Every finding on record at Salem Transitional Care

Based on observation, interview and record review it was determined the facility failed to implement appropriate contact precautions for 3 of 3 sampled residents (#s 8, 23 and 125) reviewed for contact precautions. This placed residents at risk for the spread of infection. Findings include: The facility's Contact Precautions policy, dated 9/10/25, indicated to don appropriate PPE before or upon entry into the environment (e.g., room) of resident on contact precautions. 1. Resident 8 was admitted to the facility in 8/2026 with diagnoses including vascular dementia and a stroke. A 7/15/26 care plan revealed Resident 8 had CRE (Carbapenem-resistant Enterobacterales, a bacteria that causes infection in the stomach and is resistant to most antibiotics) and was on Contact Precautions in attempt to prevent transmission of the bacteria. On 7/20/26 at 2:12 PM a Contact Precautions sign was observed outside Resident 8's room. The Contact Precautions sign directed staff to perform hand hygiene, wear gloves and gown upon entering the room, discard the PPE upon exiting and perform hand hygiene again. On 7/20/26 at 2:14 PM Staff 19 (CNA) was observed assisting Resident 8 to eat a snack inside the resident's room. Staff 19 was observed not wearing gloves or a gown. On 7/20/26 at 2:21 PM Staff 19 stated she was unsure when to wear PPE and thought PPE was only needed when Resident 8 required ADL care. Staff 19 reviewed the Contact Precautions sign on Resident 8's door and stated she did not need to wear PPE all the time when in Resident 8's room. On 7/23/26 at 12:34 PM Staff 5 (RNCM) stated staff were to wear a gown and gloves every time they were in a room for a resident on Contact Precautions. On 7/24/26 at 11:14 AM Staff 16 (IP) stated staff were to wear a gown and gloves every time they entered a room of a resident on Contact Precautions, especially when assisting the resident to eat, and staff were to wash their hands with soap and water before exiting the resident's room. 2. Resident 23 was admitted to the facility in 7/2026 with diagnoses including C. diff (Clostridium difficile, a bacterium which causes an infection of the colon) and diabetes. A 7/6/26 care plan revealed staff were to follow Contact Precautions when they provided care to Resident 125 due to a diagnosis of C. diff. On 7/23/26 at 10:40 AM a Contact Precautions sign was observed outside Resident 23's room. The Contact Precautions sign directed staff to: perform hand hygiene, wear gloves and gown upon entering room, and wash hands with soap and water prior to exiting the resident room. On 7/23/26 at 10:42 AM Staff 20 (CNA) was observed in Resident 23's room and was not wearing gloves or a gown while placing Resident 23's personal belongings in a bag and picking up Resident 23's water container from the bedside table. Staff 20 was observed to exit Resident 23's room without washing her hands with soap and water. Staff 20 was observed to speak with the nurse and then wash her hands with soap and water at the sink located at the nurses station. On 7/23/26 at 10:49 AM Staff 20 confirmed she was not wearing the required PPE while in Resident 23's room and did not wash her hands as required prior to exiting the resident's room. On 7/23/26 at 12:34 PM Staff 5 (RNCM) stated staff were to wear a gown and gloves every time they were in a room for a resident on Contact Precautions. On 7/24/26 at 11:14 AM Staff 16 (IP) stated staff were to wear a gown and gloves every time they entered a room for a resident on Contact Precautions, especially when touching items in the residents room, and staff were to wash their hands with soap and water before exiting the resident's room. 3. Resident 125 admitted to the facility in 7/2026 with diagnoses including C. diff (Clostridium difficile, a bacterium which causes an infection of the colon). A 7/17/26 Care Plan revealed staff were to follow Contact Precautions when they provided care to Resident 125 due to a diagnosis of C. diff. On 7/20/26 at 10:32 AM a Contact Precautions sign was observed outside Resident 125's room. The Contact Precautions sign directed staff to: perform hand hygiene with soap and water, wear gloves and gown upon entering room, and wash hands with soap and water prior to exiting the resident room. On 7/20/26 at 10:35 AM Staff 9 (CNA) was observed to exit Resident 125's room without washing her hands with soap and water. Staff 9 stated she planned to wash her hands outside of the resident's room. Staff 9 reviewed the Contact Precautions sign on Resident 125's door and confirmed it directed her to wash her hands with soap and water before she exited the room. On 7/20/26 at 12:51 PM Staff 10 (CMA) was observed to exit Resident 125's room without washing his hands with soap and water. Staff 10 confirmed he did not wash his hands with soap and water before he exited the resident's room. On 7/20/26 at 12:54 PM Staff 12 (CNA) entered Resident 125's room without donning a gown or gloves to deliver Resident 125's room to deliver a lunch tray and did not wash her hands with soap and water before she exited the room. Staff 12 stated she believed it was not necessary to follow the Contact Precautions when she dropped off a meal in Resident 125's room. 0n 7/23/2026 at 2:18 PM Staff 2 (DNS) stated staff were to wear a gown and gloves every time they entered a room for a resident on Contact Precautions and were to wash their hands with soap and water before they exited Resident 125's room.

Based on observation, interview, and record review it was determined the facility failed to provide a homelike dining environment for 1 of 1 dining rooms reviewed for resident council. This placed residents at risk for an institutional dining experience and lower quality of life. Findings include: A review of the 6/2026 Resident Council Meeting Minutes revealed the residents liked having tablecloths on the tables in the dining room. The dietary department responded stating, labor cuts have eliminated linens on tables. I don't see them coming back any time soon.Random observations from 7/20/26 through 7/24/26 during mealtimes revealed the dining room to not have tablecloths on any table.On 7/22/26 at 2:00 PM during the resident council meeting, the residents in attendance stated the dining room was more inviting with tablecloths and made residents want to eat meals in the dining room. One resident stated she/he ate in her/his room because, the facility doesn't put in the effort, so it makes you not want to put in the effort in coming down to the dining room. The residents stated they were told by the facility due to budget reasons they could not have tablecloths. On 7/22/26 at 4:00 PM Staff 17 (Activity Director) stated the tablecloths in the dining room went away around the time of transition to the new company in December 2025 or January 2026.On 7/24/26 at 12:22 PM Staff 1 (Executive Director) and Staff 3 (CEO Lead) stated they were unsure why the previous administrator discontinued tablecloths in the dining room. Staff 3 stated it was not a direction from upper management and labor cuts would not have anything to do with tablecloths in the dining room. Staff 1 and Staff 3 acknowledged the dining room was not a homelike environment.

Based on interview and record review it was determined the facility failed to ensure there was a designated staff member responsible for collaborating and communicating with hospice representatives, and that the care plan included the hospice plan of care for 1 of 1 sampled resident(#2) reviewed for hospice. This placed residents at risk for uncoordinated and unmet hospice care needs. Findings include:Resident 2 was admitted to the facility in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder.An Election of Benefits and Informed Consent document revealed Resident 2 was admitted to hospice services on 5/24/26. Resident 2's Care Plan did not include hospice related information, such as a Hospice Plan of Care. On 7/22/26 at 12:06 PM Staff 6 (RNCM) indicated she did not know what information needed to be on a care plan for residents receiving hospice services and did not know which staff members were responsible for collaborating and coordinating with hospice representatives for Resident 2. Staff 6 acknowledged Hospice Plan of Care information was not included in Resident 2's Care Plan. On 7/22/26 at 12:34 PM Staff 2 (DNS) acknowledged the facility did not have designated staff members identified to communicate and collaborate with hospice representatives for Resident 2, and Hospice Plan of Care information was not included in Resident 2's Care Plan.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary antihypertensive and anticonvulsant medications for 1 of 6 sampled residents (#112) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medication. Findings include:Resident 112 was admitted to the facility in 4/2026 with diagnoses including depression and diabetes.A review of Resident 112's Allergy List included an allergy to gabapentin (an anticonvulsant medication).The 4/17/26 admission MDS revealed Resident 112 had a BIMS score of 14, indicating she/he was cognitively intact.On 4/26/26 a public complaint was received by the State Agency alleging the facility administered Resident 112 gabapentin and hydralazine (an antihypertensive medication) that were not prescribed to her/him. Resident 112 was allergic to gabapentin and was sent to the hospital emergency room.A 4/26/26 at 3:06 PM Progress Note by Staff 21 (LPN) revealed a CMA administered the wrong medication including gabapentin 300 mg and hydralazine 50 mg to Resident 112. It was noted Resident 112 had an allergy to gabapentin. Staff 21 notified the resident of the medication error, assessed her/him, notified the resident's emergency contact and the physician, who directed the staff to send the resident to the emergency room.A 4/26/26 at 10:38 PM Progress Note revealed Resident 112 returned to the facility from the hospital emergency room with no new orders.A Medication Error Report dated 4/27/26 revealed Staff 22 (CMA) mistakenly entered the wrong resident room and administered gabapentin 300 mg and hydralazine 50 mg to Resident 112 on 4/26/26. Staff 22 immediately realized the mistake and notified Staff 21 of the medication error. On 7/23/26 at 4:04 PM Staff 22 stated on 4/26/26 she was covering a hall she never worked on before and mixed up the resident rooms. Staff 22 stated she realized her mistake right away and notified Staff 21. Staff 22 stated it was an accident and she learned her lesson to always complete the five rights of medication administration- the right patient, the right medication, the right dose, the right route and the right time.On 7/24/26 at 11:49 AM Staff 2 (DNS) stated she expected staff who administered medication to residents to verify the five rights, look at the resident picture in the medical record and to ask the charge nurse if they were unsure. Staff 2 acknowledged Resident 112 was administered gabapentin and hydralazine unnecessarily.

Based on interview and record review it was determined the facility failed to initiate treatment for an identified skin issue for 1 of 1 sampled resident (#32) reviewed for pressure wounds. This placed residents at risk for worsening wounds. Findings include: Resident 32 admitted to the facility on [DATE] with diagnoses including sepsis.A 7/19/26 Skin Inspection Evaluation revealed Resident 32 admitted to the facility with an open lesion and redness to her/his coccyx.A review of Resident 32's medical record revealed no orders or care instructions related to Resident 32's coccyx skin lesion. On 7/20/26 at 2:22 PM Resident 32 stated she/he admitted from the hospital with a crack in my seat and the facility was supposed to continue treating the area, but she/he had not yet heard an update on it.On 7/22/26 at 1:15 PM Staff 11 (LPN) stated she completed the Skin Inspection Evaluation on 7/19/26 when Resident 32 admitted to the facility and recalled there was a small skin area identified. Staff 11 did not recall if Resident 32's skin area was an actual wound and stated she passed it along to the next shift to follow up on care.On 7/23/26 at 11:13 AM Staff 14 (LPN) stated she worked with Resident 32 and was not aware of any current wounds.On 7/23/26 at 12:139 PM Staff 5 (RNCM) reviewed Resident 32's Skin Inspection Evaluation and stated the nurse was expected to request care orders for any identified skin concerns.On 7/23/26 at 1:29 PM Staff 5 stated Resident 32's skin was observed and confirmed there were no orders in place for care. Staff 5 stated she expected the nurse who identified the skin issue to notify the provider and request treatment.

Based on interview and record review it was determined the facility failed to complete a comprehensive assessment within the regulatory timeframe for 1 of 2 sampled residents (#128) reviewed for resident assessment. This placed residents at risk for unassessed care needs. Findings include: Resident 128 admitted to the facility on [DATE].A 7/9/2026 admission MDS was completed on 7/22/26, five days after the regulatory timeframe.On 7/22/26 at 12:06 PM Staff 7 (RN MDS Coordinator) confirmed Resident 128's admission MDS was not completed within the regulatory timeframe.

Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notification to 1 of 3 sampled residents (#130) reviewed for Beneficiary Notification. This placed residents at risk for lack of information related to financial liability. Findings include: Resident 130 admitted to the facility on [DATE] with Medicare Part A benefits.A Notice of Medicare Non-Coverage was issued to Resident 130 on 2/14/26 with the last day covered by Medicare Part A of 2/17/26. A review of the medical record revealed Resident 130 remained private pay in the facility from 2/18/26 to 2/24/26, and there was no evidence of a SNF ABN.On 7/22/26 at 2:00 PM Staff 13 (Resident Support Services Assistant) confirmed she issued a Notice of Medicare Non-Coverage with a last Medicare covered day of 2/17/26 to Resident 130. Staff 13 confirmed Resident 130 remained in the facility after 2/17/26 and she/he did not receive a SNF ABN.On 7/24/26 at 12:53 PM Staff 1 (Executive Director) acknowledged the SNF ABN was not issued to Resident 130.

Based on interview and record review it was determined the facility failed to complete a Significant Change MDS within the required timeframe for 1 of 1 sampled resident (#2) reviewed for hospice. This placed residents at risk for unassessed needs. Findings include:Resident 2 was admitted to the facility in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document revealed Resident 2 was admitted to hospice services on 5/24/26. The Significant Change MDS was completed on 6/18/26, 11 days after the required 14-day timeframe. On 7/22/26 at 12:27 PM Staff 8 (MDS Coordinator) acknowledged the Significant Change MDS completion date exceeded the required 14-day timeframe.

Based on observation, interview and record review it was determined the facility failed to ensure the state survey inspection results contained the most recent survey results for 1 of 1 facility reviewed for resident council. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include:On 7/22/26 at 2 PM during the resident council meeting, the residents in attendance stated they were not aware of where to find the state survey inspection results in the facility.On 7/22/26 at 4:14 PM an observation was made of the Survey Findings Binder at the front entrance to the facility across from the receptionist desk. The binder did not contain all of the 2025 survey findings and there were no 2026 survey findings included. On 7/22/26 at 4:48 PM Staff 1 (Executive Director) stated the administrator oversaw updating the state survey inspection result binder. Staff 1 acknowledged the binder was not updated with the most recent survey results.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 7 sampled residents (# 2) reviewed for physician orders. This placed residents at risk for medical complications and unmet medication needs. Findings include: Resident 2 was admitted to the facility in 7/2025 with a diagnosis of fracture right lower leg. Resident 2's admission MDS dated [DATE] revealed the resident had a BIMS score of 13 and was cognitively intact. The facility's Risk Management report dated 8/3/25 and a Progress Note dated 8/3/25 identified the facility failed to follow a physician's STAT order placed on 8/1/25 for Lokelma (a medication used to treat high blood potassium levels) for Resident 2. The on-call provider was notified of the missed medication and instructed nursing staff to send the resident to the emergency room. Resident 2 was sent to the emergency room on 8/3/25. On 1/26/25 at 2:59 PM, Witness 2 (Hospital Social Worker) stated the facility failed to administer a physician-ordered medication for Resident 2's elevated potassium level, and the resident was sent to the hospital related to the missed medication. On 1/29/26 at 2:08 PM, Staff 10 (LPN) stated a medication error occurred in August involving Resident 2's Lokelma dose. Staff 10 stated an incident report should have been written but could not recall if one was completed. Staff 10 recalled Resident 2 was sent to the hospital due to the missed medication. On 1/29/26 at 1:11 PM, Staff 6 (RN/RCM) stated she remembered a medication error involving Resident 2's Lokelma but could not recall any details of the findings. On 1/28/26 at 2:02 PM, Staff 1 (Assistant Administrator in Training), Staff 2 (Field Lead for Oregon/Cascadia), Staff 3 (Chief Nursing Officer), and Staff 4 (Assistant Chief Nursing Officer) all acknowledged Resident 2 should have received the STAT Lokelma dose as ordered.

Based on interview and record review it was determined the facility failed to provide transfer assistance for 1 of 3 sampled residents (# 4) reviewed for ADL assistance. This placed residents at risk for unmet care needs.Resident 4 was admitted to the facility in 10/2025 with diagnoses of sepsis (unspecified organism), lobar pneumonia, and acute respiratory failure with hypoxia. A Nursing Care Note dated 10/31/25 documented Resident 4 was assisted back to her/his room after dinner. The assisting staff left the resident alone in her/his wheelchair in the room while obtaining assistance for a two-person transfer. Staff did not return to the resident's room for over one hour. Resident 4's MDS admission assessment dated [DATE] indicated the resident had a BIMS score of 14, was cognitively intact and was dependent for wheelchair mobility. A Risk Management Report dated 10/31/25, completed by Staff 12 (LPN), confirmed Resident 4 was left alone in her/his wheelchair in the room for over an hour while awaiting transfer assistance. On 1/26/26 at 2:10 PM, Witness 4 (Complainant) stated her/his family member was left alone in her/his wheelchair for an extended period of time waiting to be transferred into bed. On 1/28/26 at 11:50 AM, Staff 13 (CNA) stated Resident 4 was assigned to the resident on 10/31/25, evening shift. Staff 13 reported she was also assigned dining room duties and was unable to leave the dining room while residents were still eating. Staff 13 stated she requested another CNA to assist Resident 4 back to her/his room. Staff 13 later found Resident 4 sitting alone in her/his wheelchair in the room awaiting transfer to bed. On 1/28/26 at 6:35 PM, Staff 12 (LPN) confirmed completion of a Risk Management Report related to Resident 4 being left alone in her/his wheelchair for over an hour while awaiting transfer assistance. On 1/29/26 at 10:02 AM, Resident 4 stated she/he was left alone in her/his room for approximately one hour and ten minutes waiting to be transferred into bed. Resident 4 stated she/he did not have a call light or phone within reach, experienced pain, and was unable to transfer or ambulate the wheelchair independently. On 1/28/26 at 2:02 PM. Staff 1 (Assistant Administrator in Training), Staff 2 (Field Lead for Oregon/Cascadia), Staff 3 (Chief Nursing Officer), and Staff 4 (Assistant Chief Nursing Officer) all acknowledged Resident 4 should have received more timely transfer assistance.

Based on interview and record review it was determined the facility failed to ensure a heat pack was safely applied for 1 of 1 sampled resident (#76) reviewed for accidents. Resident 76 sustained burns. Findings include: On 11/23/24 the Past Noncompliance was corrected when the facility initiated an investigation, identified the root cause of the incident, and provided CNA and nurse in-service training on the use of heat packs. The training included: 1. A nurse was to approve a heat pack prior to use for each resident, 2. A barrier was to be applied between the heat source and the resident's skin, and 3. A heat pack was only to be left on for a maximum of 20 minutes. Resident 76 was admitted to the facility in 10/2024 with a diagnosis of kidney disease. Resident 76's 11/3/24 admission MDS revealed she/he was cognitively intact, required partial assistance with upper body dressing, and did not have skin impairment. Resident 76's 11/2024 TAR did not have interventions for a heat pack. Resident 76's Progress Notes revealed the following: -11/23/24: Resident 76 was provided a heat pack on 11/22/24 and she/he did not know there was a limit on how long to apply the heat pack. Resident 76 was not able to verbalize how long the heat pack was left on her/his skin. The resident's skin was assessed to have small uncapped blisters to the shoulder and arm. Resident 76's skin was red and the blisters were noted to be superficial. A 11/23/24 Burn investigation revealed on 11/23/24 Resident 26 presented with superficial blisters on the left shoulder and underarm. Resident 26 reported the blisters were from a heat pack. The investigation revealed a CNA obtained the heat pack without communicating with a nurse prior to providing the heat pack to Resident 76. The heat pack was an insta-hot pack which was activated when pressure was applied. The CNA did not apply the heat pack but handed it to Resident 76. A barrier was not provided to the resident. On 4/8/25 at 2:26 PM Staff 18 (CNA) stated in 11/2024 she recalled providing Resident 76 a heat pack and Resident 76 applied the heat pack her/himself. Staff 18 stated she did not recall additional details. On 4/9/25 at 10:42 AM a telephone call was placed to Resident 76. The phone number was no longer in service. On 4/9/25 at 11:42 AM Staff 2 (DNS) stated Resident 76 had standing orders for a heat pack but the orders were not transcribed onto the TAR. An unidentified CNA provided the heat pack, the resident applied the heat pack, but staff did not ensure the heat pack was removed timely. On 4/10/25 at 9:14 AM Staff 14 (LPN) stated Resident 76 had chronic skin conditions. On 11/22/24 Resident 76 requested a heat pack at the end of a CNA's shift. An unidentified CNA provided a heat pack to the resident and left the facility. Resident 76 kept the heat pack on for a long time, exact amount of time was unknown. The next morning, Resident 76 reported she/he had itching to her/his arm and shoulder region and when Staff 14 assessed the area, she observed clear blisters and uncapped blisters. It looked like the top of her/his skin came off. Staff 14 stated Resident 14 did not report increased pain.

Based on interview and record review, it was determined the facility failed to ensure annual performance reviews for CNA staff were completed for 5 of 5 sampled CNA staff (#s 3, 4, 5, 6, and 7) reviewed for staffing. This placed residents at risk due to lack of competent staff. Findings include: A review of personnel profile records revealed the following. -Staff 3 (hired on 2/19/15): performance review dated 3/20/20. -Staff 4 (hired on 1/13/15): performance review dated 2/2/18. -Staff 5 (hired on 3/23/15): performance review dated 3/11/21. -Staff 6 (hired on 12/5/18): performance review dated 3/25/20. -Staff 7 (hired on 2/19/20): No performance review provided. In a 4/15/25 interview at 7:18 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 22 (Administrator in Training), Staff 2 stated she expected annual performance reviews to be completed in a timely manner.

Based on interview and record review, it was determined the facility failed to have a system to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 4, 5, 6, and 7) reviewed for in-service training. This placed residents at risk for care provided by incompetent staff. Findings include: A review of the facility's staff training records revealed the following: -Staff 4 (CNA), hired 1/13/15, had 1.5 hours of documented training (1/13/24-1/13/25). -Staff 5 (CNA), hired 3/23/15, had 2.25 hours of documented training (3/23/24-3/23/25). -Staff 6 (CNA), hired 12/5/18, had no documented training hours (12/5/23-12/5/24). -Staff 7 (CNA), hired 2/19/20, had 8.62 hours of documented training (2/19/24-2/19/25). In a 4/15/25 interview at 7:18 AM with Staff 1 (Administrator), Staff 2 (DNS), and Staff 22 (Administrator in Training), Staff 2 stated CNA staff were expected to complete the required 12 hours of training annually.

Based on interview and record review, it was determined the facility staff failed to follow professional standards of practice for medication administration for 1 of 1 sampled resident (# 77) reviewed for medication administration.This placed residents at risk for unsafe medication administration. Findings include: Resident 77 was admitted to the facility in 9/2024 with diagnoses including brain cancer and stroke. On 9/20/24, a FRI was received on 9/20/24 which alleged Staff 30 (Former CNA) administered medication to Resident 77. The 4/2019 facility policy; Administering Medications indicated: -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. -The 10/2024 Scope of Practice Nurses vs CNAs indicated when medications are left in the resident's room, (usually not allowed) notify the nurse; do not administer or assist. The FRI indicated Staff 29 (CMA) entered Resident 77's room with morning medications and found Staff 30 was providing personal care for Resident 77. Staff 29 left the resident's medication on the bedside table and left the resident's room. Staff 30 attempted to administer medication to Resident 77, but Resident 77 stated no, no no and told Staff 30 to stop. Witness 7 (Friend) also told Staff 30 to stop administering medication to Resident 77, ran out of Resident 77's room to the nurses station, and yelled, Staff 30 was administering medication to Resident 77 by the spoonful. Resident 77 was able to take medications one at a time with water. Witness 7 stated, Resident 77 was yelling no, no, no and spitting the medication back into the medication cup. Witness 7 stated Staff 30 continued to administer medications until Staff 29 and Staff 32 (RCM-LPN) removed her from Resident 77's room. Resident 77 was discharged from the facility on 10/31/24. On 4/9/25 at 11:21 AM, 4/10/25 at 9:39 AM, and 4/10/25 at 9:45 AM, Staff 30 was called for an interview multiple times, answered the phone, then hung up. On 4/9/25 at 3:12 PM, Staff 32 stated Staff 29 left Resident 77's medication on the bedside table while Staff 30 provided personal care for the resident and left the resident's room to provide privacy. Staff 30 began administering the resident's medications; Resident 77 and Witness 7 told her to stop but she did not. On 4/10/25 at 8:29 AM, Staff 29 stated he went to Resident 77's room to administer her/his morning medication, but Staff 30 was providing personal care, so he left the resident's medication on the bedside table and left the resident's room. Staff 29 stated Witness 7 came out of the resident's room yelling Staff 30 was administering Resident 77's medication by the spoonful, and she/he told her to stop, but she did not stop. Staff 29 stated he went to Resident 77's room with Staff 32 to help the resident. Staff 29 acknowledged he should not have left medications on the resident's bedside table. On 10/4/25 at 9:04 AM, Staff 14 (LPN) stated she heard Witness 7 yelling and headed to the nurses station, stating Staff 30 was administering Resident 77's medication, and Resident 77 told Staff 30 to stop, but she did not. On 4/10/25 at 9:12 AM, Staff 7 (CNA) stated she went into Resident 77's room to assist Staff 30 with personal care for the resident and observed Staff 30 administering medication to Resident 77. Resident 77 and Witness 7 yelled for her to stop. Staff 29 and Staff 27 came into the resident's room to assist the resident and removed Staff 30 from the resident's room. On 4/10/25 at 3:33 PM, Staff 2 (DNS) stated Staff 30 acknowledged she understood administering medications to residents was a task she was not allowed to complete. Staff 2 stated CNAs should not administer medications, and her expectation is for certified, trained staff to administer medications, and definitely not a CNA.

Based on interview and record review, the facility failed to honor resident preference for medication administration for 1 of 1 resident (#77) reviewed for choices. This placed residents at risk for not having the opportunity to exercise her/his autonomy (self-governance) regarding choices. Findings include: Resident 77 was admitted to the facility in 9/2024 with diagnoses including stroke. A FRI (Facility Reported Incident) was received on 9/20/24. It alleged Resident 77 was administered her/his medications with a spoon, all at one time, by Staff 30 (Former CNA). Resident 77 was to receive her/his medication one pill at a time with water or applesauce. Resident 77 and Witness 7 (Friend) told Staff 30 to stop administering the medications multiple times, but she did not stop. Witness 7 went to the nurses station and found a nurse to stop Staff 30 from administering Resident 77's medications. Resident 77 and Witness 7 told Staff 14 (LPN) the resident took her/his medications one at a time with water or applesauce per her/his choice. A 9/20/24 Nursing Care Note added to special instructions per resident request: Meds: one at a time with water, cut large pills in half Instructions placed on the cover sheet for staff to follow. On 4/9/25 at 3:12 PM, Staff 32 (LPN-RCM) stated Resident 77 took her/his medication one pill at a time with water or applesauce, one at a time per her/his choice.

2. Resident 52 was admitted to the facility in 3/2024 with a diagnosis of Parkinson's disease. Resident 52's Progress Notes revealed on 3/18/25 she/he was discharged to the hospital. Resident 52's clinical record did not indicate the State's LTCO's (Long Term Care Ombudsman) office was notified of her/his facility discharge. On 4/10/25 at 12:02 PM Staff 23 (Discharge Coordinator) stated she did not notify the State's LTCO office of residents' discharges. On 4/10/25 at 3:04 PM Staff 2 (DNS) stated she thought Staff 23 notified the LTCO office when residents were discharged . Staff 2 stated the LTCO office was not notified on 3/18/25 when Resident 52 was discharged from the facility. Based on interview and record review it was determined the facility failed to notify office of the State long-term care ombudsman of the transfer/discharge for 2 of 2 sampled residents (#s 26 and 52) reviewed for hospitalization. This placed residents at risk for lack of notification of their transfer/discharge. Findings include: Resident 26 admitted to the facility in 2/2025 with diagnoses including acute kidney failure and sepsis. A 3/15/25 progress note indicated Resident 26 was sent to the hospital on 3/17/25 for shortness of breath. A review of the resident's clinical record revealed no evidence the Long-term care ombudsman's office was notified of the resident's transfer/discharge. On 3/18/25 at 12:33 PM Staff 2 (DNS) acknowledged the ombudsman was not notified of Resident 26's discharge to the hospital.

Based on interview and record review, it was determined the facility failed to honor resident choice for 1 of 1 sampled resident (#77) reviewed for medication administration. This placed residents at risk for choking. Findings include: Resident 77 was admitted to the facility in 9/2024 with diagnoses including brain cancer and stroke. A 9/20/24 FRI was received on 9/20/24 which alleged Staff 30 (Former CNA) administered medication to Resident 77. The 4/2019 facility policy, Administering Medications indicated: -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. -The 10/2024 Scope of Practice Nurses vs CNAs indicated when medications are left in the resident's room, (usually not allowed) notify the nurse; do not administer or assist. The FRI indicated Staff 29 (CMA) entered Resident 77's room with her/his morning medications and realized Staff 30 was providing personal care for Resident 77. Staff 29 placed the resident's medication on the bedside table and left the resident's room. Staff 30 attempted to administer the medications to Resident 77. Witness 7 (Friend) ran out of Resident 77's room to the nurses station and yelled, Staff 30 was administering medications to Resident 77 by the spoonful, but Resident 77 was only able to take medications one at a time with water. Witness 7 stated, Resident 77 was yelling no, no, no and spitting the medications back into the medication cup, but Staff 30 did not stop. On 4/9/25 at 11:21 AM, 4/10/25 at 9:39 AM, and 4/10/25 at 9:45 AM, Staff 30 was called multiple times for an interview, answered the phone, then hung up. On 4/9/25 at 3:12 PM, Staff 14 (LPN) stated Staff 29 left Resident 77's medication on the bedside table and left the resident's room while Staff 30 provided personal care for Resident 77. Staff 30 attempted to administer Resident 77's medications while the resident and Witness 7 told her to stop. On 4/10/25 at 8:29 AM, Staff 29 stated he went to Resident 77's room to administer her/his morning medication, but Staff 30 was providing personal care, so he left her/his medication at the bedside to return later to administer the medication. Staff 29 stated Witness 7 came out of Resident 77's room yelling Staff 30 administered Resident 77's medications by the spoonful, was told to stop multiple times but did not stop. On 4/10/25 at 9:04 AM, Staff 32 (RCM-LPN) heard Witness 7 yelling and headed to the nurses station, stating Staff 30 was administering Resident 77's medications, and Resident 77 and Witness 7 told her to stop multiple times but she did not stop. On 4/10/25 at 9:12 AM, Staff 7 (CNA) stated she went into Resident 77's room to assist Staff 30 with care for Resident 77 and observed Staff 30 administering medications to Resident 77. Resident 77 and Witness 7 were yelling for her to stop, but she did not. Staff 29 and Staff 32 came into the resident's room to assist the resident and remove Staff 30 from the resident's room. On 4/15/25 at 9:38 AM, Staff 2 (DNS) stated Staff 30 was observed administering Resident 77 her/his medications when she knew this was outside her scope of practice. Staff 2 stated if a resident is stating no, staff need to stop what they are doing. Staff 2 stated her expectation was certified staff and nurses were the only staff allowed to administer medications, not CNAs.

Based on observation, interview, and record review it was determined the facility failed to ensure residents' pressure injuries were monitored and care plans were updated for 2 of 3 sampled residents (#s 52 and 77) reviewed for pressure ulcers and choices. This placed residents at risk for worsening pressure injuries. Findings include: 1. Resident 52 was readmitted to the facility on [DATE] with a diagnosis of blood loss anemia. Resident 52's care plan for skin impairment initiated 3/7/25 and last revised on 3/10/25 revealed she/he was at risk for pressure ulcers due to weakness. Interventions included weekly skin assessments and new skin impairments were to be reported to the nurse. Resident 52's 3/18/25 admission MDS revealed Resident 52 was admitted to the facility with no pressure ulcers but had maroon discoloration to her/his great toes. Staff were to monitor her/his skin weekly. Resident 52's 3/30/25 Admission Nursing Database revealed Resident 52 did not have skin impairment. Resident 52's Progress Notes dated 3/31/25 by Staff 13 (RN) revealed a second skin check was completed and Resident 52 was assessed to have redness to the tips of both great toes. Resident 52's clinical record had no additional assessments related to the redness to the tips of the great toes related to size and if the impairment was blancheable (Pushing on a red area of the skin impedes circulation, when the pressure is removed, the areas is white and should return to the original color). Resident 52's 4/2025 TAR revealed staff applied compression socks in the morning and removed the socks at bedtime from 4/1/25 though 4/8/25. On 4/7/25 at 3:30 PM, during a phone interview, Witness 6 (Spouse) stated Resident 52 had pressure areas to the tips of her/his toes from he/his compression socks. Witness 6 stated she/he tried to loosen the toes of Resident 52's compression socks to prevent pressure. On 4/8/25 at 3:31 PM with Staff 16 (RNCM/Assistant DNS) Resident 52 was observed to have dark red/brown areas to the tops of both great toes. Staff 16 stated Resident 52's clinical record indicated she/he did not have skin impairment on 4/2/25. A 4/9/25 Weekly Skin Audit revealed a skin irregularity was previously identified. DTIs (Deep tissue injury-purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear). On 4/9/25 at 3:14 PM an interview occurred with Staff 16 and Staff 2 (DNS). Staff 2 stated if a skin issue was identified she was to be notified then she reassessed the skin injury and determined the type of care and monitoring the injury required. Staff 2 stated if a skin injury was a pressure ulcer it should be monitored and measured weekly. Staff 2 stated she was not aware Resident 52 had skin impairment to her/his great toes. On 4/9/25 at 3:26 PM Staff 13 (RN) stated on 3/31/25 when she assessed Resident 52, she/he had red areas to her/his great toes. Staff 13 stated she did not measure the red areas and did not reassess the areas after 3/31/25. Staff 13 stated the redness may have been from the compression socks. Staff 20 (LPN) stated he believed he checked the red areas to Resident 52's toes, the areas were blancheable, and Resident 52 expressed pain when the toes were touched. 34703 2. Resident 77 was admitted to the facility in 9/2024 with diagnoses including brain cancer and stroke. The facility's Accident and Incidents-Investigation and Reporting policy dated 7/2017 indicated the nurse supervisor, charge nurse, and/or the department director or supervisor shall promptly initiate and document an investigation of an accident or incident. The 9/12/24 Nursing Admission Evaluation revealed Resident 77 had intact skin, bruising around an IV (Intravenous line), and a small scab on her/his right shin. There was no evidence which indicated Resident 77 had redness to her/his coccyx (tailbone) or to her/his buttocks. The 9/16/24 Admission MDS indicated: Resident 77 was incontinent of bladder and bowel, at risk for skin breakdown, and needed assistance with bed mobility. The resident had no pressure injuries and was cognitively intact. Staff would proceed to the care plan for ongoing assessment for prevention of skin breakdown. Staff would monitor and document the location, size, and treatment of any skin injury. Staff would report abnormalities, failure to heal, signs and symptoms of infection, maceration (softening of skin due to moisture), etc., to the MD (Medical Doctor). Staff would report any new skin impairment to the LN (Licensed Nurse) immediately. The 9/17/24 Skin and Wound Evaluation indicated Resident 77 developed a facility-acquired Stage 2 (partial-thickness skin loss) pressure wound to the sacrum (triangular bone at the base of the spine), medial, and middle areas. The wound measured 77.9 cm by 8.9 cm by 11.3 cm. On 4/10/25 at 10:38 AM, Staff 2 (DNS) acknowledged the resident's wound was most likely present upon admission but was not identified until 9/17/24. Staff 2 stated the resident had a DTI (deep tissue injury) from the coccyx to the medial gluteal cleft (the crease between the buttocks), a Stage 2 pressure ulcer to the right buttocks, and redness to the surrounding areas. Staff 2 acknowledged the wound assessment was not accurate, the care plan was not revised related to the wounds, and no incident report was completed. Staff 2 stated her expectation was if a new wound was identified, the nurses should call the physician, start an investigation, document accurately, and update the care plan.

Based on interview and record review it was determined the facility failed to provide a resident representative a bed hold policy for 1 of 2 sampled residents (#52) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to their right to return to the facility. Findings include: Resident 52 was admitted to the facility in 3/2024 with a diagnosis of Parkinson's disease. Resident 52's 3/11/25 admission MDS revealed she/he was cognitively impaired. Resident 52's Progress Notes revealed she/he was discharged to the hospital on 3/18/25. Resident 52's clinical record did not indicate Witness 6 (Spouse) was notified of the facility's bed hold policy. On 4/7/25 at 3:28 PM Witness 6 stated on 3/18/25, when Resident 52 was hospitalized , she/he was not notified of the bed hold policy. On 4/10/25 at 10:27 AM Staff 23 (Admissions) stated she provided the bed-hold policy to residents and/or their representative upon admission to the facility and when residents were hospitalized . If a resident was hospitalized she called the resident or representative and provided the information by phone then documented in the resident's progress notes. Staff 23 stated on 3/18/25 she did not notify Resident 52's representative of the bed-hold policy. Staff 23 stated if she was not in the facility, nurses were to provide the notification and document in the progress notes. On 4/10/25 at 3:04 PM Staff 2 (DNS) verified on 3/18/25 the bed hold policy was not provided to Resident 52 or her/his representative.

Based on interview and record review it was determined the facility failed to accurately assess, monitor, and prevent worsening of pressure ulcers for 1 of 3 residents (#1) reviewed for pressure ulcers. This failure resulted in the resident developing bilateral (both sides) Stage 4 pressure ulcers to the buttocks which required hospitalization , surgical intervention and placed other residents at risk for worsening pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel defined the following pressure injury stages: Stage 2 pressure ulcers: partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident 1 admitted to the facility in 12/2023 with diagnoses including diabetes with a foot ulcer, renal failure, spinal cord injury, and failure to thrive. On 12/14/23 a Brief Interview for Mental Status Evaluation the resident had a score of 15 which indicated she/he was cognitively intact. On 12/14/23 A Braden Scale for Predicting Pressure Sore Risk indicated the resident scored 16 and was at risk for developing pressure ulcers. An Admission Nursing database note dated 12/14/23 under skin integrity indicated the resident's skin was normal, warm, and dry. The resident had no open wounds. There was blanchable redness to the buttocks, a penny size scab to the mid abdomen, a scar scab to the left shin, a left second toe pressure sore, and groin redness. Resident 1's 12/2023 TAR contained an order with a start date of 12/15/23 for staff to monitor the blanching redness to the buttocks and to notify the provider if any worsening occurred until resolved and every day shift ensure CNAs were applying barrier cream. The TAR indicated staff documented they monitored the redness and ensured the barrier cream was applied from 12/16/23 through 12/27/23. The nursing staff monitoring the redness on the buttocks failed to identify a Stage 2 pressure ulcer that developed on 12/20/23 or that it worsened to an Unstageable pressure ulcer on 12/27/23. An Admission MDS dated [DATE] indicated the resident was at risk for developing pressure ulcers based on needing extensive assistance with bed mobility. The MDS also indicated the resident had a Stage 2 pressure ulcer and a deep tissue injury (DTI) on admission. According to Admission Nursing Database records the resident did not have a Stage 2 pressure ulcer or a (DTI) on admission. A review of the daily Nursing Advanced Skilled Evaluations for Resident 1 from 12/14/23 through 1/3/24 revealed nursing staff failed to identify the redness on the resident's buttocks had deteriorated to a Stage 2 pressure ulcer on 12/20/23 and then to an Unstageable pressure ulcer on 12/27/23. A Documentation Survey Report for December 2023 directed CNAs to encourage frequent position changes to promote skin integrity and was put in place on 12/27/23, after the resident's wound was identified as an Unstageable pressure ulcer. A facility receipt indicated an air mattress for Resident 1 was delivered on 1/11/2024. Its placement on the resident's bed was not noted in the resident's documentation until 1/17/23. A review of the six Facility Wound Evaluations beginning 12/20/23 revealed the following: -On 12/20/23 a Stage 2 pressure ulcer was found on the resident's coccyx. The area measured 32.6 cm2 by 7.7 cm length and 5.34 cm width. Treatment was a general wound cleanser and zinc barrier cream. The wound was healable. - On 12/27/23 the wound was now a bilateral (both sides) Unstageable coccyx wound. No measurements were found. The facility added stoma powder crusting to the treatment. Notes indicated the resident spent most of her/his time in a recliner and slept there as well. The nurse spoke to the resident about repositioning. -On 1/3/23 the wound looked substantially larger but no measurements were found. Meta-honey alginate was added to the treatment. Notes indicated the resident was staying in bed more and sleeping there. The nurse requested an air mattress. -On 1/10/23 wound measurements were provided as follows: Area: 242.37 cm2 increased +643 % Length: 21.14 cm increased +174 % Width: 15.07 increased +182% The wound bed had evidence of infection-redness and inflammation. No documentation was found to indicate the evidence of infection was addressed by staff. -On 1/17/23 no wound measurements were found. There was evidence of infection listed as redness and inflammation. An air mattress was added for the resident but no documentation was found related to treatment for the evidence of infection. -On 1/24/23 no wound measurements were found. No evidence of infection was listed. The wound was progressing as expected. A Hospital History and Physical dated 1/25/24 indicated Resident 1 was hospitalized prior to admission to the facility. While at the facility, the resident developed sacral decubitus ulcers. The resident was seen at the wound care clinic and referred to the emergency department related to the sacral wounds. The decubitus ulcers were deep and appeared to extend to the bone. They were described as malodorous and when cultured, were positive for infection. The resident received an antibiotic. On 2/2/24 at 1:52 PM Witness 2 (Hospital Licensed Clinical Social Worker) reported on 1/25/24 the resident was admitted to the hospital for wounds on the buttocks and Resident 1's surgeon had concerns about the resident's care while at the facility. The resident was seen six weeks prior at the wound clinic for a diabetic foot wound and had no buttock pressure ulcers at the time. The resident went to a wound care appointment on 1/25/24 and the physician found significant bilateral (both sides) buttock pressure ulcers. The wounds also smelled. The surgeon felt the resident may not have received adequate repositioning and off-loading (not bearing weight on an extremity with a wound or where a wound could develop, which included the buttocks or hips if bed or chair-bound) at the facility. The wound care clinic physician sent the resident directly to the emergency department for wound care. On 1/25/24 a Brief Operative Note indicated Resident 1's Pre-Operative diagnosis was sacral decubitus ulcer bilateral. The Post Operative diagnosis was Stage 4 sacral decubitus ulcer bilateral. Findings included: Right wound measures: 11 cm by 7 cm by 4.5 cm with tunneling (wounds extend from the skin surface to various underlying issues.) Left wound measures: 8 cm by 4 cm by 2 cm deep with tunneling. On 2/16/24 at 2:50 PM Staff 2 (DNS) acknowledged the following: -The wound was facility acquired and not present on admission. -The facility knew the resident sat and slept in a recliner all the time and interventions and education should have been done sooner. -Assessments were not thorough as evidenced by not identifying wounds accurately, missing measurements and limited description of the wound condition. -Daily Skilled Nursing Evaluations failed to capture the wounds or the deterioration until 1/4/2024. -The TAR monitoring by staff failed to capture the wound and the deterioration of the wound from 12/16/23 to 12/27/23. -Signs of an infection were indicated by the wound nurse on 1/10/24 and 1/17/24 but no interventions were put in place and the resident was found to have a bacterial infection on admission to the hospital on 1/25/24.

Based on interview and record review it was determined the facility failed to provide immediate interventions, ongoing assessments and monitoring for identified skin impairment for 1 of 1 sampled resident (#1) reviewed for a pressure ulcer. This resulted in Resident 1 developing an unstageable pressure ulcer. Findings include: CMS Appendix PP S483.25(b) Skin Integrity and S483.25(b)(1) Pressure ulcers, defined the following: - Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. - Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. - Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. - Friction is the mechanical force exerted on skin that is dragged across any surface. - Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. - Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident ' s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Resident 1 was readmitted to the facility in 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 1's Re-Entry Nursing Data Base dated 7/31/22 revealed the resident was readmitted to the facility with skin sheer noted to left buttock, 4x1 cm. A review of Resident 1's clinical record revealed no interventions initiated specific to the shear identified on 7/31/22. The clinical record also did not include any routine monitoring or assessments of the wound. A Progress Note dated 8/11/22 by Staff 4 (Student Nurse) indicated she spoke with Staff 3 (RN/Wound Care Nurse) who ordered a foam dressing be applied to Resident 1. Staff 4 indicated Cleansed today with normal saline, pat dry, and foam dressing applied. Pictures gathered. The note failed to indicate why a foam dressing was needed, to what part of the resident's body the dressing was applied, or an assessment of the wound or injury to which the dressing was applied. A Progress Note dated 8/11/22 by Staff 3 indicated Resident 1 had what appears to be a combination of MASD [moisture associated skin damage]/shearing and pressure to sacrum/coccyx and buttocks [tailbone]. Resident 1's Progress Notes contained Skilled Evaluations with skin assessments on the following dates: - 8/1/22 Skin warm & dry, skin color WNL [within normal limits] and turgor is normal. and No skin issues - 8/2/22 Skin warm & dry, skin color WNL and turgor is normal. and No skin issues - 8/3/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/4/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/5/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/6/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/7/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/8/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/9/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/10/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/11/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/12/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/13/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/14/22 Skin warm & dry, skin color WNL and turgor is normal. - 8/15/22 Skin warm & dry, skin color WNL and turgor is normal. None of the assessments from 8/1/22 through 8/15/22 identified or included assessments of the resident's shear identified on 7/31/22 or the unstageable pressure injury identified on 8/11/22. Resident 1's Skin & Wound Evaluation dated 8/11/22 indicated the resident had a wound which measured 8.6 cm by 7.4 cm with 40% slough and moderate drainage. There was redness to the surrounding skin. The assessment failed to indicate the type of wound, location or how long the wound had been present. Resident 1's Wound Evaluation dated 8/11/22 indicated the resident had a wound located Location not set which measured 8.64 cm by 7.37 cm. The wound bed was 40% slough with moderate drainage. The assessment indicated Additional care with Turning/repositioning program. The assessment failed to indicate if the wound was present on admission or was facility acquired. (A facility photograph included with the assessment showed the wound was located on the coccyx and sacral areas of Resident 1 and showed large areas of the wound covered in tissue which was tan or dark brown to nearly black.) Resident 1's Care Plan for Potential for Impaired Skin Integrity/Pressure Injury r/t impaired mobility and Resident has potential/actual impairment to skin integrity r/t fragile skin initiated on 6/9/22 included [Licensed Nurse] to complete weekly skin assessment, Notify MD and family of new skin impairments and Treatments per MD order. The care plan did not include a turning and repositioning program as indicated on the 8/11/22 Wound Evaluation. The care plan did not include any new interventions after 6/10/22 even though the care plan identified the shearing noted 7/31/22 but was not added to the care plan until 8/3/22. The care plan was not revised related to the deteriorated wound condition noted on 8/11/22. Resident 1's 8/2022 TAR revealed a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR did not indicate this treatment was specifically for, or related to, the shear identified on 7/31/22. The TAR included a treatment initiated on 8/11/22 for Sacrum wound; cleanse with normal saline; sureprep [skin protectant] surrounding skin; apply foam dressing every 3 days or as needed. The TAR also included weekly skin audits with an audit on 8/7/22 which indicated no new skin issues were identified. A review of Resident 1's clinical record revealed no signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/31/22 at 9:07 AM Staff 6 (Medical Records) was asked to provide a copy of the signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No signed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/31/22 at 8:50 AM Staff 5 (RNCM) stated a student nurse found the wound on Resident 1, took pictures of the wound and notified Staff 3. Staff 3 stated she would look at the wound. Staff 5 stated he assessed the wound when he took the picture. Staff 5 stated he did not notify the physician and left that for Staff 3 to do. Staff 5 stated the physician should have already been notified because the wound was present when the resident was admitted to the facility [on 7/31/22]. Staff 5 stated Staff 3 obtained the treatment orders and there were standing orders for wound care. Staff 5 was asked how the wound progressed from the 1 cm by 4 cm shear identified on 7/31/22 to the large wound identified on 8/11/22. Staff 5 stated he was not aware of the wound until 8/11/22, but the resident sometimes refused care. Staff 5 confirmed the shear identified on 7/31/22 should have been placed on the TAR for treatment and monitoring. A review of Resident 1's clinical record revealed no indication the resident refused routine repositioning. On 9/1/22 at 11:17 AM Staff 7 (Nurse Practitioner) stated she was not aware of Resident 1's sacral pressure injury until 8/15/22 and stated she did not assess the wound. Staff 7 stated on 8/15/22 she sought clarification regarding the wound and approved the treatment order that was currently in place. During interviews with Staff 3 (RN/Wound Care Nurse) on 8/30/22 at 11:51 AM and 9/1/22 at 1:28 PM, Staff 3 verified Resident 1 readmitted to the facility on [DATE] with a 1 cm by 4 cm shear on her/his buttock. Staff 3 confirmed no treatment was initiated for the shear. Staff 3 stated a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 3 stated the wound was caused by a combination of factors and the resident's wound was on the fleshy part of the buttocks. She stated for a wound to be pressure related it was required to be over a bony interface (Resident 1's wound was identified by Staff 3's 8/11/22 Progress Note as being located on the sacrum and coccyx which are bony prominences. The location of the wound was further corroborated by the photograph of the wound taken on 8/11/22). Staff 3 confirmed the daily Skilled Evaluations failed to include either the shear identified on 7/31/22 or the pressure injury identified on 8/11/22. Staff 3 stated she completed Resident 1's Wound Evaluation dated 8/11/22 based on the photograph taken of the pressure injury by Staff 5 (RNCM) and acknowledged that she never physically assessed the resident's pressure injury. Staff 3 stated, based on the photograph, the resident's pressure injury wound bed included slough, however she provided no clinical rationale for her determination that it was slough and not eschar. Staff 3 confirmed Resident 1's care plan was not revised with new interventions after 6/10/22. Staff 3 confirmed Staff 7 was not aware of the pressure ulcer until 8/15/22. Staff 3 was asked how Resident 1 went from a shear identified on 7/31/22 to an unstageable pressure injury that was not identified until 8/11/22, Staff 3 stated Resident 1 did not like to reposition and likely spent lots of time on her/his back. Staff 3 acknowledged there was no documentation which indicated Resident 1 refused repositioning.

Based on observation, interview and record review it was determined the facility failed to ensure 1 of 2 sampled residents (#2) reviewed for abuse was free from sexual abuse and, failed to ensure the ongoing safety of vulnerable female residents who were unable to consent from potential sexual abuse after Resident 1 sexually abused Resident 2. This failure, the facility's lack of supervision and monitoring of Resident 1 after Resident 2 was sexually abused, placed all female vulnerable residents who were unable to consent to sexual advances at risk of sexual abuse was determined to be an Immediate Jeopardy (IJ) situation. Findings include: Resident 1 admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Resident 2 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. Resident 3 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. On 10/29/19 Resident 1 was observed to move independently and without staff supervision in her/his wheelchair throughout the facility, both on and off the 200 Hall unit. The 10/11/19 Significant Facility Incident Report revealed on 10/7/19 Resident 1 entered Resident 3's room uninvited and inappropriately touched Resident 3's upper leg and attempted to kiss Resident 3. Resident 3 refused Resident 1's physical advance and asked Resident 1 to leave. Resident 1 exited Resident 3's room. The facility counseled Resident 1 not to go into any resident rooms uninvited. Review of Resident 1's care plan revealed no care plan revisions after the 10/7/19 incident and no monitoring or supervision was initiated. Review of Resident 1's medical record revealed the 10/7/19 incident was the first incident when Resident 1 initiated uninvited and unwanted physical contact with another resident. On 10/29/19 at 8:34 AM Staff 5 (LPN) stated on 10/7/19 Resident 3 and Resident 4 each reported Resident 1 sat in their rooms doorways, attempted to enter each of their rooms and did enter the room of Resident 3. Staff 5 verified Resident 3 reported to him Resident 1 attempted to touch her/him on the leg and arm. Staff 5 further stated he reported this information on the staff communication board. On 10/29/19 at 9:16 AM Resident 3 stated Resident 1 entered her/his room (on 10/7/19)uninvited and started to talk with her/him. Resident 3 stated she/he told Resident 1 she/he was getting ready for bed but Resident 1 came closer to her/him. Resident 3 stated she/he kept backing up until she/he was cornered in the room. Resident 3 stated Resident 1 placed her/his hand on Resident 3's leg and told Resident 3 how nice it felt. Resident 3 stated she/he told Resident 1 she was uncomfortable and didn't like her/his behavior. Resident 1 then asked for a kiss goodnight but Resident 3 pushed her/him away. Resident 3 stated Resident 1 then exited the room and she reported the incident to Staff 5 (LPN). Resident 3 stated she/he was pretty nervous after the incident and remained uncomfortable whenever she/he was near Resident 1 however Resident 3 stated she/he did not purposely avoid Resident 1 or leave activities because Resident 1 was also there. Resident 3 stated being in Resident 1's presence was hard. The 10/20/19 Alleged Abuse Facility Incident Report revealed Resident 1 entered Resident 2's room uninvited, touched Resident 2's breast and kissed Resident 2 on the mouth. The report revealed Resident 1 was placed on 15 minute safety checks. Resident 2's Comprehensive Care Plan was revised on 10/20/19 to reveal Resident 1 had problematic behavior characterized by inappropriate behavior of going into other resident rooms. Interventions included staff to approach Resident 1 calmly and unhurriedly, frequent safety checks every shift and to ensure the (safety check) form was completed every shift. On 10/28/19 the care plan was again revised to reveal Resident 1 was unaware of personal boundaries and sought female companionship. A 10/29/19 progress note revealed Resident 1 was looking into a female resident room, noticed staff watching her/him and returned to her/his room. Resident 2's medical record revealed a PASSRII or medication review was requested after the 10/7/19 or 10/20/19 resident to resident incidents. The physician was contacted to request a [DIAGNOSES REDACTED]. On 10/29/19 at 9:35 AM Resident 2 stated Resident 1 entered her/his room uninvited (on 10/20/19) via her/his wheelchair, approached, hugged and then kissed her/him. Resident 2 stated she/he told Resident 1 to stop and to leave. Resident 1 left but stated she/he would be back. Resident 2 stated she/he reported the incident to the facility staff. Resident 2 stated she/he remained uncomfortable in the presence of Resident 1 but did not allow the incident to change her/his behavior. On 10/29/19 at 7:45 AM, 3:57 PM and 5:15 PM Staff 6 (RN) stated Resident 1 would verbalize she/he loves the ladies and was known to go find who she/he was looking for. Staff 6 verified Resident 1 was on 15 minute safety checks and not 1:1 supervision. Staff 16 stated Resident 1 would independently move about the facility and the facility could not monitor or keep track of Resident 1. Staff 6 stated Resident 1 would wake up between 7:00 AM and 8:00 AM, would get out of bed independently most of the time and then move about the facility independently. Staff 6 further stated on days Resident 1 went to [MEDICAL TREATMENT] she/he would return with only slight tiredness and kept her/his normal evening routine. Staff 6 stated Resident 1 did not go to bed until 10:00 PM. On 10/29/19 at 11:39 AM through 11:59 AM Staff 7 (CNA), Staff 8 (CNA) and Staff 9 (CNA) all stated Resident 1 would go into other resident rooms and was on 15 minute safety checks. On 10/29/19 between 5:20 PM through 5:29 PM Staff 11 (CNA), Staff 12 (CNA), Staff 13 (LPN) and Staff 14 (LPN) stated Resident 1 was independent when up in her/his wheelchair and would wheel her/himself throughout the facility. On 10/29/19 at 7:40 AM Resident 4 stated Resident 1 came to her/his door one night on the graveyard shift but did not harm her/him. Resident 4 stated Resident 1 was a bit off. On 10/29/19 at 9:25 AM Resident 7 stated Resident 1 had entered her/his room uninvited and stayed for about ten minutes asking her/him questions. On 10/29/19 at 9:28 AM Resident 10 stated she/he knew all about Resident 1's behaviors and her/his intrusions into her/his room and other resident rooms. On 10/29/19 at 12:03 PM Staff 3 (RNCM) stated the 10/7/19 resident to resident incident between Resident 1 and Resident 3 was the first occurrence when Resident 1 bothered another female resident. Staff 3 verified Resident 1's care plan was not revised. Staff 3 verified on 10/20/19 Resident 1 touched Resident 2 on the breast and kissed Resident 2 on the mouth. Staff 3 stated after the incident she informed staff of Resident 1's behaviors and updated her/his plan of care which included frequent checks. Staff 3 stated frequent checks were not a specific frequency, it was at staff discretion and every 15 to 30 minutes seemed reasonable. Staff 3 verified Resident 1 would be able to enter a female residents room between the 15 minute safety checks. On 10/29/19 at 1:53 PM Staff 2 (DNS) stated the 10/7/19 incident between Resident 1 and Resident 3 was a respect and dignity concern. Staff 2 acknowledged the 10/20/19 incident between Resident 1 and Resident 2 met the definition of sexual abuse. Staff 2 stated after the 10/20/19 incident Resident 1 was placed on 15 minute checks and verified when Resident 1 was up in her/his wheelchair she/he was independent and moved quickly. On 10/29/19 at 2:31 PM Staff 3 (RNCM) identified 13 residents as vulnerable (vulnerable due to poor cognitive status, weakened condition or communication or mobility restrictions) and would be unable to provide consent or interrupt Resident 1's advances. Staff 3 stated Resident 1 could independently wheel her/himself into any female residents' room between the 15 minute safety checks. On 10/29/19 at 6:39 PM Staff 2 identified 33 total female residents as vulnerable to Resident 1's behaviors. Staff 2 stated there were 13 vulnerable female residents in the 300 South Hall and 20 identified vulnerable female residents in the 200 North Hall. On 10/29/19 at 6:45 PM the facility was informed of the identified Immediate Jeopardy for the failure to ensure the ongoing safety of the vulnerable, female residents from potential sexual abuse after Resident 1 sexually abused Resident 2. Thirty three vulnerable, female residents were identified as potential victims for Resident 1. Resident 1 was on every 15 minute safety checks and staff were aware of Resident 1's behaviors however Resident 1 was independent and highly mobile when up in her/his wheelchair and was able to move from place to place very quickly. Resident 1 had the potential to seriously harm any vulnerable resident between the 15 minute safety checks. Facility staff verified they are unaware of Resident 1's location between the 15 minute checks. On 10/29/19 at 7:42 PM the IJ Abatement Plan was received and approved. The Plan included: 1. The facility would provide Resident 1 with 1:1 monitoring 24 hours per day. Active monitoring was started on 10/29/19 at 6:22 PM. Monitoring would be completed by the facility staff or Resident 1's family. Documentation of the monitoring would be completed on a 24 hour staffing sheet which would be reviewed daily. Resident 1's care plan and Kardex (CNA care plan) would be revised to reflect the 1:1 required monitoring. 2. All CNA and licensed nursing staff would be in-serviced prior to the start of the next shift on the need for active monitoring to ensure no inappropriate contact with other residents. The in-servicing would be completed by 10/30/19 at 12:00 PM. 3. Resident 1's family would actively participate in relocation of Resident 1 to a more appropriate facility. Additionally, family would provided 1:1 monitoring assistance and support as the family desired. 4. When Resident 1 was out of the facility at [MEDICAL TREATMENT] the 1:1 monitoring would cease at the facility level and resume when Resident 1 returned to the facility. The receptionist would alert nursing staff when Resident 1 returned and would be responsible to monitoring Resident 1 until the assigned 1:1 staff member arrived. 5. A PASSRII would be requested for Resident 1. 6. The interdisciplinary team would be in-serviced by 10/30/19 at 12:00 PM on appropriate monitoring to be applied in similar events. On 10/29/19 at 8:00 PM observation, interview and record review verified the IJ Abatement Plan actions of the 1:1 supervision were in place and the staff in-servicing was started. On 10/30/19 at 11:50 AM the IJ Abatement Plan was reviewed for implementation. Observations, record reviews and staff interviews confirmed the Plan was fully implemented.

Based on observation, interview and record review the facility failed to ensure appropriate contact precautions for 1 of 6 sampled residents (#42). This failure was determined to be an immediate jeopardy situation due to potential contamination of common areas with an antibiotic resistant microorganism.This placed residents at risk for cross contamination by an antibiotic resistant microorganism. Findings include: The 1/2012 Infection Control Policy and Procedure Manual revealed the following precautions for diarrhea associated with [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium causing symptoms ranging from diarrhea to life threatening inflammation of the colon): -In addition to wearing gloves as outlined under standard precautions, wear gloves when entering the room; -While caring for a resident, change gloves after having contact with infective material (i.e. fecal material); -Remove gloves and wash hands, do not touch potentially environmental surfaces or items in the resident's room; -Wear a disposable gown upon entering the room; -After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces; -Residents transported to another unit within the facility will notify the unit of the type of precautions the resident is on and the resident's suspected or confirmed type of infection. The facility is responsible for notifying transportation staff of residents that require special care due to infectious conditions. Review of the CDC's recommendations, showed the following: -Use gloves when entering patients' rooms and during patient care; -Perform hand hygiene after removing gloves; -Use gowns when entering patients' rooms and during patient care; -Dedicate or perform cleaning of any shared medical equipment; -Continue precautions until diarrhea ceases; -Implement an environmental cleaning and disinfection strategy; -[MEDICAL CONDITION] infection will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed. The infection can usually be treated with an appropriate course (about 10 days) of antibiotics. Review of the CDC's (YEAR) [MEDICAL CONDITION] Infection Information for Patients, revealed the following: -Patients could get sick from [MEDICAL CONDITION] from contaminated surfaces or spread from a healthcare provider's hands; -Elderly are at greater risk of acquiring the disease; -The bacteria are found in feces; -People become infected if they touch any items or surfaces (e.g. toilets, bathing tubs) that are contaminated with feces and then touch their mouth or mucous membranes; -Healthcare workers can spread the bacteria to patients or contaminated surfaces through hand contact; -[MEDICAL CONDITION] can live for long periods on surfaces. Resident 42 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. The 10/2017 and 11/2017 MARS revealed the resident received [MEDICATION NAME] (antibiotic) 500mg three times daily related to [MEDICAL CONDITION] from 10/28/17 through 11/11/17. According to the 11/4/17 admission MDS the resident was severely cognitively impaired. Review of the resident's care plan dated 11/12/17 revealed the following: -The resident had limited mobility related to confusion and [MEDICAL CONDITION] and staff were to provide intermittent supervision with physical assist as needed for hand hygiene; -The resident had alteration in cognition and/or communication related to cognitive impairment and staff were to speak clearly, and allow time for the resident to process information, if the resident did not seem to understand, paraphrase and repeat; -The resident was at risk for falls related to deconditioning and cognitive impairment and staff were not to leave the resident unsupervised in the bathroom or on the bedside commode. Review of the resident's undated Kardex revealed the following: -Do not leave the resident unsupervised in the bathroom or on the beside commode; -Universal and contact precautions for [MEDICAL CONDITION]; -Use short statements, speak clearly and allow time for resident to process information Resident 42's 11/19/17 laboratory results revealed the resident was positive for toxigenic [MEDICAL CONDITION]. The 11/2017 and 12/2017 MAR indicated [REDACTED]. Review of the resident's bowel record revealed the following: -On 11/21/17 at 3:56 am, 1:51 pm and 5:24 pm loose/diarrhea stool; -On 11/22/17 at 2:32 am, 10:33 am and 8:17 pm loose/diarrhea stool; -On 11/23/17 at 5:59 am, 9:38 am and 9:59 pm loose/diarrhea stool; -On 11/24/17 at 5:59 am loose/diarrhea stool; -On 11/25/17 at 12:51 am loose/diarrhea stool, at 1:45 pm soft stool; -On 11/26/17 at 8:39 pm loose/diarrhea stool; -On 11/27/17 at 8:09 pm loose/diarrhea stool; -On 11/28/17 at 3:15 am soft stool; -On 11/29/17 at 10:43 am loose/diarrhea stool; -On 11/30/17 at 5:59 am soft stool. Observations on 11/30/17 revealed the following: -At 9:38 am there was a sign on the resident's door for contact precautions. The resident wheeled her/himself down the hall, entered her/his bathroom, touched the light switch and sink surfaces and wheeled her/himself out the bathroom without washing her/his hands. The resident took tissues out of her/his pocket and wiped her/his nose; -At 9:40 am the resident wheeled her/himself to a common area, and started putting a puzzle together with visitors; -At 10:16 am the resident wheeled her/himself into the bathroom and touched the bathroom sink, applied face cream, and left the bathroom without washing hands. The resident wheeled her/himself back to the common area, started putting a puzzle together with visitors. Resident 42 placed the used tissues on the table; -At 11:58 am the resident sat in the common dining room with three other residents at her/his table and touched the items on the table; -At 12:22 pm the resident remained in the dining room eating, six other residents were at the same table. During an interview 11/29/17 at 8:29 am Staff 2 (DNS) stated when a resident was positive for [MEDICAL CONDITION] and cognitively unable to understand the need to wash her/his hands, staff would physically help the resident wash her/his hands. Resident 42 entered the facility with [MEDICAL CONDITION] which resolved, but Resident 42 acquired [MEDICAL CONDITION] again. During an interview on 11/29/17 at 9:11 am, Staff 12 (RN) stated staff only donned gloves and gown when assisting the resident to the restroom. The staff encouraged the resident to wash her/his hands before leaving the bathroom. During an interview on 11/29/17 at 9:20 am, Staff 13 (CNA) stated she was unaware why the resident was on contact precautions. When asked, Staff 13 stated the residents with [MEDICAL CONDITION] could go anywhere but should be in line of sight when a resident with [MEDICAL CONDITION] was at meals. Staff were responsible to ensure the resident washed her/his hands before exiting the room. During an interview on 11/29/17 at 10:23 am, Staff 14 (RNCM) stated she was not aware which residents were on contact precautions and there was no process to identify the residents on contact precautions. During an interview on 11/30/17 at 12:05 pm Staff 15 (CNA) stated the resident was on some kind of precautions but was not sure what they were. Staff 15 asked the nurse, who confirmed it was for [MEDICAL CONDITION]. Staff 15 knew the resident was on hourly checks and could not be in the bathroom unless someone was in the bathroom to assist the resident. If Resident 42 entered the bathroom staff needed to ensure the resident's hands were washed prior to leaving the room. During an interview on 12/4/17 at 7:54 am Staff 16 (Housekeeper) stated housekeeping cleaned the residents' rooms daily. Staff 16 indicated housekeeping did not sanitize the bathroom after each bowel movement for residents with [MEDICAL CONDITION] and was unaware if bathrooms were sanitized when housekeeping was not in the building. During an interview on 12/4/17 at 9:07 am Staff 18 (Housekeeping Supervisor) stated rooms for residents on contact precautions were cleaned clockwise using a ten to one solution of bleach changing gloves and rags often. [MEDICAL CONDITION] precaution rooms were cleaned daily, sometimes twice a day, but bathrooms of residents with [MEDICAL CONDITION] were not cleaned after each bowel movement. On 12/4/17 at 2:37 PM Staff 24 (Regional Nurse Consultant) indicated they disconnected the water to the toilet in Resident 42's room to see if she/he had a bowel movement without staff knowledge. On 11/30/17 at 3:12 pm an Immediate Jeopardy (IJ) was called due to Resident 42 not sanitizing her/his hands prior to exiting the room. Resident 42 was observed to enter the common area without sanitizing her/his hands and touched multiple surfaces. This failure resulted in Resident 42 potentially contaminating the common areas with an antitibiotic resistant microorganism placing all residents at risk for infection. On 11/30/17 at 6:08 PM the immediate plan of correction submitted by the facility was accepted. The Plan of Correction stated: All residents with cognitive deficits that have the inability to follow contact protocol will be placed on 1-1 when out of bed to assure that Infection Control protocol is followed while allowing resident's to be out of their room. All staff will be educated on contact precautions beginning on 11/30/17 and ongoing until all have received appropriate training. The target date for completion is 12/4/17. Direct care staff will receive copies of facility policy and procedure for contact precautions. The facility will utilize bleach solution to clean all facility surfaces twice per day. Protocol for Out of Room -After proper disposal of PPE -Per 2006 CDC guidelines, secretions are controlled and contained. -Staff required to utilyze PPE realted to risk factors while caring for resident and contact with body secretions, and are required to use soap and water prior to leaving the room. -Resident is able to leave the room when loose stool is controlled and contained. Hands are washed with soap and water and clothing is clean with no visible signs of being soiled. -Contact precautions will be removed 48 hours after antibiotics are completed or 48 hours after diarrhea has stopped and patient may then leave the room. -If family is present, education on proper handwashing will be provided 1-1, ultimately this responsibility will fall on the CNA. Monitoring The DNS or designee will audit all residents on contact precautions three days per week to ensure the care plan and Kardex refelcts the reason, necessary intervention for contact precautions, one on one when out of the room if appropriate and that all interventions were being followed. Any areas found out fo compliance will be immediately corrected. Results will be tracked monthly at QAPI and quarterly Quality Assurance meeting to identify any trends and plan of correction. 11/30/17 at 6:08 pm and the IJ was abated. Resident 42 was observed to have one on one attention in her/his room, the puzzle in the common area was thrown out and all the areas were wiped down with clorox. 2. Based on observation, interview and record review the facility failed to ensure proper hand hygiene during wound care and medication administration for 2 of 19 sampled residents (#s 11 and 193) and two unsampled resident rooms with contact precautions (rooms [ROOM NUMBERS]) reviewed for infection control. This placed the residents at risk for cross contamination. Findings include: The 1/2012 Infection Control Policy and Procedure Manual revealed the following precautions for diarrhea associated with [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium causing symptoms ranging from diarrhea to life threatening inflammation of the colon): -In addition to wearing gloves as outlined under standard precautions, wear gloves when entering the room; -While caring for a resident, change gloves after having contact with infective material (i.e. fecal material); -Remove gloves and wash hands, do not touch potentially environmental surfaces or items in the resident's room; -Wear a disposable gown upon entering the room; -After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces; -Residents transported to another unit within the facility will notify the unit of the type of precautions the resident is on and the resident's suspected or confirmed type of infection. The facility is responsible for notifying transportation staff of residents that require special care due to infectious conditions. Review of the CDC's recommendations, showed the following: -Use gloves when entering patients' rooms and during patient care; -Perform hand hygiene after removing gloves; -Use gowns when entering patients' rooms and during patient care; -Dedicate or perform cleaning of any shared medical equipment; -Continue precautions until diarrhea ceases; -Implement an environmental cleaning and disinfection strategy; -[MEDICAL CONDITION] infection will resolve within 2-3 days of discontinuing the antibiotic to which the patient was previously exposed. The infection can usually be treated with an appropriate course (about 10 days) of antibiotics a. On 11/29/17 at 10:24 am Staff 26 (CNA) was observed to enter room [ROOM NUMBER]. A sign was posted on the door for contact precautions. A resident was sitting outside of room [ROOM NUMBER]. Staff 26 entered and exited room [ROOM NUMBER] without sanitzing her hands and touched the resident's oxygen tubing. Staff 26 then, without sanitizing her hands, entered room [ROOM NUMBER] which also had a contact precautions sign posted. On 11/29/17 at 10:25 am Staff 26 indicated she should have sanitized her hands prior to entering and exiting the residents' rooms with identified contact precautions. b. On 12/1/17 at 9:46 am Staff 9 (LPN) was observed removing soiled bandages from the legs of Resident 193. Staff 9 cleaned the resident's leg wounds and retrieved and opened a package of clean bandages without changing her gloves. The surveyor intervened prior to Staff 9 applying new bandages to the resident while wearing soiled gloves. In an interview on 12/1/17 at 10:11 am Staff 9 acknowledged she had not changed her gloves after removing soiled bandages from the resident's legs. She also confirmed she should have changed her gloves before retrieving and opening the new bandages. c. On 11/29/17 at 12:40 pm Staff 6 (LPN) touched his hair, face and nose during medication administration for Resident 11. Staff 6 provided direct contact with the resident without santizing his hands. On 11/29/17 at 12:50 pm Staff 6 confirmed he touched his hair, face and nose without performing hand hygiene prior to direct contact with Resident 11.

1. Based on interview and record review it was determined the facility failed to revise a care plan and ensure a bed alarm was present for 1 of 3 sampled residents (#4) reviewed for falls. The resident fell and sustained a cervical spine (neck) fracture and an increase in the size of a brain bleed. Findings include: Resident 4 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 9/4/15 Admission MDS and associated CAAs indicated the resident had a history of [REDACTED]. The resident was identified to have balance problems and was on medications that increased the resident's risk for continued falls. The resident's Care Plan initiated on 5/8/15 and revised on 9/4/15 indicated the resident was at risk for falls related to impaired balance, a history of falls and the use of antidepressants. Interventions included the resident was not to be left unsupervised in the bathroom or bedside commode, the resident was to have frequent visual checks and the resident's bed was to be in the low position. The resident's Progress Notes on 9/4/15 at 6:30 am indicated the resident reported the current order for insomnia was not effective and the resident requested temazepam (sedative). The note indicated the resident's physician was notified. The 9/4/15 note at 4:03 pm revealed a new order for temazepam was obtained. The September 2015 MAR revealed the resident was administered temazepam at bedtime from 9/6/15 through 9/9/15. The instructions on the MAR for the use of the temazepam was use bed alarm for safety. The resident's Care Plan was not updated after the temazepam was initiated with directions to use a bed alarm for safety. The Progress Notes indicated on 9/9/15 the resident was heard calling for help. Staff observed the resident suspended between the bed and wheel chair. The resident indicated she/he attempted to self transfer. The 9/11/15 at 1:41 am note indicated the resident was found on the floor by staff. The Incident reports for the incidents associated with the 9/9/15 and 9/11/15 Progress Note, did not indicate the resident's bed alarm was in place or activated when the resident attempted to self transfer and when the resident was found on the floor. The investigation also did not address when the resident was last visualized. The resident's 9/11/15 hospital Emergency Department summary indicated the resident's imaging studies of the brain included an acute on chronic (new findings to previously identified issue) left brain bleed and the neck imaging studies included a fracture of the cervical spine. The 9/14/15 hospital Discharge Summary indicated the resident's final [DIAGNOSES REDACTED]. On 9/15/15 Staff 3 (RNCM) indicated the resident's Care Plan generated the CNA staff Kardex/tasks (resident specific interventions). If a resident was identified to need an alarm, the Care Plan included the bed alarm and then the CNA Kardex/tasks would indicate the resident required an alarm. Staff 3 acknowledged the resident's care plan included the low bed, not to be left unattended and was to have frequent checks. Staff 3 indicated the resident did not have an alarm for an intervention but the MARs indicated the resident was to have an alarm for safety due to the use of the temazepam. On 12/22/15 at 1:00 pm a request was made to Staff 2 (DNS) for documentation to indicate the resident had a bed alarm present on the 9/9/15 and 9/10/15 incidents. No additional information was provided. 2. Based on interview and record review it was determined the facility failed to thoroughly investigate all possible causes of an injury for 1 of 3 sampled residents (#5) who were reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 5 was admitted to the facility in August 2015 with [DIAGNOSES REDACTED]. On 9/10/15 a nursing note indicated a CNA reported that she placed a sock on the resident when her/his toenail came loose and was barely attached. The resident denied pain, the nurse provided first aid, and the physician was notified. On 9/10/15 an incident report indicated the resident's toenail came loose and started bleeding and there was fungus present on the resident's toenail. The resident did not know how the incident occurred. A documented witness statement from Staff 25 (CNA) identified she asked the nurse (Staff 18) to come to the resident's room and stated, there's blood and reported the resident's toenail came loose while placing a sock. In interview on 12/21/15 at 9:05 am Staff 25 (CNA) who was assigned to the resident on 9/10/15, reported Resident 5 needed to use the bathroom so she and Staff 26 (CNA) assisted with toileting. Staff 25 reported Staff 26 placed shoes on the resident prior to transferring. Resident 5 complained about the shoes hurting, however, they continued to transfer and toilet the resident. After toileting, the resident was brought back to bed and Staff 26 left to assist another resident while she (Staff 25) took off the resident's shoes. Staff 25 noticed her/his toenail was hanging on by the cuticle and bleeding. She found a sock stuffed inside of the toe of the shoe that Staff 26 had placed on the resident's foot. In interview on 12/21/15 at 11:49 am Staff 18 (RN) reported Staff 25 reported Resident 5's toenail had come off. She found the toenail attached at the base and bleeding. Staff 18 cleaned and bandaged the toe and did not know if the resident's toenail had fungus. Staff 18 could not recall how the injury happened other than she was told her/his toe was bleeding. In interview on 12/22/15 at 1:06 pm Staff 26 (CNA) reported on 9/10/15 Resident 5 had to use the restroom and her and Staff 25 (CNA) assisted the resident to the bathroom. She stated she placed shoes on the resident's feet and the resident stated her/his toe hurt. The resident had to go to the restroom so they left the shoe on, transferred the resident to the bathroom, and then placed her/him back in bed. Staff 26 stated she left to assist another resident while Staff 25 made the resident comfortable. Staff 25 called her back into the room because Resident 5's toenail was lifted up and bleeding. Staff 25 stated she saw a sock stuffed down in the toe of the resident's shoe but didn't know how it got there. Facility staff did not stop to investigate the resident's shoes after her/his statement of pain prior to continuing with the transfer to and from the bathroom. At the time of the survey, the facility did not have a full witness statement of how the injury occurred from Staff 25 and had no witness statement from Staff 26 as to what happened on 9/10/15. There was no evidence the facility evaluated and analyzed the event to determine if interventions to prevent reoccurrence were needed.

1. Based on interview and record review it was determined the facility failed to ensure medications were administered in a manner to decrease a resident's risk for falls for 1 of 3 sampled residents (#1) reviewed for falls. Resident 1 was hospitalized for [REDACTED]. Findings include: Resident 1 was admitted to the facility 5/14/15 with [DIAGNOSES REDACTED]. The resident's 5/13/15 hospital Nursing Facility Transfer Orders (orders from the hospital to the facility) included the resident was to be administered Klonopin (Benzodiazepine used for [MEDICAL CONDITION]) twice a day PRN. The orders also included the resident was to be administered [MEDICATION NAME] (Benzodiazepine used for anxiety) every fours hours as needed for tremors. The resident's Progress Notes on 5/15/15 at 7:18 am indicated the resident did not have reports of pain or discomfort. The Late Entry note dated 5/16/15 at 2:52 am by Witness 2 (Former LPN) indicated the resident requested both the [MEDICATION NAME] and the Klonopin be administered together. The note indicated the resident reported she/he normally took six of each at home. On 8/10/15 at 10:15 am Witness 1 (Spouse) stated Resident 1 only took one [MEDICATION NAME] with [MEDICATION NAME] for shakes. A telephone call was placed to Witness 2 (Licensed Nurse) on 8/11/15 at 7:35 pm. A return call was received on 8/12/15 to indicate the number no longer was for Witness 2. The resident's May 2015 MAR indicated [REDACTED]. The resident's Progress Notes dated 5/15/15 at 10:18 pm indicated the resident was found on the floor. The resident reported she/he attempted to answer the phone and fell to the floor from the bed. The 5/16/15 note at 2:25 am note indicated the resident was found on the floor. The resident reported increased knee pain after the fall. The 7:35 am note on 5/16/15 indicated at 6:10 am the resident was observed on the floor. The resident reported she/he attempted to walk to the bathroom. On 8/11/15 at 8:28 am Witness 3 (Facility Pharmacist) stated Klonopin and [MEDICATION NAME] used together was duplicative therapy and the medications were not to be administered at the same time. If one medication was administered, at least two hours should pass before the next medication was administered. The combination of the medication caused possible complications including increased drowsiness, decreased coordination and the increased risk for falls. The resident's Progress Note dated 5/16/15 at 2:25 am by Witness 2 (Former Staff/Licensed Nurse) indicated the resident reported increased pain to the right knee after the resident fell . The resident's 5/16/15 at 4:32 pm Progress Note indicated the resident's Klonopin was to be held for 72 hours related to falls. The 5/16/15 at 7:35 am note indicated the resident had redness from the incision to the groin. The note also included the resident's dressing was saturated and required to be changed at 2:30 am and again at 6:30 am. Review of the resident's May 2015 MAR indicated [REDACTED]. The first dose of PRN pain medication was documented to be administered on 5/16/15 at 6:23 am. The resident's 5/16/15 Progress Note at 3:57 pm by Staff 6 (LPN) indicated the resident's knee dressing was saturated with blood and the dressing was changed. The note also included the resident's right leg had redness and swelling but there was no increased warmth noted to the resident's leg. The resident's incision was documented to be intact. The resident's 5/17/15 at 2:47 am Progress Note indicated the resident's dressing was saturated and the dressing was changed once. The note also included the resident's incision had significant swelling around the surgical incision. The resident was also documented to have redness up to the thigh. No warmth was noted in red [MEDICAL CONDITION] area. The resident's 5/18/15 Progress Note at 12:02 pm and 7:43 pm indicated the resident reported increased knee pain after the three falls. The note indicated the MD office was called and x-rays were requested. The resident's 5/20/15 Physical Therapy Note dated 5/20/15 indicated the resident had significant active bleeding from the incision and required a dressing change. The resident's 5/20/15 Progress note at 4:04 pm indicated the resident's dressing had a moderate amount of drainage and the resident's incision was red. The 5/21/15 note at 5:07 am and 5:14 am indicated the resident's incision had an open area and the resident's physician was faxed. The resident's 5/21/15 at 7:26 pm Progress Note indicated the resident's dressing was changed and the incision had serosanguinous drainage (straw colored with some blood in it). The 5/22/15 at 4:09 am note indicated the resident required two dressing changes. The note indicated a thick dressing was applied. The 5/22/15 note at 7:19 pm indicated the resident had continued swelling to the right knee, there was an increase in drainage, two dressing changes were done on the day shift and two on the previous shift. The resident was noted to have redness extending up to the inner thigh. The note also indicated the incision had some redness. The outer knee was also noted to be red. The resident reported increased knee pain and was not able to extend the knee. The on-call orthopedist was notified and orders were obtained for x-rays. The resident's Progress Note on 5/23/15 at 9:55 am by Staff 5 (LPN) indicated the resident had a 100.8 temperature, a moderate amount of drainage was on the resident's knee dressing and redness extended from the inner thigh. The 11:40 am note indicated the on-call orthopedic physician was notified and the resident was transported to the emergency department for [MEDICAL CONDITION] (complications from an infection). The resident's 5/23/15 Hospital Admission History and Physical indicated the resident had a right knee replacement on 5/11/15. The resident was discharged to the nursing facility post-operative day three. The resident reportedly had falls shortly after the admission. The staff at the facility had concerns related to the wound and contacted the on-call orthopedic surgeon on 5/23/15. The report indicated the resident was admitted to the hospital for urgent surgery. The resident's 5/24/15 Operative/Invasive Procedure Note indicated the resident had a infected right knee. The resident's 6/18/15 Orthopedic Clinic Notes indicated the resident's surgical site opened post-operatively and the orthopedic practitioners were not notified for four to five days. The resident had a second surgery to clean the wound on 5/23/15. On 8/12/15 at 10:10 am Witness 4 (Orthopedic Physician Assistant) stated resident's may have drainage from knee surgery for [REDACTED]. After 48 hours if there was more than a scant amount of drainage it indicated there were potential complications including infection. Witness 4 also indicated after knee surgery residents could have moderate swelling to the knee but anything more than moderate swelling was a concern. Witness 4 indicated an on-call orthopedic provider was available to answer calls from nursing facilities 24 hours a day. Witness 4 indicated the orthopedic team was not notified the Resident 1 fell on [DATE] and 5/16/15 and the orthopedic team was also not notified immediately after the incision opened. Once the incision opened it created a portal for infection. The resident required a second surgery. The resident's sutures inside the knee joint were compromised. Witness 4 indicated the break in sutures likely occurred with the falls. Witness 4 also indicated the internal sutures would not break with routine physical therapy. Witness 4 indicated nurses were to call the orthopedic for concerns that could impact the surgery and the primary care physician was notified of medical conditions such as a low blood pressure. On 8/12/15 at 8:45 am Staff 4 (DNS) stated she did not have a more current telephone number for Witness 2. Staff 4 acknowledged the resident was administered the Klonopin and the [MEDICATION NAME] at the same time. Staff 4 also indicated the staff provided the medication per the resident's request. The resident was noted to be alert and oriented and was able to make needs know. No additional information was provided to indicate the Klonopin and [MEDICATION NAME] were safe to be administered at the same time. 2. Based on interview and record review it was determined the facility failed to ensure a care plan was developed and non-pharmacological interventions were provided prior to the use of [MEDICAL CONDITION] medications for 3 of 4 residents (#s 2, 3 and 4) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: A. Resident 2 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's 7/29/15 Physician order [REDACTED]. Review of the resident's Care Plan initiated on 6/23/15 was not updated to indicate the resident was on [MEDICAL CONDITION] medications. A care plan was not developed to include the resident's identified behaviors, side effects of the medication and did not include interventions to be provided if the resident had behaviors. The resident's chart also did not have an AIMS (abnormal involuntary movement scale/a screening tool used to detect abnormal movement associated with [MEDICAL CONDITION] medications) performed when the [MEDICATION NAME] was initiated. On 8/12/15 at 8:45 am Staff 4 (DNS) acknowledged the resident's care plan was not updated after the resident was started on [MEDICATION NAME]. Staff 4 also indicated an AIMS was not initiated at the start of the [MEDICATION NAME] to monitor the resident for potential side effects of the medication. B. Resident 3 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. a. Review of the resident's current orders included the resident was to be administered [MEDICATION NAME] (antipsychotic medication) PRN. The resident's Care Plan initiated on 6/3/15 did not include the resident was on [MEDICATION NAME], did not include the resident's identified behaviors and nonpharmacological interventions to be provide prior to the use of the PRN [MEDICATION NAME]. The resident's chart also did not have an AIMS (abnormal involuntary movement scale/a screening tool used to detect abnormal movement associated with [MEDICAL CONDITION] medications) performed when the resident's [MEDICATION NAME] was initiated. The resident's August 2015 MAR indicated [REDACTED]. Review of the resident's Progress Notes indicated the resident was crying out and was verbally aggressive. There were no notes to indicate if non-pharmacological interventions were tried prior to the use of the PRN [MEDICATION NAME]. On 8/10/15 at 10:50 am Staff 1 (RNCM) acknowledged a care plan was not developed after the resident was started on [MEDICATION NAME]. Staff 1 also acknowledged an AIMS was not initiated to monitor for possible side effects of the [MEDICATION NAME]. Staff 1 stated the AIMS was to be completed when the [MEDICATION NAME] was started. b. The resident's orders included the resident was to be [MEDICATION NAME](Hypnotic/used to assist with sleep) PRN. The resident's Care Plan initiated on 6/3/15 did not include the resident was on Ambien. The care plan did not include potential side effect of the medication and PRN interventions to try prior to the use of the Ambien. The resident's July 2015 MAR indicated [REDACTED]. The resident's Progress Notes did not include non-pharmacological interventions were provided prior to the use of the Ambien. On 8/12/15 at 8:45 am Staff 4 (DNS) indicated she was not [MEDICATION NAME] a hypnotic. No additional information was provided to indicated non-pharmacological interventions were tried prior to the use of Ambien. C. Resident 4 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's 5/1/15 through 8/31/15 Order Summary (all orders obtained within a specified time frame) included on 7/13/15 the resident was started on PRN [MEDICATION NAME] (antipsychotic medication). The resident's July 2015 MAR indicated [REDACTED]. The resident' Progress Notes dated 7/13/15 indicated the [MEDICATION NAME] was administered for agitation. The notes did not include interventions provided prior to the use of the [MEDICATION NAME]. The resident's Care Plan initiate on 5/26/15 was not updated to include the resident was on [MEDICATION NAME]. The care plan did not identify the resident's behaviors and interventions to assist with the resident's behaviors. The care plan also did not include the potential side effects of the [MEDICATION NAME]. On 8/12/15 at 8:45 am Staff 4 (DNS) indicated the resident was initially on PRN [MEDICATION NAME] and was later changed to a scheduled dose. Staff 4 acknowledged the Care Plan did not include the use of the [MEDICATION NAME], potential side effects of [MEDICATION NAME] and interventions were not developed to use if the effective for the resident had behaviors. Documentation for nonpharmacological interventions tried prior to the PRN dose of [MEDICATION NAME] was requested. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure a gait belt was in place during a resident transfer for 1 of 3 sampled residents (#1). Resident 1's legs gave out, she/he fell to the floor and sustained a leg fracture. Findings include: Resident 1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan dated 10/17/12 indicated the resident was alert, oriented and made her/his needs known. The resident was noted to have weakness and required one person transfer assistance with moderate to extensive assistance required. The care plan further noted to use a gait belt with physical assist transfers unless otherwise ordered. A hospital History and Physical (H & P) dated 11/13/12 indicated the resident was seen for shortness of breath. The resident was noted to have a pathological fracture of the shoulder which was treated previously with radiation. The resident was found to have a blood clot in her/his left lung and was started on blood thinners with improved oxygenation. The resident was noted to have chronic pain related to the shoulder fracture and Stage 4 lung cancer that had metastasized to the bone. The resident's pain was to be addressed with narcotic pain medications. The resident was discharged back to the skilled nursing facility on 11/16/12. A NN dated 11/16/12 indicated the resident was sent to the emergency department for knee pain after a fall. There were no other NNs with information regarding the resident's fall. A facility investigation dated 11/16/12 indicated the resident fell during a transfer in the bathroom. The resident was being assisted by Staff 2 (LPN) and Witness 1 (Family) to stand at the bar in the bathroom and pivot to the toilet. The investigation noted the resident stated she/he did not know if she/he could do it, the resident's legs buckled and she/he collapsed to the floor. A pop was heard as the resident fell to the floor. The report further indicated the resident had [DIAGNOSES REDACTED] and a right shoulder fracture that was in an immobilizer. The resident cried out in pain whenever someone moved her/his arm, the resident was heavy and weak which made transfers difficult. An orthopedic consult dated 11/17/12 indicated the resident had a left femur fracture above the resident's prosthetic knee. The X-ray showed the resident's leg fracture was not pathological and was unrelated to the resident's [DIAGNOSES REDACTED]. Surgery was performed to pin the left femur fracture but the resident developed complications and was admitted to hospice care. The resident was discharged to a new skilled nursing facility on 11/21/12 and passed away on 12/29/12. Interviews conducted on 2/26/13 between 12:05 pm and 1:30 pm showed: Staff 2 (LPN) indicated the resident had [DIAGNOSES REDACTED] so her/his bones were very brittle. The resident had one current fracture of the shoulder related to her/his cancer. The resident had an immobilizer in place with a sling for the resident's arm and a belt attached to the resident's waist. The sling was hooked to the belt to keep the resident's arm stationary. Staff 2 stepped into the hall from another resident's room and was grabbed by Witness 1 (Family) to help assist the resident to the rest room. Staff 2 stated he did not have a gait belt on him so he used the immobilizer belt which was already on the resident. Staff 2 stated he and Witness 1 transferred the resident but Witness 1 did not really have any room to have hands on the resident. Witness 1 provided verbal direction to the resident. The resident was standing at the bar and then before she/he could turn to sit the resident's legs gave out and she/he started to fall. Staff 2 heard a popping sound and then the resident was on the floor. Staff 2 further indicated they were not able to stop the resident's fall. Staff 2 stated the resident was in pain and was sent to the hospital for evaluation. Staff 3 (RNCM) indicated the resident was fully alert and oriented. The resident was very capable of making her/his needs known. Staff 3 indicated the resident was safe and appropriate for a one person transfer with a gait belt. The staff could always get additional assistance based on the resident's current condition and comfort. Staff 3 stated once the resident's leg gave out and she/he started to fall there was nothing the staff could do. They could only try to slow the resident down. Staff 4 and 5 (CNAs) indicated the resident was alert and oriented. The resident was a one person transfer and usually did very well with only one staff to assist. The resident sometimes was more tired or more painful at which point Staff 4 and 5 indicated they would get additional assistance before transferring. The staff indicated the resident's assistance level varied somewhat. Staff 4 and 5 both indicated regardless if one or two staff assisted the resident to transfer, the resident needed a gait belt to be in place. Interviews conducted on 2/28/13 between 11:10 am and 12:30 pm showed: Staff 6 (Rehabilitation Director) indicated the resident was safe and appropriate for 1-2 person assistance for transfers. The resident had a shoulder immobilizer in place which held the resident's arm/hand next to the her/his stomach. The arm was in a sling that was attached to a belt around the resident's waist. Staff 6 stated the resident required a gait belt for transfers. The resident's immobilizer belt was not to be used in place of a gait belt. When asked if the immobilizer belt could be used for a transfer Staff 6 stated "no, absolutely not," the resident's shoulder was painful. Staff 6 further indicated pulling on the immobilizer belt would jostle the resident's shoulder and potentially increase pain. Witness 1 (Family) stated the resident returned to the facility on [DATE] after a hospitalization for breathing difficulties. The resident was at the facility a few hours when she/he needed to use the restroom. Witness 1 called for assistance but nobody came so she went into the hall and asked Staff 2 (LPN) for assistance. The resident was already in the bathroom in her/his wheelchair. Staff 2 assisted the resident to stand at the bar without use of a gait belt. Witness 1 did not have her hands on the resident at all during the process. Staff 2 used the resident's immobilizer belt to assist the resident to stand. The resident's shoulder was pulled up and down and caused the resident pain. Witness 1 stated the resident was hunched over the bar, said she/he could not do it and then fell to the floor. Witness 1 indicated she heard a pop/crack sound before the resident landed on the floor. The resident was sent to the hospital and found to have a leg fracture. Witness 1 further indicated the fracture was not related to the resident's cancer. In an interview on 3/1/13 at 12:00 pm Witness 2 (Physician) indicated the resident had a pathological fracture of the shoulder due to her/his cancer diagnosis. The resident had an immobilizer in place to help support the arm and maintain comfort. Witness 2 stated a gait belt should be placed around the resident's waist for transfers. The immobilizer belt could not be used in place of a gait belt. Witness 2 stated pulling on the immobilizer belt at all would increase movement of the resident's arm, put pressure on the arm and increase pain.

Based on record reviews and interviews, the facility failed to ensure a resident that entered the facility without a pressure ulcer did not develop a pressure ulcer for 1 of 3 sampled residents (# 1). The resident developed a pressure ulcer, was admitted to the hospital with [REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's 11/26/10 facility Admission Nursing Database revealed the resident did not have a pressure ulcer. Review of the resident's 11/26/10, 12/5/10 and 12/12/10 Braden Scale For Predicting Pressure Sore Risk revealed the resident was not at risk for developing a pressure sore. Review of the resident's 11/30/10 Admission Care Plan revealed the resident was to be turned and repositioned every two hours. Review of the resident's 12/6/10 MDS revealed the resident understood others and others understood the resident. The resident was assessed as needing extensive assistance for bed mobility with the assist of two staff, the resident did not have pressure ulcers and was not at risk for developing ulcers. Review of the resident's 12/6/10 CAA (Care Area Assessment) revealed the resident was alert, oriented, was continent of bowel and bladder and the resident needed the assistance of two staff for most ADLs. The resident was at minimal risk for developing pressure ulcers and did not currently have pressure ulcers. The CAA also revealed the resident initiated turning and repositioning and the staff routinely encouraged the resident to reposition. Review of the 11/28/10 through 11/30/10 Interdisciplinary Progress Notes revealed the resident was reluctant to move or reposition due to pain, the resident's physician was notified and the facility obtained additional medication to manage the resident's pain. On 12/12/10 at 3:00 pm the note revealed staff wrote "putting bed pan on to relieve pressure off open area on bottom. WCTM (will continue to monitor)." On 12/12/10 at 6:30 pm the note read the "wound on coccyx, base has eshare (sic) (eschar meaning necrotic or dead tissue), wound edges pink, see skin sheet for measurements, wound on (right) gluteal cleft is pink, see skin sheet for measurements." The note also revealed the staff educated the resident to reposition to relieve pressure off the buttocks. The note also revealed the resident stated "I don't care. I'll do what I want to." On 1/7/11 Staff 8 (LPN) stated she wrote the note on 12/12/10 describing the ulcer as having eschar. Staff 8 stated she was a new nurse and did not chart correctly and meant to write the coccyx was pink and blanchable. Staff 8 stated she did not work with the resident after 12/12/10. Staff 8 stated the resident could not turn to the side without assistance and the resident was encouraged by staff to turn and reposition. On 1/13/11 at 9:27 pm Staff 7 (RN) stated the resident was very noncompliant. Staff continually told the resident to turn and if the resident did not turn the resident could develop a pressure ulcer. Staff 7 stated she did not remember the specific note on 12/12/10 but remembered the situation around the 12/12/10 nursing note. The resident had stated the bedpan was used on night shift to keep pressure off the coccyx. Staff 7 educated the resident to not use the bedpan because the bedpan could create more pressure. Staff 7 stated the skin to the coccyx was red and excoriated and was "like an abrasion." Staff 7 stated only "a little" was open. On 1/10/11 at 11:00 am Staff 2 (DNS) verified the 12/12/10 documentation revealed the resident had an open area and stated Staff 7 (RN) and Staff 8 (LPN) were new graduate nurses and did not document correctly in the nursing notes on 12/12/10. Review of the 12/12/10 Skin Condition Flow Sheet revealed the resident had a 3 (cm) by 3 (cm) pink blanchable area to the upper cleft/buttock. On 12/19/10 the assessment revealed the coccyx ulcer was 3 (cm) by 3 (cm) and the base of the ulcer was greenish yellow. The resident was also noted to have a blister to the right heal. Review of the Pressure Ulcer Risk Assessment and Plan of Care revealed on 12/13/10 the resident had a "possible" Stage One Ulcer (skin intact with redness that is non-blanchable), was at risk for pressure sores related to bed mobility problems and confounding factors included noncompliance. Preventative measures included a nutritional assessment, pillows for positioning, resident education and treatments per orders. Review of the Interdisciplinary Progress Notes from 12/13/10 through 12/15/10 revealed no documented assessment of the resident's coccyx ulcer. On 12/16/10 there was no documentation. Review of the December 2010 Treatment Sheets revealed no monitoring of the coccyx ulcer from 12/13/10 through 12/18/10. Review of the 12/16/10 Registered Dietician note revealed the resident had an open area to the coccyx. On 1/11/11 at 9:12 am Witness 1 (Registered Dietician) stated she did not remember the resident. Information regarding the resident's skin condition was obtained from the resident's records such as the nurses notes and through interviews with facility staff. Witness 1 did not remember if the information regarding the resident's coccyx was obtained from the facility staff or just the resident's records. Review of the resident's 12/17/10 Interdisciplinary Notes at 9:00 am the resident was regularly medicated and repositioned for pain, at 10:45 pm the resident's coccyx wounds were open and the resident refused to rotate off the resident's coccyx. On 12/18/10 at 4:30 am the note revealed "This LN (licensed nurse) has not assessed area, will give report to the oncoming nurse." Review of the 12/18/10 fax revealed the resident's physician was notified the coccyx wound "progressed" and orders for wound care per facility wound care team were obtained. On 12/19/10 the note revealed the coccyx wound was "greenish yellow. WCTM (will continue to monitor). The 12/20/10 through 12/21/10 notes revealed the resident refused to turn, reposition and float heels off the bed. The 12/22/10 note revealed the resident was sent to the local hospital. Review of the 12/20/10 Skin Condition Flow Sheet assessment revealed the upper cleft/coccyx wound was 4.5 cm long and 3 cm wide. The base was red/black with a scant amount of drainage/odor. Below the cleft/coccyx ulcer was a 1.5 cm long by 1.5 cm wide ulcer with a yellow base. Review of the Pressure Ulcer Risk Assessment and Plan of Care revealed on 12/20/10 pressure ulcer locations included the coccyx. Review of the Resident's Treatment sheet revealed wound care was not done to the coccyx ulcer until 12/20/10. Review of the resident's 12/20/10 Skin Assessment revealed the resident was a two person assist with transfers and was noted to have open areas to the gluteal cleft region the weekend of the 12/12/10. The resident was turned, repositioned and provided with education. The following week the resident refused all approaches to follow the care planned interventions for all shifts. The assessment revealed the resident's preferred position was halfway inclined and on his/her back. Ulcers were observed that included a primary wound on the coccyx and a smaller slough covered wound directly below. The care plan was updated and the resident's physician was notified. The care plan included to float the resident's heals, side to side repositioning at least every two hours and the resident was to use the commode and not the bed pan to void. The resident previously requested the bedpan "mistakenly thinking this would relieve presure (sic) on (her/his) butt." A risk and benefit waiver would be implemented if the resident refused the interventions put in place. Review of the resident's record revealed risks of not turning and repositioning were not discussed with the resident until 12/20/10. Review of the 12/20/10 "REFUSAL OF CARE AND/OR TREATMENT" sheet revealed the resident was advised to turn and reposition at least every two hours, avoid back laying and not to use the bed pan to prevent further deterioration of skin issues/ulcers to buttock. The consequences listed for not following the care plan included infection and re-hospitalization . The form was signed by Staff 2 (DNS) and Staff 3 (RNCM). A hand written note revealed the resident declined to sign the form. On 1/10/11 at 11:00 am Staff 2 (DNS) stated Risk and Benefit forms were filled out when the outcome was serious and if the resident did not follow the plan of care and or treatments. Review of the 12/22/10 OT (Occupational Therapy) daily treatment note revealed the resident was 75 percent dependent for hygiene. The resident was noted to give a strong effort but had a marked decline and the resident had a foul odor to the peri-area. The resident's decline and odor was reported to the nursing staff and the RNCM. Review of the 12/22/10 hospital Emergency Department Report revealed the resident was admitted with complaints of nausea and pain to the coccyx. The resident was in acute kidney failure and developed multi-system organ failure [MEDICAL CONDITION] syndrome. Review of the resident's 12/23/10 hospital Operative/Invasive Procedure Note revealed the resident had an ulcer and the ulcer was the cause of the resident'[MEDICAL CONDITION]. The ulcer developed while the resident was in the facility for therapy post-orthopedic surgery. The ulcer developed while the resident was immobile. The ulcer was "very deep" with dead tissue extending down to the sacrum, coccyx and the rectal wall. The ulcer was "only a few centimeters away from the anal verge." The report also revealed the resident "may end up needing a [MEDICAL CONDITION]." Review of the resident's 1/4/11 hospital Discharge/Transfer dictation revealed the resident was admitted with acute kidney failure [MEDICAL CONDITION] secondary to necrotic sacral pressure ulcer. The resident required care in the intensive care unit, a consultation for Infectious Disease and surgery to clean the ulcer. The resident improved before discharge, but the resident was "not very motivated to get out of bed." The resident was discharged with ongoing need for wound care. On 1/7/10 at 8:45 am Witness 2 (hospital CWON/Certified Wound Ostomy Nurse) stated she was consulted when the resident was admitted to the hospital. The resident was admitted to the hospital with [REDACTED]. Witness 2 stated she could smell the wound as soon as she exited the elevator. The sore started at the bone and this type of wound could take 2-3 weeks to develop. It could not be determined by looking at the wound how deep the wound was. The resident wound was not measured upon admit because the recommendation was to take the resident to surgery to remove the necrotic tissue because the wound was "beyond" the ability of the wound nurse to provide care. The resident's coccyx was removed in surgery because of infection and the resident may require a [MEDICAL CONDITION] in order for the wound to heal. The resident informed the hospital staff that he/she complained of pain and a sore to the coccyx but the facility staff did nothing to help the resident. Witness 2 stated the hospital staff stated the resident was difficult to turn and took persistence from the hospital staff to keep the resident off the ulcer. On 1/7/11 at 10:00 am and 1:00 pm Staff 13 (Therapy Director) stated at times in the beginning of the resident's facility stay, the resident was resistive and was not willing to participate in therapy. The resident had a cushion in the wheel chair upon admission to the facility and was then fitted for a new cushion. The resident did not like to be positioned with pillows and would remove the pillows after the staff left the room. The resident required two people for bed mobility. The therapy staff frequently educated the resident on the importance of turning, however the education was not documented in the therapy notes. The resident's ulcer was not observed by therapy during the resident's therapy sessions and the resident did not have an odor until 12/22/10. On 1/6/10 Staff 3 (RNCM) stated the resident did not have a pressure ulcer before 12/12/10. The care of resident's skin after 12/12/10 included repositioning the resident and educating the resident to keep pressure off the coccyx. On 12/20/10 Staff 3, Staff 2 (DNS) and Staff 5 (RN) reviewed the risk and benefit form with the resident and the resident did not want to sign the form and just said "ok" after the resident was presented with the information. On 1/10/11 Staff 5 (RN) stated the resident was able to move and reposition in bed without assistance. If pillows were placed to support the resident off the coccyx, the resident would remove the pillows and return to a supine position. The resident needed constant reminders to turn. Staff 5 saw the resident's ulcer once before the resident left the facility. On 12/20/10 the wound looked like a bruise, did not have an odor and it looked like a deep tissue injury. Staff 5 was not in the resident's room when the risk and benefit form was presented to the resident. Staff 5 stated the resident did not have dressings prior to 12/20/10. Staff 5 also did not remember receiving report from previous shifts that the resident had an ulcer. If a resident had an ulcer it was documented on the treatment sheet so the ulcer could be monitored at least every shift. On 1/10/11 at 12:20 pm Staff 4 (CNA) stated the resident would "wiggle" onto his/her back after the facility staff turned the resident to the side. The resident had a red area upon admission. The resident liked to sit in a semi-upright position. Staff 4 stated the coccyx was open and Staff 5 (RN) did dressing changes to the coccyx. Staff 4 did not remember how long the coccyx ulcer was open. On 1/10/11 at 12:25 pm Staff 5 (RN) denied performing dressing changes to the resident's coccyx ulcers. On 1/10/11 at 2:00 pm Staff 6 (LPN) stated the resident was not compliant with turning. The resident had a small ulcer on the coccyx and at first was treated with [MEDICATION NAME] (ointment to protect the skin). On 1/13/11 at 7:51 am Staff 16 (LPN) stated the resident was noncompliant with turning and repositioning. It took three facility staff to turn the resident onto the bed pan. The facility staff routinely communicated with the resident about turning to prevent pressure to the coccyx, but the resident would ignore the recommendations. Staff 16 stated she did not assess the resident's skin. The resident complained of surgical pain and did not complain of coccyx pain until the end of the resident's stay at the facility. Treatment was started at the end of the resident's facility stay. On 1/13/11 at 7:55 am Staff 17 (CNA) stated the resident could turn side to side but preferred to sit up in bed as if sitting in a chair. The resident complained of her/his bottom hurting but the resident refused to turn to the side. The resident was told by staff to turn or a sore would develop. The resident did develop a sore about one week after the resident was admitted to the facility. Staff 17 reported the sore to Staff 16 (LPN) and Staff 5 (RN). Staff 17 did not remember what the sore looked like.