan of Care to have two or more staff members present for assistance with transfers. On 06/15/23 Certified Nurse Aide (CNA) #1 transferred Resident #1 using the Hoyer Lift (a mechanical lift, which also required two staff members) without assistance from another staff member. During the transfer, Resident #1 sustained an injury to the outer aspect of his/her right leg, was transferred to the Hospital Emergency Department, and required six sutures to close his/her leg wound. Findings include: The Facility Policy, titled Comprehensive Care Plan, dated 01/2023, indicated a comprehensive, person-centered care plan would be developed and implemented for each resident, and the services provided by the Facility as outlined by the comprehensive care plan would be provided in accordance with each resident's written plan of care. The Facility Policy, titled Transfers, dated 01/2023, indicated at least two staff members were needed to transfer a resident when using a lift device. Resident #1 was admitted to the Facility in August 2013, diagnoses included dementia, toxic encephalopathy, and arthritis. Review of Resident #1's Care Kardex (used as a quick reference for caregivers and updated to reflect the most current Care Plan), indicated he/she required extensive assistance from two staff members for all transfers. Review of Resident #1's Physical Therapy Plan of Care, indicated Resident #1 was unable to ambulate, and required the use of the Hoyer Lift for transfers. Review of the Activities of Daily Living Care Plan, dated as revised on 01/23/23, indicated Resident #1 was dependent for transfers and required the assistance of two staff members. Review of the Quarterly Minimal Data Set Assessment, dated 03/30/23, indicated Resident #1 was totally dependent for transfers and required a minimum of two staff members to help with transfers. Review of the Nurse Progress Note, dated 06/15/23, indicated Resident #1 had an injury on his/her right leg that was bleeding, open, and deep into the skin tissue. The Note indicated Resident #1 was transferred to the Hospital Emergency Department via ambulance. Review of the Hospital Emergency Department Discharge Note, dated 06/16/23, indicated Resident #1 was evaluated and treated for a laceration to his/her right leg and required sutures (total of six sutures) to close the wound. Review of the Initial Wound Evaluation and Management Summary, dated 06/20/23, indicated Resident #1 had a trauma related wound to his/her right anterior (outside) shin, which measured 4.5 centimeters (cm) long x 0.1 cm wide, and there were six sutures in place. During interview on 07/25/23 at 1:59 P.M., Certified Nurse Aide (CNA) #1 said that on 06/15/23 she was the CNA assigned to Resident #1, and at 7:00 P.M., she transferred Resident #1 from his/her reclining wheelchair to his/her bed using the Hoyer Lift by herself. CNA #1 said she wasn't sure if Resident #1's leg had bumped into anything during the transfer. CNA #1 said after she transferred Resident #1 and positioned him/her on the bed, she noticed blood on Resident #1's right foot and pants leg, and said she then notified Nurse #5. CNA #1 said she knew it was Facility policy that resident transfers using the Hoyer Lift required at least two staff members to be present. CNA #1 said she knew where to access Resident #1's Care Kardex, and that Resident #1 required physical assistance from two staff members for transfers. CNA #1 said she should have had another staff member there to assist her with the transfer, but did not. During interview on 07/26/23 at 12:45 P.M., Nurse #5 said that on 06/15/23 at 7:00 P.M., CNA #1 told her that Resident #1 had a wound on his/her right leg. Nurse #5 said she assessed Resident #1's right leg wound and said it was a fresh wound that was bleeding. Nurse #5 said CNA #1 told her that she had transferred Resident #1 to bed using the Hoyer Lift by herself. During interview on 07/25/23 at 1:03 P.M., Nurse #1 said that on 06/15/23 at 7:00 P.M., Nurse #5 told her that Resident #1 had a new wound on his/her right leg. Nurse #1 said the wound was deep and open, and Resident #1 was transferred to the Hospital Emergency Department. Nurse #1 said CNA #1 said she had transferred Resident #1 using the Hoyer Lift by herself. Nurse #1 said staff were required to have at least two staff members present to assist with a Hoyer Lift transfers for safety. Nurse #1 said Resident #1's Care Plan and Kardex indicated staff were to transfer him/her with assistance of two staff members. During interview on 07/25/23 at 8:26 A.M., the Director of Nurses (DON) said it was an intervention identified in Resident #1's Care Plan and on his/her Care Kardex that he/she required two staff assistance for transfers with the Hoyer Lift. The DON said the facility policy also indicated that two staff members where required for mechanical lift transfers. The DON said CNA #1 should have had another staff member with her assisting with Resident #1's transfer, but had not, and as a result, Resident #1 sustained a wound to his/her right leg. On 07/25/23, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 06/16/23, The Hospital Emergency Department Discharge Note indicated Resident #1 was evaluated and treated for a laceration to his/her right leg and sutures (six) were placed to close the wound. B. 06/16/23, The Hoyer/Lift/Sit-to-stand Inspection Log indicated the Director of Maintenance inspected the Hoyer Lift and found no sharp edges or other signs of defects. C. 06/19/23, The Quality Improvement Plan minutes indicated the Facility developed a plan of correction related to Hoyer transfers. D. 06/19/23, The Inservice and Training Record indicated nursing staff were re-educated by the DON/designee to the Facility Policy titled, Transfers. E. 06/18/23 through 07/03/23, the DON conducted weekly audits of Hoyer transfers with staff and found staff were using two assist, as required. F. Audits of Hoyer Lift transfers will be conducted by the DON/designee monthly for three months. G. The results of the audits will be brought to QAPI for three months or until compliance is met. H. The DON and/or designee are responsible for ongoing compliance.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members assistance for transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in injury. On 06/15/23, Certified Nurse Aide #1, who was assigned to provide care for Resident #1, transferred him/her using the Facility's Hoyer Lift (a mechanical lift, which also requires two staff members) without assistance from another staff member. As a result, during the transfer Resident #1 sustained an injury to the outer aspect of his/her right leg, was transferred to the Hospital Emergency Department and required six sutures to close his/her leg wound. Findings include: The Facility Policy titled, Accidents and Incidents, dated 10/2022, indicated an incident was defined as any occurrence not consistent with the routine operation of the Facility, or normal care of the residents. The Facility Policy, titled Transfers, dated 01/2023, indicated at least two staff members were needed to transfer a resident when using a lift device. Resident #1 was admitted to the Facility in August 2013, diagnoses included dementia, toxic encephalopathy, and arthritis. Review of Resident #1's Care Kardex (used as a quick reference for caregivers and updated to reflect the most current Care Plan), indicated he/she required extensive physical assistance from two staff members for all transfers. Review of Resident #1's Physical Therapy Plan of Care, indicated Resident #1 was unable to ambulate, and required the use of the Hoyer Lift for transfers. Review of the Activities of Daily Living Care Plan, dated as revised on 01/23/23 indicated Resident #1 was dependent for transfers and required physical assistance of two staff members. Review of the Quarterly Minimal Data Set Assessment, dated 03/30/23, indicated Resident #1 was totally dependent for transfers and required a minimum of two nursing staff members for assistance with transfers. Review of the Nurse Progress Note, dated 06/15/23, indicated Resident #1 had an injury on his/her right leg that was bleeding, open, and deep into the skin tissue. The Note indicated Resident #1 was transferred to the Hospital Emergency Department via ambulance. Review of the Hospital Emergency Department Discharge Note, dated 06/16/23, indicated Resident #1 was evaluated and treated for a laceration to his/her right leg and required sutures (total of six) to close the wound. Review of the Initial Wound Evaluation and Management Summary, dated 06/20/23, indicated Resident #1 had a trauma related wound to his/her right anterior (outside) shin, which measured 4.5 centimeters (cm) long x 0.1 cm wide, and there were six sutures in place. During interview on 07/25/23 at 1:59 P.M., Certified Nurse Aide (CNA) #1 said that on 06/15/23 she was the CNA assigned to Resident #1, and at 7:00 P.M., she transferred Resident #1 from his/her reclining wheelchair to his/her bed using the Hoyer Lift by herself, and said she wasn't sure if Resident #1's leg had bumped into anything during the transfer. CNA #1 said after she transferred Resident #1 and positioned him/her on the bed, she noticed blood on Resident #1's right foot and pants leg, and said she then notified Nurse #5. CNA #1 said she knew it was Facility policy that resident transfers using the Hoyer Lift required at least two staff members to be present. CNA #1 said she knew where and how to access Resident #1's Care Kardex. CNA #1 said that Resident #1 required physical assistance from two staff members for transfers, and said she should have had another staff member assist with the transfer, but had not. During interview on 07/26/23 at 12:45 P.M., Nurse #5 said that on 06/15/23 at 7:00 P.M., CNA #1 told her that Resident #1 had a wound on his/her right leg. Nurse #5 said she assessed Resident #1's right leg wound and said it was a fresh wound that was bleeding. Nurse #5 said CNA #1 told her she had transferred Resident #1 to bed using the Hoyer Lift by herself. During interview on 07/25/23 at 1:03 P.M., Nurse #1 said that on 06/15/23 at 7:00 P.M., Nurse #5 told her that Resident #1 had a new wound on his/her right leg. Nurse #1 said the wound was deep and open, and Resident #1 was transferred to the Hospital Emergency Department. Nurse #1 said CNA #1 said she transferred Resident #1 using the Hoyer Lift by herself. Nurse #1 said staff were required to have at least two staff members present to assist for Hoyer Lift transfers for safety. Nurse #1 said Resident #1's Care Plan and Care Kardex indicated staff were to transfer him/her with an assistance of two staff members. During interview on 07/25/23 at 8:26 A.M., the Director of Nurses (DON) said it was an intervention identified in Resident #1's Care Plan and Care Kardex for two staff to provide assistance for transfers, and that it was also facility policy that two staff members are required to transfer with the Hoyer Lift. The DON said CNA #1 should have had another staff member assisting with Resident #1's transfer, but had not, and as a result, Resident #1 sustained a wound to his/her right leg. On 07/25/23, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 06/16/23, The Hospital Emergency Department Discharge Note indicated Resident #1 was evaluated and treated for a laceration to his/her right leg and sutures were placed to close the wound. B. 06/16/23, The Hoyer/Lift/Sit-to-stand Inspection Log indicated the Director of Maintenance inspected the Hoyer Lift and found no sharp edges or other sign of defects. C. 06/19/23, The Quality Improvement Plan minutes indicated the Facility developed a plan of correction related to Hoyer transfers. D. 06/19/23, The Inservice and Training Record indicated nursing staff were re-educated by the DON/designee to the Facility Policy titled, Transfers. E. 06/18/23 through 07/03/23, the DON conducted weekly audits of Hoyer transfers with staff and found staff were using two assist, as required. F. Audits of Hoyer Lift transfers will be conducted by the DON/designee monthly for three months. G. The results of the audits will be brought to QAPI for three months or until compliance is met. H. The DON and/or Designees are responsible for ongoing compliance.

Based on observation, record review, and interview, the facility failed to ensure residents received adequate supervision and revision of care plan interventions as needed to prevent falls, resulting in falls with injury for 2 Residents (#3, #40 ) out of a total of 21 sampled residents. Findings include: Review of the facility's Fall Management policy, dated 1/28/22, indicated: *Evaluate and monitor resident of 72 hours after the fall. *Investigate fall circumstances. *Record circumstances, resident outcome, along with resident and staff response. *Implement immediate intervention within first 24 hours. *Develop plan of care. 1. Resident #3 was admitted to the facility in July 2018 with diagnoses including Alzheimer's disease, repeated falls and lack of coordination. Review of Resident #3's most recent Minimum Data Set assessment dated [DATE] and 10/15/22 indicated he/she is severely cognitively impaired and Resident #3 required physical assistance with ambulation, transfers, dressing and tilting. On 4/14/22 at 8:05 A.M., the surveyor observed Resident #3 seated alone in the [NAME] Unit dining room. There were no staff in the area to monitor or supervise him/her. Review of Resident #3's falls reports indicated the following: 4/11/21: Resident found on floor by bathroom sent to emergency room . Resident #3 sustained a left ankle fracture. Resident #3's fall care plan was revised on 4/24/21 with an intervention to ensure Resident #3 was wearing appropriate foot wear while mobilizing in his/her wheelchair; (an intervention first initiated on 7/5/2018.) 7/2/21: Resident #3 was found on the floor in his/her in bathroom. There were no updates to his/her care plan. 8/7/21: Resident #3 was found on the floor in his/her bathroom. There were no updates to his/her care plan in response to the fall. 10/9/21: Resident #3 was found standing in his/her bathroom calling for help and staff arrived and lowered him/her to the floor. There were were no updates to his/her care plan in response to the fall. 11/8/21: Resident #3 was found just outside his/her bedroom door on the floor. Resident #3 was sent to the hospital and sustained a left tibia and fibula fracture and dislocated his/her left shoulder, and multiple stitches on his/her forehead and chin. There were no updates to his/her care plan in response to the fall. 12/16/21: Resident #3 was found on the floor in his/her bathroom calling for help. There were no updates to his/her care plan in response to the fall. 1/20/22: Resident #3 was found on the floor in his/her bathroom calling for help. There were no updates to his/her care plan in response to the fall. 2/23/22: Resident #3 was found on the floor in his/her bathroom calling for help. There were no updates to his/her care plan in response to the fall. During an interview with the Covering Director of Nursing on 4/13/22 at 1:00 P.M., she said that when a resident falls, it is expected that the residents' care plan is updated with an intervention. She said that Resident #3's falls care plan should have been updated. 2. For Resident #40, the facility failed to revise/update the care plan to prevent further falls. Resident #40 had 3 falls from November 2021 to February 2022 with 2 falls resulting in fractures. Resident #40 was admitted to the facility in 10/2018 with a diagnosis of dementia. A quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #40 scored a 3 out of a possible 15 on the Brief Interview of Mental Status, indicating Resident #40 had severe cognitive impairment. Resident #40 also required limited assistance with bed mobility, transfers and locomotion. Review of Resident #40's care plan for falls included the following interventions: - Lock brakes on bed, chair before transferring. - Call light within reach. - Area free of clutter. - Prompt response to all requests for assistance. - Wear appropriate footwear. Review of a facility Incident Report Form dated 11/8/21 indicated Resident #40 fell at 9:00 P.M. on 11/8/21. According to the report, a yell was heard from down the hall. Resident #40 was found slumped against the side of the bed laying on the right side. Resident #40 complained of right hip pain and had difficulty extending right leg and bearing weight. Resident #40 was sent to the emergency room and diagnosed with a right pubic ramus fracture. Review of Resident #40's care plan indicated there were no further interventions put in place to prevent further falls upon his/her return from the hospital. On 11/20/21 at 9:14 A.M., Resident #40 fell again. According to the facility's Incident Report, Resident #40's roommate came out of the room screaming and Resident #40 was found sitting on the floor in front of his/her bed. Resident #40 was unable to state what happened due to memory impairment. There were no injuries noted at the time. Review of Resident #40's care plan for falls indicated the care plan was not updated with interventions to prevent further falls. A significant change Minimum Data Set, dated dated dated [DATE] indicated Resident #40 scored a 3 out of a possible 15 on the Brief Interview for Mental Status, indicating Resident #40 had severe cognitive impairment. Resident #40 also required extensive assistance with bed mobility and limited assistance with transfers and locomotion. A facility Incident Report dated 2/22/22 indicated Resident #40 sustained another fall resulting in a fracture. According to the report, on 2/22/22 at 2:30 P.M., Resident #40 was observed in the hallway on his/her left side. Resident #40 complained of discomfort to the left hip and was sent to the emergency room where he/she was diagnosed with a left hip fracture. The report indicated there were no witnesses to the incident, although review of a witness statement dated 2/22/22 from CNA #4 indicated Resident #40 was walking down the hall alone and fell on the floor. Resident #40 was not receiving assistance as required. Review of a physician's note dated 3/1/22 indicated the physician addressed Resident #40's most recent fall and made the following recommendation: - Hip protectors or hip pads for added protection. Review of Resident #40's care plan was not updated to include hip protectors, nor any other new interventions. During an interview with Nurse #3 on 4/14/22 at 12:15 P.M., she stated Resident #40 has never had hip protectors and did know if they were available. On 4/14/22 at 12:30 P.M., the Director of Nursing stated residents care plans should be updated to include interventions to prevent further falls.

Based on interview and record review, the Facility failed to implement it's suicide prevention policy. On [DATE], Nurse #1 and the Nurse Practitioner became aware that Family Member #1 reported that Resident #1 said he/she was going to kill him/herself. Nurse #1 and the Nurse Practitioner did not notify the Director of Nursing and all personnel involved in caring for Resident #1 consistent with the Facility Policy for Suicide Threats. The Physician said that, on [DATE], he read the Nurse Practitioner's note, dated [DATE], regarding Resident #1's alleged statement about killing him/herself and did not notify the Director of Nursing and all personnel involved in caring for Resident #1 consistent with the Facility Policy for Suicide Threats. Resident #1 shot him/herself in the head with a 357 Magnum his/her room around 10:15 P.M. on [DATE]. Findings include: The Surveyor reviewed the Facility Policy for Suicide Threats revised [DATE] which indicated that staff should report any knowledge of resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse who would immediately assess the situation and notify the Director of Nursing. The Policy indicated that all personnel and other staff involved in caring for the resident shall be informed of the suicide threat/ideation and were instructed to report changes in the resident's behavior immediately. The Surveyor interviewed Nurse #1 at 12:50 P.M. on [DATE] and her undated written statement was reviewed. Nurse #1 said that, on [DATE], she received a telephone call from Family Member #1. Nurse #1 said that Family Member #1 told her that Resident #1 told Family Member #1 during a telephone call that he/she was going to kill him/herself. The Surveyor interviewed Family Member #1 at 6:25 P.M. on [DATE]. Family Member #1 said that on [DATE], she spoke to Resident #1 by telephone. Family Member #1 said that when she and Resident #1 discussed whether he/she would discharge home or remain in the Facility for long term care, Resident #1 told her that euthanasia was a third option. Family Member #1 said she was concerned about Resident #1's statement and mentioned it to Family Member #2. Family Member #1 said that Family Member #2 told her that Resident #1 had spoken to her about killing him/herself. The Surveyor asked Family Member #1 whether she reported Resident #1's statement about euthanasia to Nurse #1 and she said that she had many conversations with staff members at the Facility concerning Resident #1's status and plans but she did not specifically remember telling Nurse #1 about Resident #1's statement regarding euthanasia. The Surveyor left telephone messages for Family Member #2 on [DATE] and [DATE] but as of [DATE] had not received a response. The Surveyor interviewed the Detective at 10:20 A.M. on [DATE]. The Detective said that he interviewed Family Member #3. The Detective said that Family Member #3 told him that Family Member #2 told her that she called the Facility to notify staff members that Resident #1 was talking about killing him/herself. Nurse #1 said that on [DATE] she told the Nurse Practitioner that Family Member #1 called and told her that Resident #1 said that he/she was going to kill him/herself. The Surveyor asked Nurse #1 whether she reported Family Member #1's statement to the Nurse Manager, the Director of Nurses or staff members assigned to Resident #1's care and she said that she did not. The Surveyor interviewed the Nurse Practitioner at 6:45 P.M. on [DATE] and her note regarding her visits with Resident #1, on [DATE], was reviewed. The Nurse Practitioner said that she saw Resident #1 before breakfast on [DATE] for a routine readmission visit. The Nurse Practitioner said that during the visit, Resident #1 told her that he/she was feeling a little depressed and he/she asked the Nurse Practitioner how she would feel if she were told that she would never walk again. The Nurse Practitioner said that she offered support to Resident #1 and offered to have him/her evaluated by the Facility psychiatric service for counseling and Resident #1 said no. The Nurse Practitioner said that a while after her visit with Resident #1, Nurse #1 reported to her that she received a telephone call from Family Member #1. The Nurse Practitioner said that Nurse #1 reported to her that Family Member #1 said she spoke to Resident #1 over the telephone and Resident #1 told Family Member #1 something about wanting to die. The Nurse Practitioner said that she returned to Resident #1's room and told him/her that she was concerned because Nurse #1 had just gotten off of the telephone with Family Member #1 and Family Member #1 said that Resident #1 told her that he/she wanted to kill himself. The Nurse Practitioner said that Resident #1 told her he/she felt embarrassed that the statement trickled back to the Nurse Practitioner. The Nurse Practitioner said that Resident #1 told her that the statement was a misunderstanding and he/she said that he/she was feeling frustrated about his/her situation. The Nurse Practitioner said that Resident #1 told her that, during a conversation about finances, he/she asked Family Member #1 what would happen to financially to Family Member #2 if he/she died , if he/she killed him/herself. The Nurse Practitioner said that Resident #1 told her that he/she did not have a plan to kill him/herself. The Nurse Practitioner said that she left Resident #1 feeling comfortable with his/her safety and believing that Family Member #1's report was a misunderstanding. The Surveyor asked the Nurse Practitioner whether she attempted to contact Family Member #1 for additional information about Resident #1's statement and she said that she did not. The Nurse Practitioner said that after she spoke to Resident #1 about Family Member #1's telephone call she reviewed the content of the conversation with Nurse #1 and filed her written note, which described her conversation with Resident #1, in Resident #1's chart. The Surveyor asked the Nurse Practitioner whether she reported Nurse #1's statement about her telephone call with Family Member #1 and the subsequent interview of Resident #1 to the Director of Nurses or staff members assigned to Resident #1's care and she said that she did not. The Nurse Practitioner said that she was not aware of the Facility Policy regarding Suicide Threats at that time. The Nurse Practitioner said that the Nurse Manager was present during part of her conversation with Nurse #1 about her interview of Resident #1. The Surveyor interviewed the Nurse Manager at 3:40 P.M. on [DATE]. The Nurse Manager said that on [DATE], the Nurse Practitioner told her that she had spoken to Resident #1 because he/she asked Family Member #1 what would happen financially to Family Member #2 if he/she died . The Nurse Manager said that she worked on Resident #1's unit on [DATE], [DATE] and [DATE] and she was not aware that Family Member #1 or Family Member #2 expressed concern that Resident #1's said he/she was going to kill him/herself. The Surveyor asked the Nurse Manager whether she read the Nurse Practitioner's note on [DATE] and she said that she did not. The Surveyor interviewed all of the staff members who cared for Resident #1 on [DATE], [DATE] and [DATE]. The Surveyor interviewed Nurse #5 at 12:40 P.M. on [DATE]. The Surveyor interviewed Certified Nurse Aide (CNA) #3 at 9:00 A.M. on [DATE]. The Surveyor interviewed Nurse #6 at 10:10 A.M. on [DATE]. The Surveyor interviewed CNA #1 at 8:30 P.M. on [DATE]. The Surveyor interviewed Nurse #7 at 5:00 P.M. on [DATE]. The Surveyor interviewed CNA #4 at 10:00 A.M. on [DATE]. The Surveyor interviewed CNA #3 at 9:00 A.M. on [DATE]. The Surveyor interviewed Nurse #8 at 1:50 P.M. on [DATE]. The Surveyor interviewed Nurse #2 at 7:10 P.M. on [DATE]. The Surveyor interviewed Nurse #3 at 7:55 P.M. on [DATE]. The Surveyor interviewed Nurse #4 at 5:10 P.M. on [DATE]. The Surveyor interviewed the Nurse Supervisor at 8:50 A.M. on [DATE] and his undated written statement was reviewed. Nurses #2, #3, #4, #5, #7, #8 and CNAs #1, #3 and #4 and the Nurse Supervisor said they were not aware that Family Member #1 or Family Member #2 reported that Resident #1 said that he/she was going to kill him/herself during the shifts that they worked with him/her between [DATE] and [DATE]. Nurse #4 said that around 10:15 P.M. on [DATE], she heard a loud bang from Resident #1's room. Nurse #4 said that she and the Nurse Supervisor responded to Resident #1's room. Nurse #4 said that when she entered the room she could smell smoke and she saw Resident #2, who was Resident #1's roommate, walking toward the doorway to the room with his/her fingers blocking his/her ears. Nurse #4 said that the Nurse Supervisor said that Resident #1 shot him/herself, there was a gun on the floor and the Nurse Supervisor told her to call 911. Nurse #4 said that the 911 dispatcher told her to check Resident #1 for signs of life. Nurse #4 said that the Nurse Supervisor checked Resident #1 twice for signs of life and reported that there were none. The Nurse Supervisor said that at 10:20 P.M. on [DATE] he heard a loud pop and responded to Resident #1's room. The Nurse Supervisor said Resident #1 was slumped to the left in his/her wheelchair with blood coming out his/her mouth and nose. The Nurse Supervisor said he saw a chrome handgun with a wooden handle partly in Resident #1's hand and his/her back was covered with blood. The Nurse Supervisor said he checked Resident #1's head for an exit wound and found none. The Nurse Supervisor said he assessed Resident #1 found no pulse and let no one else in Resident #1's room until police arrived. The Police Report, dated [DATE] at 10:17 indicated police were called to the Facility for a resident who shot him/herself. The Police Report indicated that the Resident appeared to have shot himself in the mouth with a 357 Smith and Weston (SIC) revolver which was registered to him/herself. The Surveyor interviewed Resident #2 at 7:40 P.M. on [DATE]. Resident #2 said that he/she and Resident #1 shared a room. Resident #2 said that the curtain was drawn between their beds when he/she heard a loud bang and felt a rush of wind. Resident #2 said that he/she stood up and looked around the curtain and was about to ask what was that when he/she noticed that Resident #1 was holding a small gun in his/her hands and blood was coming out of Resident #1's mouth. Resident #2 said two staff members came into the room and took him/her out of the room. The Surveyor interviewed the Director of Nurses at 11:00 A.M. on [DATE]. The Director of Nurses said that he came to the Facility, around 11:00 P.M. on [DATE], after the incident in which Resident #1 shot him/herself. The Director of Nurses said that he reviewed Resident #1's referral documents and made sure that all necessary notifications were made. The Director of Nurses said that he reviewed Resident #1's record a second time, on [DATE] around 11:00 A.M., and saw the Nurse Practitioner's note from [DATE] which described the telephone call from Family Member #1 reporting that Resident #1 said that he/she was going to kill him/herself. The Director of Nurses said that the first time that he/she was aware of Resident #1's alleged statement was on [DATE], three days after the statement was reported and about 12 hours after Resident #1 killed him/herself. The Director of Nursing said that he would begin educating staff members on the Suicide Threat Policy.

Based on interview and record review, the Facility failed to develop a comprehensive care plan, for one of three sampled Residents (Resident #1), in response to a report from Family Member #1, on [DATE], that he/she said he/she intended to kill him/herself. Although the Interpretive Guidance to the Federal Regulation indicates that an interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment, the Nurse Practitioner and Physician documented their assessments of Resident #1 on [DATE] and [DATE] respectively, but did not involve the interdisciplinary team and Resident #1's family, in their plan to monitor Resident #1 for suicidal ideation. No monitoring and change to Resident #1's care plan was initiated and, on [DATE] at about 10:15 P.M., Resident #1 shot him/herself in the head with a handgun. Findings include: The Surveyor interviewed Nurse #1 at 12:50 P.M. on [DATE] and her undated written statement was reviewed. Nurse #1 said that on [DATE] she received a telephone call from Family Member #1. Nurse #1 said that Family Member #1 told her that Resident #1 told Family Member #1 during a telephone call that he/she was going to kill him/herself. The Surveyor interviewed Family Member #1 at 6:25 P.M. on [DATE]. Family Member #1 said that on [DATE] she spoke to Resident #1 by telephone. Family Member #1 said that when she and Resident #1 discussed whether he/she would discharge home or remain in the Facility for long term care, Resident #1 told her that euthanasia was a third option. Family Member #1 said she was concerned about Resident #1's statement and mentioned it to Family Member #2. Family Member #1 said that Family Member #2 told her that Resident #1 had spoken to her about killing him/herself. The Surveyor asked Family Member #1 whether she reported Resident #1's statement about euthanasia to Nurse #1 and she said that she had many conversation with staff members at the Facility concerning Resident #1's status and plans but she did not specifically remember telling Nurse #1's about Resident #1's statement regarding euthanasia being an option for him/her. The Surveyor left telephone messages for Family Member #2 on [DATE] and [DATE] but as of [DATE], did not receive a response. Nurse #1 said that after she hung up the telephone with Family Member on [DATE], she told the Nurse Practitioner that Family Member #1 called and told her that Resident #1 said that he/she was going to kill him/herself. The Surveyor interviewed the Nurse Practitioner at 6:45 P.M. on [DATE] and her note regarding her visits with Resident #1 on [DATE] was reviewed. The Nurse Practitioner said that she saw Resident #1 before breakfast on [DATE] for a routine readmission visit. The Nurse Practitioner said that during the visit, Resident #1 told her that he/she was feeling a little depressed and he/she asked the Nurse Practitioner how she would feel if she were told that she would never walk again. The Nurse Practitioner said that she offered support to Resident #1 and offered to have him/her evaluated by the Facility psychiatric service for counseling and Resident #1 said no. The Nurse Practitioner said that later in the day on [DATE], after her morning visit with Resident #1, Nurse #1 reported to her that she received a telephone call from Family Member #1. The Nurse Practitioner said that Nurse #1 reported to her that Family Member #1 said she spoke to Resident #1 over the telephone and Resident #1 told Family Member #1 something about wanting to die. The Nurse Practitioner said that she returned to Resident #1's room and told him/her that she was concerned because Nurse #1 had just gotten off of the telephone with Family Member #1 and Family Member #1 said that Resident #1 told her that he/she wanted to kill him/herself. The Nurse Practitioner said that Resident #1 told her he/she felt embarrassed that the statement trickled back to the Nurse Practitioner. The Nurse Practitioner said that Resident #1 told her that the statement was a misunderstanding and he/she said that he/she was feeling frustrated about his/her situation. The Nurse Practitioner said that Resident #1 told her that during a conversation about finances he/she asked Family Member #1 what would happen financially to Family Member #2 if he/she died , if he/she killed him/herself. The Nurse Practitioner said that Resident #1 told her that he/she did not have a plan to kill him/herself. The Nurse Practitioner said that she left Resident #1's room feeling comfortable with his/her safety and believing that Family Member #1's report was a misunderstanding. The Nurse Practitioner's Note regarding her visit with Resident #1 on [DATE] identified the following assessment and plan for Resident #1's depression: Depression-Long discussion about current situation, and statements. He/she declines plan for suicide, is able to state his/her stressors, and things that make him/her happy. He/she does not feel overly depressed but frustrated with current situation. Would continue antidepressant medication as ordered for now, continue supportive care, monitor for suicidal ideation. The Surveyor asked the Nurse Practitioner about the plan to monitor Resident #1 for suicide ideation. The Nurse Practitioner said that the plan for monitoring was for the Physician to follow up on his next scheduled visit. The Nurse Practitioner said that she did not think that monitoring by staff members between her visit and the Physician's next scheduled visit was warranted. The Nurse Practitioner said she had a conversation with Nurse #1 and the Nurse Manager and expected nurses to report back any further statements from him/her to her. The Nurse Practitioner said that she told Resident that she would be in back in the Facility on [DATE] and the Physician would be in the Facility on [DATE]. The Surveyor asked the Nurse Practitioner whether she called Family Member #1 for additional information about what Resident #1 said to her and she said that she did not. The Nurse Practitioner said that she filed her note in Resident #1's clinical record. The Physician's note, dated [DATE], indicated Resident #1 was evaluated on this date. The note indicated that Resident #1's psychiatric status was pleasant and made no references to the Nurse Practioner's note from [DATE] regarding his/her suicidal ideation. In the area identified as Assessment and Plan the Physician documented that Resident #1's depression was improved. The Surveyor interviewed the Physician at 7:45 P.M. on [DATE]. The Physician said that, on [DATE] he read the Nurse Practitioner's note from [DATE] and met with Resident #1. The Physician said that he did not ask Resident #1 about his/her conversation with Family Member #1 or with the Nurse Practitioner, but he assessed his/her mental status and mood. The Physician said that Resident #1 was fine, jovial, not depressed and not suicidal. The Surveyor asked the Physician about the Nurse Practitioner's plan to monitor Resident #1 for suicidal ideation and the Physician did not think that monitoring by staff members was warranted given his assessment of Resident #1. The Physician said that, since Resident #1 was alert and oriented, he was questioned by Nurse Practitioner regarding the statement reported by Family Member #1 about killing him/herself. The Physician said that when Resident denied that he/she intended to kill him/herself, his/her statements were taken at face value. The Physician said that the standard of care was for the Physician or Nurse Practitioner to question and assess residents who allegedly made statement indicative of suicidal ideation. The Physician said that if residents told the Physician or Nurse Practitioner that they were experiencing suicidal ideation, they were sent to the emergency department for evaluation, but if the resident said that they were not, then the Physician or Nurse Practitioner moved on. The Physician said it was not appropriate to brow beat a resident who made a statement suggestive of suicidal ideation when they might have just had a bad day. Although the Physician said that, unequivocally, additional staff monitoring of Resident #1 for suicidal ideation when he and the Nurse Practitioner were not in the Facility was not warranted, this is not consistent with the Facility Policy regarding Suicide Threats. The Surveyor reviewed the Facility Policy for Suicide Threats revised [DATE] which indicated that all personnel and other staff involved in caring for the resident shall be informed of the suicide threat/ideation and instructed to report changes in the resident's behavior immediately. The Surveyor interviewed the Nurse Supervisor at 8:50 A.M. on [DATE] and his undated written statement was reviewed. The Nurse Supervisor said that at 10:20 P.M. on [DATE] he heard a loud pop and responded to Resident #1's room. The Nurse Supervisor said Resident #1 was slumped to the left in his/her wheelchair with blood coming out his/her mouth and nose. The Nurse Supervisor's said he saw a handgun with a wooden handle partly in Resident #1's hand and his/her back was covered with blood. The Nurse Supervisor said he checked Resident #1's head for an exit wound and found none. The Nurse Supervisor said he assessed Resident #1 and found no pulse. The Nurse Practioner said he instructed other staff members to call 911 and secured Resident #1's room until police arrived. The Police Report, dated [DATE] at 10:17 P.M. indicated police were called to the Facility for a resident who shot him/herself. The Police Report indicated that the Resident appeared to have shot himself in the mouth with a 357 Smith and Weston (SIC) revolver. The Surveyor interviewed the Nurse Manager at 3:40 P.M. on [DATE]. The Nurse Manager said that on [DATE], the Nurse Practitioner told her that she had spoken to Family Member #1 because Resident #1 asked Family Member #1 what would happen financially if he/she died . The Nurse Manager said that she worked on Resident #1's unit on [DATE], [DATE] and [DATE] and she was not aware that Family Member #1 reported to Nurse #1 that Resident #1 said he/she was going to kill him/herself. The Surveyor asked the Nurse Manager whether she read the Nurse Practitioner's note on [DATE] and she said that she did not. The Nurse Manager said that normally a resident's care plan would be updated to include potential for suicidal ideation, but Resident #1's care plan for alteration in mood was not updated to include the potential for suicide ideation because she was not informed by the Nurse Practitioner or Nurse #1. The Surveyor interviewed the Social Worker at 2:30 P.M. on [DATE]. The Surveyor asked the Surveyor when she became aware that Family Member #1 reported that Resident #1 told her he/she intended to kill him/herself. The Social Worker said that she read the Nurse Practitioner's note, on [DATE], note after Resident #1's suicide. The Social Worker said that she normally would review and update a resident's alteration in mood care plan to ensure that contact information for the psychiatric crisis team was available to staff members who noted in changes in a Resident's mood or behavior.