Every finding on record at Secora Rehabilitation of Cascadia

Based on observation, interview and record review the facility failed to ensure infection control practices were observed for 1 or 2 halls reviewed for CBG monitoring. This placed residents at risk for bloodborne organisms. Findings include: A 2017 Evencare G2 glucometer Manufacturer Manual indicated, Disinfect common use glucometers with the use of approved disinfectant wipes. The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection. Resident 22 was admitted to the facility in 9/2024 with diagnoses including diabetes.On 7/7/26 at 11:54 AM, Staff 25 (Agency RN) was observed using a shared Evencare G2 glucometer to obtain Resident 22's blood sugar. Staff 25 returned to the medication cart and cleaned the glucometer with an alcohol pad wipe. Staff 22 placed the glucometer on top of the medication cart and she was stopped prior to obtaining the next blood sugar. Staff 22 stated she did not receive education prior to starting her shift related to blood sugar disinfecting the glucometer after resident use. On 7/7/26 at 12:15 PM Staff 2 (DNS) stated staff were expected to use approved EPA disinfectant wipes to disinfect the glucometers.

Based on observation, interview and record review it was determined the facility failed to inititiate wound care orders consistent with professional standards of practice for 1 or 1 sampled resident (#14) reviewed for skin conditions. This placed residents at risk for poor wound healing. Findings include:A 9/2025 Skin Integrity & Wound Prevention policy indicated the following:*Staff to complete weekly skin inspections.*Staff to notify the provider about new areas of concern that include treatment of new wounds.*Staff to obtain and initiate treatment orders that included a person-centered goal. Resident 14 was admitted to the facility on 6/2024 with diagnoses including a blister of abdominal wall. A 4/3/26 Quarterly MDS revealed Resident 14 had a BIMS score of 15 indicating Resident 14 was cognitively intact. A 8/2025 Care Plan indicated Resident 14 required the following:*Weekly skin checks and required staff to take pictures of new or old wounds identified. *Staff to monitor, document location, size and treatment of skin injury in the care plan when new wounds were identified. *Daily skin inspections during cares.1. A 7/2026 MAR/TAR indicated staff applied InterDry (fabric strip) dressing to Resident 14's abdomen daily. A 7/3/26 Skin Inspection Evaluation indicated Resident 14 refused a skin inspection. On 7/7/26 at 2:00 PM, Resident 14 stated she/he had a new wound near her/his belly button. Resident 14 pointed to the new wound. The edges of the wound were irregular. The center of the area was pink and moist. The area was draining a clear substance, and the edges of the wound had a white substance. Resident 14 did not have InterDry applied. On 7/9/26 at 9:22 AM, Staff 22 (CNA) stated Resident 14 had open wounds to her/his abdomen and nursing staff were aware. On 7/9/26 at 9:05 PM, Staff 19 (LPN) stated Resident 14 had recurrent blisters near her/his abdomen and staff were expected to apply InterDry daily for preventative breakdown of the skin. Staff 19 stated staff were expected to notify the provider when new wounds were identified. Staff 19 stated wound care orders were initiated at 2:00 AM during the night shift.On 7/9/26 at 9:57 PM, Staff 23 (RN) stated Resident 14 had an open wound near her/his belly button. Staff 23 stated the wound was from friction or moisture. Staff 23 stated he was aware Resident 14 had an open wound but did not notify the provider because he thought the wound was old. Staff 23 stated he did not apply InterDry during his shift. Resident 14 stated no wound care orders were entered for the wound near Resident 14's belly button. Staff 23 stated the center of the wound was pink several weeks ago. Staff 23 stated he did not complete a skin assessment because Resident 14 refused and did not notify the provider.On 7/10/26 at 8:39 AM, Staff 24 (LPN) stated Resident 14 had recurrent abdominal blisters and staff were able to identify skin concerns during cares like bed baths or brief changes. Staff 24 stated she did not notify the provider about frequent skin assessment refusals or new skin wounds. On 7/10/26 at 10:39 AM, Staff 4 (RNCM) stated she expected staff to notify the provider when new wounds were identified and was unaware Resident 14 had new abdominal wounds. 2. A 2/23/26 Progress Note indicated Resident 14 had a referral for dermatology related to re-occurring blisters to the abdomen.On 7/8/26 at 12:00 PM, Resident 14 stated she did not see a dermatologist or had a scheduled appointment. Resident 14 stated Staff 23 (RN) was aware about her/his abdomen wound. Resident 14 stated she/he struggled with moisture and had recurrent blisters.On 7/9/26 at 9:22 AM, Staff 22 (CNA) stated Resident 14 had open wounds to her/his abdomen. Staff 22 stated staff were aware.On 7/9/26 at 9:57 PM, Staff 23 (RN) stated he was unaware Resident 14 had recurrent abdomen blisters. Staff 23 stated Resident 14 did not have any outside dermatology appointments scheduled or after visit summaries to indicate treatment started. On 7/10/26 at 8:39 AM Staff 24 (LPN) stated she was unaware about Resident 14's recurrent abdominal blisters. Staff 24 stated Resident 14 did not have a dermatologist. On 7/10/26 at 10:39 AM, Staff 4 stated Resident 14 did not have a scheduled appointment with a dermatologist. Staff 4 stated she was unaware Resident 14 had recurrent abdominal blisters. On 7/10/26 at 11:43 AM, Staff 2 stated Resident 14 had recurrent abdominal blisters and did not have an appointment to see a dermatologist. Staff acknowledged the referral was entered on 2/23/26.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 1 sampled dependent resident (#3) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include:The facility's 8/21/2025 Activity Program Policy indicated the following:*Residents who prefer not to participate in group programs and/or are independently involved in recreational pursuits will be identified through the assessment process.*Individual interventions will be developed based on each Residents assessed needs and the family will be notified for any special requests. *The individual program will be provided according to a consistent schedule identifying specific days of the week and the time frame in which the program will occur. *Each Resident's individual program will include interventions that meet the Resident's assessed social, emotional, physical, spiritual and cognitive functioning needs. Resident 3 was admitted in 12/2025 with diagnoses including stroke and dysphagia (difficulty swallowing). Resident 3's 12/19/25 Activity Care Plan revealed the following:-The resident enjoyed group activities, entertainment, card games, Bingo, arts and crafts, gardening and plants, pet visits, social clubs, outdoor activities and shopping trips. Resident 3's 6/16/26 Quarterly MDS assessment indicated the resident's short-term memory was intact, while long-term memory was impaired. The MDS also indicated listening to music, pet visits, participating in group activities, going outside for fresh air on nice days and engaging in activities involving her/his favorite interests were very important to the resident. A review of Resident 3's Activity Task Records from 6/9/26 to 7/8/26 revealed the resident did not participate in any self-directed or independent activities and did receive any activity visits. During the review period, the only documented activity participation was conversation and reminiscing on 6/16/26 and 6/24/26. The facility's 7/2026 Activity Calendar revealed the following scheduled activities: 7/5/26:-Coffee & News-This day in History-Flower Care 7/6/26:-Coffee & News-Gardening-Movie Matinee 7/7/27:-Coffee & News-Garden Club-Bingo 7/8/26:-Coffee & News-Summer Decorating-Bingo 7/9/27-Coffee & News-One on One Visits-Chapel Service On 7/6/26 at 10:02 AM, Resident 3 was observed in her/his room in bed. The resident was nonverbal but able to answer yes/no questions by shaking her/his head. The television was on; the resident was not observed participating in an activity. No items related to the resident's identified interests, including music or activity materials, were observed available for the resident's use. Observations of Resident 3 from 7/6/26 through 7/9/26 from 8:30 AM to 4:00 PM revealed the resident to be in her/his room in bed. The television was on, no music, pet visit, activity supplies, reading materials, or other items related to the resident's identified interests and preferences were observed in the resident's room or readily available for the resident's use. On 7/9/2026 at 2:04 PM Staff 8 (CNA) stated she was not familiar with the activities listed on Resident 3's care plan. Staff 8 stated the resident did not participate in facility activities and remained in bed in her/his room watching television with her/his headphones on. On 7/9/26 at 2:12 PM Staff 10 (CNA) stated Resident 3 remained in her/his room in bed watching television. Staff 10 stated he was not familiar with Resident 3's care-planned activities and reported the resident had not participated in facility activities recently. On 7/9/26 at 2:33 PM Staff 6 (Activity Director) stated Resident 3's preferred activities included group activities, arts and crafts, and shopping trips. Staff 6 stated activities offered to Resident 3 included television and music. Staff 6 confirmed Resident 3 had not been offered additional activities and reported the only documented activity participation dates were 6/16/26 and 6/24/26 for conversation and reminiscing. On 7/9/26 at 3:25 PM Staff 2 (DNS) stated it was her expectation the facility adhered to residents identified preferences and ensure residents were provided opportunities for activities based on their individual needs. Staff 2 stated residents' activity preferences should be accurately reflected on their care plans and implemented by staff.

Based on interview and record review it was determined the facility failed to ensure access to medical records upon oral or written request within the required timeframe for 1 of 3 sampled residents (#801) reviewed for the right to access medical records. This placed residents at risk for uninformed health care needs and delayed access to records. Findings include: The facility's 10/15/22 Medical Record Policy and Procedure revealed the following: -The resident may have access to their medical record upon request to nursing leadership. -The resident and/or responsible party request for medical record documents may be made orally or in writing. It will be provided in the form and format requested, if it is readily producible in such format within two business days. 1. Resident 801 was admitted to the facility in 6/2024 with diagnoses including morbid obesity and chronic pain. The 7/5/25 Annual MDS indicated Resident 801 was cognitively intact. Record review revealed on 4/21/25 Resident 801's attorney's office had requested the facility Please: Provide Medical Records and [NAME] from 12/3/24 to Present. On 7/28/25 a public complaint was received which alleged Witness 1 (Complainant) stated Resident 801's attorney had requested medical records on 4/21/25 and did not receive the completed list of medical records until 7/29/25.On 7/31/25 at 12:24 PM Witness 2 (Case Manager) stated the attorney's office had initially sent the request for Resident 801's medical records to the facility on 4/21/25. Witness 2 stated the facility sent Resident 801's Progress Notes on 4/29/25 but no billing documentation was included. From 5/6/25 through 7/21/25, eight follow-up requests were made for Resident 801's records. All requested records were not released by the facility until 7/29/25, approximately four months later. On 7/31/25 at 2:25 PM Staff 10 (Business Office Manager) stated she had received voicemails and phone calls from Resident 801's attorney's office but had not followed up with the attorney's office because she was too busy. On 7/31/25 at 11:05 AM Staff 1 (Administrator) acknowledged a portion of Resident 801's requested medical records were provided/released to Resident 801's attorney on 4/29/25. Staff 1 acknowledged the requested billing documentation was omitted from the medical records and the billing records were subsequently received by the attorney's office on 7/29/25.a. On 7/28/25 a public complaint was received which alleged Resident 801 requested her/his medical records on 7/24/25 and had not received them in a timely manner. A review of Resident 801's medical records revealed no documentation indicating the resident received her/his requested medical records. Additionally, there was no evidence found in the medical record of a third-party request for medical records. A Disclosure/Release of Protected Health Information form dated 7/24/25, signed by Resident 801, included a request for her/his history and physical, progress notes, medication list, care plan, all financial data, foot wound care documentation, and notes from a transportation ride to be provided to the resident.On 7/30/25 at 10:10 AM Resident 801 stated she/he had not yet received the records she/he had requested and signed for on 7/24/25, approximately one week earlier. On 7/31/25 at 12:01 PM Staff 1 (Administrator) acknowledged Resident 801 was not provided a copy of her/his medical records which were formally requested on 7/24/24. Staff 1 stated the medical records were not delivered or made available to Resident 801 in the required timeframe.

Based on observation, interviews and record review it was determined the facility failed to ensure dishwasher temperatures met the minimum requirements for 1 of 1 dishwasher reviewed for the kitchen. This placed residents at risk for communicable diseases, un-sanitized dishware and utensils. Findings include: The facility's Dishwashing in the Dish Machine Policy dated 1/1/2018 states: - Test the dish machine for proper water temperatures and sanitizer levels (for low-temp machine), and record readings prior to washing the dishware. - Do not use the dish machine if sanitizer and water temperatures are not acceptable. On 3/27/25 at 11:45 AM the facility's dishwashing machine was observed with instructions stating the minimum operating temperature was 120 degrees F. On 3/27/25 the following observations were made of Staff 27 (Dietary Staff) washing dishes: - At 11:57 AM trays were washed with the water temperature reading at 90 degrees F, - At 11:59 AM plates were washed with the water temperature reading at 110 degrees F, - At 12:03 PM forks were washed with the water temperature reading at 115 degrees F and - At 1:34 PM plates and cups were washed with the water temperature reading at 118 degrees F. On 3/27/25 at 1:34 PM Staff 26 (Dietary Manager) was requested to test the dishwasher water temperature using an external thermometer which read 118 degrees F. Staff 26 stated the dishwasher water temperature should be at least 120 degrees F for adequate sanitization. Staff 26 confirmed the dishwater temperature did not meet the minimum requirements.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 9 and 18) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: The facility's Inservice Education/Training policy, last revised on 10/15/22, indicated employee education and in-service training was provided to assist in maintaining the continuing competence and knowledge of the staff. On 3/27/25 at 2:44 PM, Staff 3 (Clinical Resource) provided a list of annual training hours for CNA staff which revealed the following: -Staff 9 (CNA): 7.5 annual training hours and -Staff 18 (CNA): 1.5 annual training hours. On 3/28/25 at 1:06 PM, Staff 2 (Administrator-In-Training) and Staff 3 confirmed Staff 9 and Staff 18 did not complete the required 12 hours of annual in-service training.

Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 2 of 2 sampled residents (#s 16 and 304) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed of their legal rights. Findings include: The facility's undated arbitration agreement included the following: - The Resident and/or Legal Representative understands that his Arbitration Agreement may be rescinded by giving written notice to the Facility within 10 days of its execution, this Arbitration of its execution. If not rescinded within 10 days of its execution, this Arbitration Agreement shall remain in effect for all claims arising out of the Resident's stay at the Facility. 1. Resident 16 was admitted to the facility in 2/2025 with diagnoses including congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively). Record review revealed Resident 16's legal representative signed the facility's arbitration agreement on 3/5/25. On 3/28/25 at 1:54 PM Resident 16's legal representative stated she/he did not know about her/his right to rescind the arbitration agreement within 30 days of signing it. On 3/28/25 at 1:45 PM Staff 2 (Administrator-In-Training) stated the facility's arbitration agreement had an inaccurate timeframe for the signed agreement to be rescinded and confirmed Resident 16's arbitration agreement was signed with an inaccurate timeframe. 2. Resident 304 was admitted to the facility in 1/2025 with diagnoses including metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly). Resident 304's 1/27/25 Admissions MDS indicated the resident had severely impaired cognition. Resident 304's records included the facility's Voluntary Agreement For Arbitration, dated 1/13/25 and signed as verbal consent. On 3/28/25 at 1:38 PM Resident 304 stated she/he did not know or understand the Arbitration Agreement and did not remember signing the form or giving verbal consent. On 3/28/25 at 1:45 PM Staff 2 (Administrator-In-Training) stated the facility's arbitration agreement had an inaccurate timeframe for the signed agreement to be rescinded and confirmed Resident 304's arbitration agreement was signed with an inaccurate timeframe.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 6 sampled residents (#35) reviewed for unnecessary medications. This placed residents at risk for adverse side effect of medications. Findings include: The facility's 8/1/23 Medication Errors policy outlined the following: -A significant medication error is one which causes the resident discomfort or jeopardizes their health and safety. -In the event of a significant medication error, immediate action is taken as necessary to protect the resident's safety and welfare. -The prescriber is notified promptly of the error. -A medication error/adverse reaction report is completed. Resident 35 was admitted to the facility in 3/2024 with diagnoses including vascular dementia (cognitive decline caused by damage to the blood vessels in the brain) and a stroke. A review of Resident 35's 4/4/24 Admission MDS revealed she/he was cognitively intact and received anticoagulant therapy. A review of Resident 35's health record revealed a 4/12/24 signed physician order for 20 mg tablet of Rivaroxaban to be administered one time a day for other cerebral infarction due to occlusion or stenosis of small artery. A review of Resident 35's medication administration record revealed her/his prescribed Rivaroxaban (an anticoagulant) was not administered on 4/14/24, 4/15/24 and 4/16/24. A facility investigation completed by Staff 29 (Former Administrator) indicated Resident 35's Rivaroxaban was available but Staff 30 (LPN) failed to administer it to her/him on 4/14/24, 4/15/24, and 4/16/24. The investigation also indicated on 4/17/24 Resident 35 presented with strokelike symptoms including being unable to hold up her/his head, her/his right pupil was pinpoint and fixed, she/he had weakness on the right side of her/his body, and was unable to respond verbally to questions. As a result, Staff 31 (RN, Former DNS) sent Resident 35 to the hospital emergency department. On 3/27/25 at 11:43 AM Staff 4 (DNS) stated Resident 35 was not administed her/his medications as ordered and developed stroke-like symptoms for which she/he was sent to the hospital. Staff 4 stated Staff 30 did not notify staff, contact the provider or call the pharmacy. Staff 4 stated Staff 30 did not follow appropirate protocol or follow physician orders. On 3/27/25 at 5:23 PM Staff 31 acknowledged Staff 30 did not administer Resident 35's medication as ordered and did not notify nursing staff, call the provider, pharmacist, or write a progress note about the missed scheduled doses. Staff 31 stated Staff 30 was terminated due to the incident. On 3/28/25 at 1:56 PM Staff 30 stated she looked for Resident 35's Rivaroxaban but was unable to locate the medication. Staff 30 stated it was her mistake, she was overwhelmed by work and forgot to call the pharmacy as well as the doctor.

Based on observation, interview and record review it was determined the facility failed to provide necessary behavioral health care and services and develop a comprehensive, person-centered behavioral health care plan for 1 of 1 sampled resident (#16) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: The facility's Behavioral Health Services policy, last revised 10/15/22, indicated the facility: -provided trauma informed care which referred to approaches to care that treat the whole person, taking into account past trauma and the resulting coping mechanisms when attempting to understand behaviors and treat the resident; -ensured necessary care and services were person-centered and reflected the resident's goals for care; -monitored residents for signs and symptoms of depression, anxiety disorders, verbal behavioral symptoms directed towards others such as screaming at others. Resident 16 was admitted to the facility in 2/2025 with diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). Resident 16's 2/28/25 Clinical Evaluation Admission indicated the resident had a history of behaviors and was prescribed anti-psychotic medications. Resident 16's 3/2/25 Psychosocial Evaluation indicated the resident had schizoaffective disorder and Bipolar II (a mental health disorder characterized by depressive and hypomanic episodes) and her/his mental health was unstable. Resident 16 was in a psychiatric hospital for eight months in 2024, discharged home and failed. There were no trauma triggers identified and the resident liked to be left alone when under stress. Resident 16's 3/3/25 Suicide Risk Evaluation identified the resident as having mild depression and anxiety at a high or panic state. Resident 16 expressed feelings of helplessness, hopelessness, withdrawal and the resident had some constructive coping strategies. Resident 16 had vague, fleeting and intrusive thoughts of suicide but no suicide plan. Resident 16 was described as being labile (rapid, often exaggerated changes in mood where strong emotions such as uncontrolled laughter or crying occurred), hyperfocused on people controlling her/him and experienced thought disturbances. Resident 16's 3/4/25 care plan identified the resident as exhibiting accusations of being dishonest behaviors. No other behavioral health focuses, goals or interventions were identified. Resident 16's 3/7/25 Admission MDS indicated the resident had moderate cognitive impairment and received anti-anxiety and routine anti-psychotic medications. No evidence was found in Resident 16's health record to indicate any anxiety, mood or behavioral symptoms for the resident were monitored and a comprehensive, person-centered care plan was developed to address the resident's anxiety, feelings of helplessness or hopelessness and withdrawal, lack of coping skills, thoughts of suicide, lability or concerns regarding people controlling her/him. On 3/24/25 through 3/25/25 between the hours of 8:00 AM and 4:00 PM, Resident 16 exhibited multiple episodes of yelling and screaming. The resident reported a frequent sensation of bugs crawling on her/him. Resident 16 was observed speaking with various nursing staff, including the hospice nurse, regarding her/his anxiety and feeling bugs were crawling on her/him. The resident was observed to be upset and anxious and reported needing some medication to help reduced the sensation of bugs crawling on her/him. At times, Resident 16 mumbled and was not able to make herself/himself understood. On 3/24/25 at 11:02 AM and 3/25/25 at 8:17 AM, Resident 16 stated she/he frequently experienced a sensation of bugs crawling all over her/him, she/he needed something to help reduced this sensation but nobody understood what she/he was trying to explain to them. On 3/26/25 at 10:02 AM and 3/28/25 at 11:48 AM, Staff 10 (CNA) stated Resident 16 was easily frustrated and yelled, at times. Staff 10 stated Resident 16 became upset when people talked to her/him about being in the facility. On 3/26/25 at 10:35 AM, Staff 5 (Social Service Director) stated Resident 16 was often labile and her/his mood was mountains and mole hills. Staff 5 stated there was no behavior monitoring in place for Resident 16 and no care plan interventions for the resident's spiraling stuff. On 3/27/25 at 9:09 AM, Staff 12 (CNA) stated Resident 16 was sporadic at times and had outbursts. Staff 12 stated Resident 16 accused other residents of wearing her/his clothing and the resident usually yelled and screamed when she/he was anxious. 3/27/25 at 9:22 AM, Staff 13 (CNA) stated Resident 16 had outbursts and called people names when she/he was upset. On 3/28/25 at 9:37 AM, Staff 4 (DNS) stated any resident with mental health diagnoses were expected to be monitored and care planned for behaviors. Staff 4 confirmed Resident 16 had behaviors that were not being monitored and a comprehensive, behavioral care plan was not developed. Staff 4 stated staff should have identified Resident 16's triggers and devised strategies to help her/him feel better, asserting Resident 16 should not have experienced such distress.

Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 5 sampled residents (#16) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include: Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes and morbid obesity (having a body mass index greater than 40). Resident 16's 3/7/25 Admission MDS indicated the resident had moderate cognitive impairment and required partial to moderate assistance with bathing/showering. Resident 16's 3/13/25 bladder and bowel care plan indicated the resident was incontinent of urine and frequently incontinent of bowel. Resident 16's 2/2025 and 3/2025 bathing task logs indicated the resident received bathing on the following days: - 3/8, 3/12, 3/19, 3/22 and 3/26/25. Resident 16 was not showered until eight days after being admitted and received only one shower between 3/9/25 and 3/15/25. On 3/24/25 at 10:40 AM and 3/26/25 at 9:14 AM, Resident 16 stated she/he was scheduled for showers on Wednesday and Saturday, she/he did not receive showers as scheduled and if she/he missed a shower, the shower was not made-up on another day. Resident 16 stated she/he was incontinent of urine and bowel and, as a result, needed more than one shower a week. On 3/27/25 at 9:09 AM and 9:43 AM, Staff 12 (CNA) and Staff 15 (CNA) stated Resident 16 liked taking showers and rarely refused. Staff 15 stated if a resident refused showers the nurse was notified. Staff 15 stated they tried to make-up refused or missed showers on another day but that only occurred if the shower aid had time. On 3/27/25 at 9:53 AM, Staff 9 (CNA) stated Resident 16 typically showered on evening shift but the resident recently asked for a shower during the day and the resident's request could not be accommodated because she could not get to it. Staff 9 stated if a resident refused or missed a shower, the resident usually had to wait until their next shower day unless a slot opened up with the shower aid. On 3/27/25 at 1:18 PM, Staff 6 (LPN-Care Manager) stated residents should receive at least two showers a week, more if they wanted. Staff 6 stated CNA staff should make-up any refused or missed showers. On 3/28/25 at 9:37 AM, Staff 4 (DNS) reviewed Resident 16's shower task logs and stated her expectation was residents received a minimum of two showers a week, more if that was their preference. Staff 4 confirmed Resident 16 did not receive showers twice a week.

Based on observation, interview and record review it was determined the facility failed to implement an activity care plan and failed to include residents in group and individual activities for 1 of 3 sampled residents (# 302) reviewed for activities. This placed residents at risk for isolation, lack of social interaction and engagement. Findings include: The facility's 11/2017 Activities Policy included the following information: - The facility provides, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in the choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. - The recreation program provides stimulation or solace, promotes a sense of usefulness, and provides a sense of belonging. - The facility considers accommodations in schedules, supplies and timing in order to optimize a resident's ability to participate in an activity of choice. Examples of accommodations may include, but are not limited to: assisting residents, as needed, to get to and participate in desired activities; providing supplies (i.e. books/magazines, music.). - For the resident who has withdrawn from previous activity interests/customary routines and isolates self in room/bed most of the day: provide in-room volunteer visits, music or videos of choice; invite to special events; invite resident to participate on facility committee; invite the resident outdoors. Resident 302 was admitted to the facility in 1/2024 with diagnoses including metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly) and Cerebral Palsy (neurological disorder affecting movement). Resident 302's 10/5/24 Significant Change MDS indicated Resident 302 had impaired communication related to being non-verbal and was dependent on staff for care and mobility. Resident 302's 10/2024 Activity Profile revealed Resident 302 preferred to watch action movies, enjoyed exercise/sports, gardening/plants, music, pet visits, and spiritual/religious activities. Resident 302 also preferred talking books in the afternoon. Resident 302's 1/9/25 Care Plan indicated for Resident 302 to be invited, encouraged, and assisted to activities. Resident 302 also enjoyed non-group activities including listening to music, audio books, and spending one-on-one time with staff. Although Resident 302 was on Contact Isolation Precautions effective 3/24/25, she/he was to be encouraged to participate in activities. On 3/25/25 at 2:38 PM, Staff 7 (Activities Director) was observed inviting Resident 302's roommate to a group Bingo game. Resident 302's eyes were open, but she/he was not invited to the game. At 3:55 PM, Resident 302 was observed to be laying in bed with eyes toward the ceiling and the TV off. Audio books and music were not seen in Resident 302's area. On 3/26/25 the activity schedule included games, Uno, and Yahtzee at 1:00 PM and Activity Cart at 3:15 PM. At 1:10 PM Resident 302 was observed lying in bed with the television off and no music on. At 3:01 PM Resident 302 was observed staring at the ceiling, no television or music on. At 3:15 PM an activity cart was not seen throughout the facility. At 3:26 PM Resident 302 was observed laying in bed, no television or music on. On 3/27/25 the activity schedule included Chapel Service at 3:30 PM. At 3:36 PM, a religious program was playing on the living room television, and Resident 302 was absent from the service. On 3/27/25 at 9:08 AM Staff 9 (CNA) confirmed Resident 302 was dependent on staff for care and stated to not know if staff had ever tried to get her/him up for Bingo or other activities. On 3/27/25 at 10:04 AM Staff 8 (RN) stated he was not sure if Resident 302 participated in any activities. He stated it was usually Staff 7 (Activities Director) who turned music on for Resident 302. On 3/28/25 at 10:04 AM Staff 10 (CNA) was not sure of Resident 302's likes or activities but stated it could be found on the Activities section of the Kardex. On 3/27/25 at 11:42 AM Staff 7 (Activities Director) stated she was responsible for inviting residents to group activities. Staff 7 acknowledged she was supposed to invite Resident 302 to group activities and had not been inviting her/him. Staff 7 acknowledged that she was supposed to invite and do other activities with Resident 302 but had not been doing so. Staff 7 stated she had been struggling with doing activities with non-verbal residents as she did not know if they wanted to do anything or not. Staff 7 stated the facility had not procured any music or audio/talking books, but the software applications were accessible on her cell phone. At 3:20 PM, Staff 7 stated she did not know about asking CNAs for help with resident activities, because she did not manage the CNAs. On 3/28/25 at 8:42 AM Staff 4 (Director of Nursing Services) stated she expected staff to follow Resident 302's care plan. Staff 4 stated this included assisting residents with turning on and off televisions and music for residents. Staff 4 stated activities was a shared task amongst care and activities staff, and a resident's preferred activities could clearly be found on a resident's Kardex and care plan.

Based on interview and record review it was determined the facility failed to assist residents to formulate an advance directive for 1 of 2 residents (#21) reviewed for advance directives. This placed residents at risk for healthcare decisions to conflict with resident wishes. Findings include: The facility's Advance Directives/Health Care Decisions Policy dated 10/1/17 states: If a resident has not executed an advance directive, the facility advises the resident and family of the right to establish an advance directive, including but not limited to: - Offering assistance if the resident wishes to execute one or more directives. Resident 21 admitted to the facility in 9/2024 with diagnoses including pneumonia and anxiety. A 9/16/24 Advance Directive Review form signed by Resident 21 stated Resident 21 would like assistance with formulating an advance directive plan. A review of Resident 21's clinical record revealed no advance directive on file. On 3/26/25 at 8:27 AM Resident 21 reported she/he had not received assistance with establishing an advance directive. On 3/25/25 at 2:47 PM Staff 5 (Social Services Director) stated she had discussed advance directives with Resident 21 after she/he arrived at the facility, but no follow-up occurred with assisting Resident 21 with formulating an advance directive. On 3/28/25 at 12:55 PM Staff 1 (Administrator) confirmed no follow-up had be completed to assist Resident 21 with formulating an advance directive.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#28) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration and adverse medication side effects. Findings include: The facility's Self-Administration of Medications policy, dated 11/28/17, revealed the resident may self-administer drugs if the interdisciplinary team (IDT) determined the practice was safe as follows: -The resident had the capacity to follow directions. -The resident had comprehension of instructions for the medications they were taking. -The resident had the ability to store medications securely and safely. -Appropriate notation of determinations were documented in the resident's medical record and care plan. Resident 28 was admitted to the facility in 1/2024 with diagnoses including major depressive disorder. Resident 28's 1/31/25 Annual MDS indicated the resident had no cognitive impairment. During multiple observations from 3/24/25 through 3/26/25 between the hours of 9:00 AM and 4:00 PM, mycostatin (a medication used to treat infections caused by fungi) and trimincolone acetonide (a potent corticosteroid medication used to treat inflammatory conditions of the skin) were observed on the resident's nightstand, within the resident's reach. Multiple staff, residents and resident visitors were observed going in and out of the room. Resident 28 reported that she/he self-administered the medications at times. Review of Resident 28's health record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer the mycostatin or trimincolone acetonide and there were no physician orders for either medication. On 3/26/25 at 8:49 AM, Staff 11 (CMA) stated when any medications were left at the bedside, a self-administration of medication assessment needed to be completed before allowing the resident to self-administer medications. On 3/26/25 at 10:14 AM, Staff 10 (CNA) stated no medications were to be left at a resident's bedside and if medications were left at the beside, the nurse should be notified. Staff 10 confirmed mycostatin and trimincolone acetonide were on Resident 28's nightstand within reach of the resident. On 3/26/25 at 10:16 AM, Staff 4 (DNS) observed Resident 28's medications within the resident's reach. Staff 4 confirmed the resident was not assessed to safely self-medicate and the medications should not be left in her/his room.

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 1 of 4 randomly selected CNA staff (#19) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 3/27/25 at 12:41 PM with Staff 20 (Human Resources) indicated the following employee had not received their annual performance evaluation: -Staff 19 (CNA), hire date 11/6/23: no annual performance review was completed. On 3/28/25 at 1:44 PM, Staff 20 confirmed an annual performance review for Staff 19 was not completed.

Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were comprehensively assessed and care plans were followed for 2 of 4 sampled residents (#s 15 and 16) reviewed for pressure ulcers and positioning. This placed residents at risk for incomplete assessments and worsening of wounds. Findings include: The facility's Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, last revised 10/15/22, indicated the facility had a system in place to promote skin integrity, prevent pressure ulcer development/other skin alterations, promote healing of existing wounds and prevent further development of additional skin alterations unless the individual's clinical condition demonstrated they were unavoidable. When assessing the pressure injury and/or non-pressure areas it was important that documentation addressed: -the type of injury; -the stage of the injury (a method of classifying wounds based on the depth of tissue damage); -a description of the pressure injury's characteristics; -if infection was present; -the presence of pain, what was done to address it, and the effectiveness of the intervention and -a description of the dressings and treatment. 1. Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes and acute kidney failure. Resident 16's 3/7/25 Admission MDS indicated the resident did not have any pressure injuries. Resident 16's 3/19/25 Skin and Wound Evaluation indicated Resident 16 had a new pressure injury wound to her/his left heel which developed since the resident's admission. The Skin and Wound Evaluation did not include the stage of the pressure injury or any wound characteristics such as a description of the wound bed, if odor was present, a description of the periwound (the area of skin/tissue around the wound), how the wound was acquired or if the resident experienced pain. A review of Resident 16's health record revealed no additional Skin and Wound Evaluations regarding the resident's left heel pressure ulcer. Resident 16's skin and tissue integrity care plan, dated 3/19/25, indicated the resident had a new pressure related injury to her/his left heel. A 3/20/25 skin and tissue intervention indicated staff were to off-load (minimize or remove pressure from the heel area) pressure to Resident 16's heel using a pressure relieving boot or pillows. Multiple observations on 3/25/25, between the hours of 8:00 AM and 4:30 PM revealed Resident 16 in bed without her/his left heel being off-loaded with pillows or a pressure relieving boot. On 3/26/25 at 9:28 AM, Staff 6 (LPN-Care Manager) examined Resident 16's left heel which was resting directly on the floor. Staff 6 prepared Resident 16 for wound care on her/his left heel pressure injury and stated Resident 16's left heel should not have been resting directly on a hard surface. Staff 6 stated nursing staff should have caught that before and ensured the resident had orders to wear her/his pressure relieving boot while out of bed, as well as, when in bed. On 3/26/25 at 11:48 AM, Staff 8 (RN) stated he found Resident 16's left heel pressure injury on 3/19/25 and contacted hospice. Hospice sent an LPN the same day to look at the wound, but the wound was not staged or comprehensively assessed. Staff 8 stated Resident 16 was not supposed to have her/his heel on the floor and was supposed to have her/his left heel off-loaded using pillows or a pressure relieving boot when in bed. Staff 8 stated once in a while the resident refused to have her/his heel off-loaded but any refusals would be documented in the resident's health record. A review of Resident 16's 3/25/25 progress notes revealed no refusals for off-loading her/his left heel. On 3/27/25 at 9:09 AM and 9:22 AM and 3/28/25 at 11:35 AM, Staff 12 (CNA) and Staff 13 (CNA) stated they did not off-load Resident 16's left heel when she/he was in bed. Staff 22 (CNA) stated Resident 16 did not have a pressure relieving boot until yesterday and the resident allowed staff to off-load her/his left heel as long as her/his legs were not too painful. On 3/28/25 at 9:37 AM, Staff 4 (DNS) stated she was made aware of concerns regarding Resident 16's left heel pressure injury, yesterday, and there were some miscommunications with hospice regarding Resident 16. Staff 4 stated she expected staff offered to off-load Resident 16's left heel while in bed using pillows or a pressure relieving boot and new physician orders were secured to ensure Resident 16 wore her/his pressure relieving boot while out of bed. 46053 2. Resident 15 was admitted to the facility in 7/2019 with diagnoses including spinal stenosis, cervical region (a narrowing of the spaces in the spinal canal characterized by back pain and other nerve issues) and spondylosis with radiculopathy, lumbar region (age-related wear and tear of the lower back spinal disks which result in back and leg pain). A review of Resident 15's 12/14/24 Quarterly MDS revealed she/he had mild cognitive impairment and was dependent on staff for assistance with bed mobility. Resident 15's 3/24/25 quarterly Braden Scale for Predicting Pressure Sores indicated she/he was at moderate risk for developing pressure sores, her/his ability to change and control body position was very limited and required moderate to maximum assistance for repositioning. Resident 15's care plan dated 4/25/24 revealed she/he was at risk of skin/tissue integrity related to impaired mobility, incontinence, fragile skin, age, and use of an anticoagulant. Resident 15's care plan indicated her/his heals were to be floated on a pillow or wear prevalon boots while in bed. Resident 15 signed orders for a Specialty Air Mattress with settings for, low air loss, alternating, 120 lbs. The order reflected Resident 15's care plan and Kardex a note to, Notify nursing if settings need to be adjusted. A review of Resident 15's weight history revealed she/he weighed 135.9 pounds on 3/21/25. On 3/24/25 at 11:17 AM Resident 15 was observed in bed with the right side of her/his neck pushed into the air mattress. Resident 15 stated she/he was uncomfortable on the air mattress and told staff she/he wanted a regular mattress instead. On 3/25/25 at 1:58 PM Resident 15 was observed in bed. Resident 15 was in the middle of the bed, the air mattress was deflated and her/his heels were not floated on a pillow. Resident 15 stated she/he requested a regular mattress and staff told her/him the air mattress was better for her/him. Resident 15 stated her/his position on the air mattress created a hollow feeling which added to her/his discomfort. On 3/26/25 at 8:26 AM Resident 15 was observed in the same sunken position with her/his heals not floated or wearing prevalon boots. Resident 15 reported she/he did not sleep well because of the uncomfortable mattress. On 3/26/25 at 9:37 AM Staff 10 (CNA) stated Resident 15 needed to be repositioned every two hours because the air mattress had a tendency to pull her/him down into it. Staff 10 stated she should report Resident 15's sunken position to the nurse. Staff 10 reviewed Resident 15's air mattress settings and stated the air mattress was supposed to be set at 120 pounds but was set at 50 pounds. On 3/26/25 at 9:52 AM Staff 28 (LPN) stated Resident 15 weighed 135 pounds and verified the air mattress was to be set at 120 pounds. Staff 28 observed Resident 15's air mattress setting and confirmed it was set at 50 pounds but the physician order was for the air mattress setting to be at 120 pounds. On 3/27/25 at 11:52 AM Staff 4 (DNS) stated the air mattress alleviated pressure in places which were prone to skin breakdown. Staff 4 stated she expected staff to follow physician orders. Staff 4 stated she was unaware resident 15 did not care for the air mattress. 3. Resident 15 was admitted to the facility in 7/2019 with diagnoses including spinal stenosis, cervical region (a narrowing of the spaces in the spinal canal characterized by back pain and other nerve issues) and spondylosis with radiculopathy, lumbar region (age-related wear and tear of the lower back spinal disks which result in back and leg pain). A review of Resident 15's 12/14/24 Quarterly MDS revealed she/he had mild cognitive impairment and was dependent on staff for assistance with bed mobility. Resident 15's 3/24/25 quarterly Braden Scale for Predicting Pressure Sores indicated she/he was at moderate risk for developing pressure sores, her/his ability to change and control body position was very limited and she/he required moderate to maximum assistance for repositioning. Resident 15's care plan 4/25/24 revealed she was at risk of skin/tissue integrity related to impaired mobility, incontinence, fragile skin, age, and use of an anticoagulant. Resident 15's care plan indicated her/his heals were to be floated on a pillow or she/he was to wear prevalon boots while in bed. On 3/25/25 at 1:56 PM and 3/26/25 at 8:25 AM Resident 15 was observed in bed and slumped to her/his right. Resident 15's heels were not floated. On 3/26/25 at 9:37 AM Staff 10 (CNA) stated Resident 15's heels were to be offloaded when she/he was in bed. Staff 10 entered Resident 15's room and acknowledged her/his heels were not offloaded. On 3/26/25 at 10:05 AM Staff 6 (LPN Care Manager) acknowledged Resident 15's heels were not floated and stated she expected Resident 15's heels to be floated to prevent skin breakdown. On 3/27/25 at 11:52 AM Staff 4 (DNS) stated she expected staff to float Resident 15's heels as an intervention to prevent pressure ulcers and to follow the care plan.

Based on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate for 13 of 38 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include: The facility's Posting Licensed and Unlicensed Direct Care Staff policy, dated 11/28/17, indicated the facility posted nurse staffing data on a daily basis at the beginning of each shift which included facility name, current date, total number of actual hours worked by licensed and unlicensed staff and the resident census. A review of the facility's DCSDRs revealed the following: From 2/15/25 through 3/24/25, 38 days were reviewed and revealed 13 days when licensed nurse staff hours were inaccurate or the postings had missing/incomplete information on 2/16/25, 2/18/25, 2/19/25, 2/28/25, 3/1/25, 3/2/25, 3/4/25, 3/10/25, 3/16/25, 3/17/25, 3/18/25, 3/21/25 and 3/24/25. On 3/27/25 at 1:41 PM, Staff 23 (Staffing Coordinator) reviewed the 2/15/25 through 3/24/25 DCSDRs and verified the reports were inaccurate or incomplete on the days identified.

Based on observation and interview it was determined the facility failed to maintain a clean and homelike environment for 1 of 1 facility reviewed for homelike environment. This placed residents at risk for adverse health conditions related to an unclean environment. Findings include: Observations of the air intake floor vents in the north and south residents' hallways and the entrance hallway from 3/24/25 through 3/28/25 between the hours of 7:45 AM and 4:30 PM revealed accumulations of dust, fuzz and paper debris on and below the grates covering them. On 3/24/25 at 1:47 PM Resident 14 stated staff swept the dust from the floors into the vents on the floor which made them filthy. On 3/26/25 at 2:17 PM Staff 25 (Maintenance Manager) stated cleaning the floor vents was part of housekeeping's duties and he was involved if they needed to be fixed. On 3/27/25 at 10:11 AM Staff 24 (Housekeeping Manager) stated the floor vents were cleaned every quarter and their most recent cleaning was 11/21/24. She acknowledged the vents were filthy. On 3/28/25 at 12:39 PM Staff 2 (Administrator in Training) acknowledged the vents were dirty and needed to be cleaned. Staff 2 stated he expected the floor vents to be cleaned weekly by housekeeping and more frequently if staff noticed the vents were dirty.

Based on interview and record review it was determined the facility failed to ensure residents were free from physical restraints for 1 of 3 sampled residents (#7) reviewed for restraints. This placed residents at risk for mistreatment. Findings include: On 6/8/23, the Past Noncompliance was corrected when the facility implemented a plan of correction, which included: -Residents on the same unit were interviewed and no other restraints were found to be improperly utilized; -Educated the staff responsible and placed on corrective discipline; -Provided in-service training to all nursing staff for abuse and neglect which included the use of restraints; and -Provided signature sheet verifying nursing staff had completed the training. Resident 7 was admitted to the facility in 5/2023, with diagnoses including stroke and repeated falls. Resident 7's care plan dated 5/4/23 revealed she/he was a high fall risk and had a history of falls. Staff were to encourage Resident 7 to transfer to her/his bed, wheelchair or ambulate when she/he was on the unit to prevent further falls. On 6/7/23 the facility submitted a report to the State Survey Agency (SSA) which stated Resident 7 had been placed in a device which limited her/his ability to stand. Staff 3 (RCM) assisted the resident to the bathroom and found the resident's gait belt was tied to the resident's wheelchair. Staff 11 (CNA) told Staff 3 he had tied the gait belt to the wheelchair to keep Resident 7 from falling while Staff 11 assisted other residents. The facility investigation revealed Staff 11 was suspended, the resident was placed on alert, a skin check was completed and staff education was initiated. The investigation included a handwritten statement from Staff 11 dated 6/7/23 which stated in part, Resident 7 was a super high fall risk. In order to keep a close watch on [the resident] and also be able to care for my other residents, I wheeled [the resident] along with me to rooms. I had a gait belt around [the resident's] waist and tied the extra length of the belt to part of [the resident's] wheelchair. If [the resident's] alarm chimed, I would have enough time to conclude whatever I am doing and still get to [the resident]. On 9/19/24 at 12:55 PM, Staff 3 confirmed on 6/7/23, Resident 7 was observed by her to have a gait belt tied to her/his wheelchair. She stated she completed a full skin check with no negative findings and Resident 7 did not report any pain or discomfort as a result of the restraint. On 9/19/24 at 1:20 PM, Staff 11 confirmed he had written the statement on 6/7/23 and had tied Resident 7's gait belt to her/his wheelchair to keep her/him from falling. On 9/19/24 at 1:30 PM, Staff 1 (Administrator) and Staff 2 (DNS) were advised of the investigative findings and provided no additional information.

Based on interview and record review it was determined the facility failed to provide pain management to 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at increased risk of unmanaged pain. Findings include: The facility's pain management policy, revised 10/2022 recognized a resident's right to be free of pain and promoted pain relief utilizing a pain management plan during the resident's stay at the facility. Facility procedures included an initial pain assessment upon admission for all residents. Resident 3 admitted to the facility in 10/2023, with diagnoses including spinal fractures and chronic pain syndrome. Resident 3's physician orders dated 10/23/23 included a prescription for morphine tablets (15 mg), to be administered every 12 hours for pain. Resident 3's care plan dated 10/24/23 revealed she/he was at risk for acute pain related to her/his diagnoses following a spinal cord injury. Interventions were to administer medications as ordered, anticipate need for pain relief and respond immediately to any complaint of pain. Resident 3's initial pain assessment was completed on 10/24/23 at 5:46 PM by Staff 12 (RN). The assessment revealed Resident 3 reported a pain level of 10 and she/he was in severe pain. Resident 3's 10/2023 MAR revealed she/he was not administered morphine on 10/24/23 evening shift due to the medication being unavailable. Pharmacy delivery records revealed the morphine was delivered to the facility on [DATE] at 2:30 AM. The MAR revealed the resident received the first dose of morphine on 10/25/23 at 8:00 AM. A nursing note written on 10/25/23 at 9:20 AM by Staff 4 (RCM) revealed she gave Resident 3 her/his morning medications which included the morphine, the resident was upset and said she/he had asked for the medication earlier but had not received it. On 9/19/24 at 11:23 AM, Staff 5 (LPN) stated she completed resident assessments for new admissions to the facility. If a resident complained of pain during her/his assessment, the facility was expected to provide pain medication to the resident as ordered. If the resident's pain medication was not available, it was the responsibility of the admitting nurse to contact the pharmacy and get a code for the Cubix (a medication system that dispenses common medications for emergent care needs). Staff 5 stated pain medications typically found in the Cubix included morphine. Resident 3's clinical record did not reveal any efforts were made by nursing staff on 10/24/23 to dispense pain medications from the Cubix. On 9/19/24 at 11:40 AM, Staff 4 confirmed the morphine was not administered to Resident 3 on 10/24/23 and there were no progress notes to explain the delay of the medication's delivery to the facility. Resident 3 was not interviewed due to discharging from the facility. Staff 12 was not interviewed due to medical leave. On 9/19/24 at 1:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated it was an expectation that residents receive pain medication timely.

Based on observation and interview it was determined the facility failed to provide a private space for resident council meetings for 1 of 1 resident council group reviewed. This placed the residents at risk for unaddressed concerns and needs related to resident care and quality of life. Findings include: On 11/15/23 at 11:30 AM the resident council group meeting was held in the facility dining room with state surveyors. The facility dining room did not provide privacy as the dining room was open to the lobby and living room. There were no doors or barriers to provide privacy. During the meeting, staff walked into the dining room to administer medications to one of the residents, one staff sat in the corner on her computer, the hallways were loud with staff and residents walking past the dining room and staff were vacuuming nearby while residents were speaking making it difficult to hear them. On 11/15/23 at 2:14 PM Resident 2 stated there were privacy concerns with resident council meetings. She/he confirmed the resident council meetings were held in the facility dining room. There were no private areas in the facility to hold the resident council meetings. Resident 2 expressed some residents were afraid to speak out in meetings due to the lack of privacy. The resident also stated the facility had not implemented any measures to make the meetings more private. On 11/15/23 at 2:20 PM Resident 14 confirmed the resident council meetings were held in the facility dining room. She/he stated the dining room was open and did not feel very comfortable voicing concerns. The resident expressed this was the residents' home and there was no privacy for the meetings. She/he stated there have been employee arguments, outside noises, vacuuming, guests coming in and out of the facility, residents walked to and from staff offices and staff walked into the meetings to administer medications to residents during the resident council meeting. On 11/16/23 at 9:09 AM Staff 9 (Activities Director) stated she was not aware of any of any privacy concerns. Staff 9 confirmed the resident council meetings were held in an open space and it was the only place the meetings could be held. When asked about any measures to ensure privacy during these meetings, Staff 9 indicated there had not been any other privacy measures implemented. On 11/16/23 at 9:15 AM Staff 1 (Administrator) stated he was unaware of the issues regarding privacy and acknowledged no other privacy measures have been put into place.

1. Based on interview and record review, it was determined the facility failed to respond timely to a change of condition for 1 of 1 sampled resident (#12) reviewed for change of condition. As a result, Resident 12 was hospitalized for [REDACTED]. Resident 12 was admitted to the facility in 7/2019 with [DIAGNOSES REDACTED]. Resident 12's 7/2019 Physician order [REDACTED]. -[MEDICATION NAME] 10/325 mg (an opioid pain reliever with a high propensity to cause constipation) every six hours as needed for pain. -Milk of Magnesia Suspension (bowel medication) 1200 mg. Give 30 mls as needed for no bowel movement for two days. -[MEDICATION NAME] Suppository (bowel medication) 10 mg as needed for constipation. Give if no results from Milk of Magnesia. -Fleet Enema (bowel medication) 7-19 GM as needed for constipation. Give if no results from [MEDICATION NAME] Suppository. -Senna (bowel medication) 8.6 mg, give two tablets as needed for constipation. Review of Resident 12's 7/2019 MAR revealed [MEDICATION NAME] 10/325 mg was administered three times each day from 7/19/19 through 7/24/19 and no bowel medications were documented as administered. Review of Resident 12's Bowel Movement Tracking Sheet revealed no bowel movement for seven days from 7/18/19 through 7/24/19. Review of Resident 12's Progress Notes revealed on 7/18/19, staff assessed Resident 12's abdomen as soft, non-tender, bowel sounds present and had a bowel movement yesterday. No other progress notes related to bowel movements and abdomen assessments were documented until 7/25/19 when Resident 12 was sent to the emergency room . According to the 7/2019 Patient/Facility Transfer Form, Resident 12 was admitted to the emergency roiagnom on [DATE] with complaints of severe, sharp, 10/10 rated abdominal pain. Resident 12 returned to the facility on [DATE]. The 7/30/19 Hospital Discharge Summary indicated Resident 12 was hospitalized for [REDACTED]. On 8/12/19 at 8:48 AM, Resident 12 stated on 7/24/19 and 7/25/19, she/he was constipated and miserable, screamed in pain and knew something was wrong. She/he stated staff did not respond timely to her/his complaints of constipation until the morning of 7/25/19. On 8/15/19 at 10:04 AM, Staff 9 (CNA) stated when a resident was independent to the bathroom, the CNAs asked the residents if they had a bowel movement and recorded it. On 8/15/19 at 10:06 AM, Staff 8 (LPN) stated if a resident does not have a bowel movement for three days, staff was alerted via the electronic health record. Staff 8 stated upon receipt of the no bowel movement alert, the resident's PRN bowel protocol should be initiated. Staff 8 stated she came on shift the morning of 7/25/19 and Resident 12 was yelling in pain and her/his abdomen was distended and tender. Staff 8 stated the night nurse had called the physician and Resident 12 was sent to the emergency room . On 8/15/19 at 11:43 AM, Staff 3 (RNCM) stated if a resident does not have a bowel movement for three days, staff was alerted via the electronic health record. Staff 3 stated she reviewed the alerts every morning, printed them for the nurses, and expected the nurses to initiate the bowel protocol. Staff 3 stated she did not realize Resident 12 did not have a bowel movement for seven days and was unsure how it was missed. On 8/16/19 at 10:46 AM, Staff 2 (DNS) stated she was aware Resident 12 was in severe pain with no bowel movement for seven days, which resulted in the resident being hospitalized . Staff 2 stated her expectation was for the nurses to check the alerts for residents' bowel movements and initiate bowel protocols immediately. 2. Based on interview and record review, it was determined the facility failed to follow physician orders [REDACTED].#12) reviewed for change of condition. This placed residents at risk for not receiving their medications as ordered. Findings include: Resident 12 was readmitted to the facility in 7/2019 after a five day hospital stay for [DIAGNOSES REDACTED]. The 7/30/19 Hospital Discharge Summary included an order for [REDACTED]. Review of Resident 12's 7/2019 and 8/2019 MAR revealed [MEDICATION NAME] 100 mg bid was not transcribed onto the MAR and not administered. On 8/15/19 at 3:40 PM, Staff 3 (RNCM) confirmed [MEDICATION NAME] 100 mg bid was on Resident 12's Hospital Discharge Summary and was not transcribed onto Resident 12's facility MAR. On 8/16/19 at 10:46 AM, Staff 2 (DNS) stated she was not aware Resident 12's [MEDICATION NAME] 100 mg bid order was not transcribed onto Resident 12's facility MAR. No other information was provided.

Based on observations, interview and record review it was determined the facility's quality assessment and assurance committee (QAA) failed to systematically identify and correct deficiencies in the areas of care and services of pain management, comprehensive assessments, treatments and services to prevent pressure ulcers, accidents, infection prevention, physical restraints, care planning timing and revision, storage of medications and treatment and services for dementia. This resulted in multiple occurrences of immediate jeopardy and substandard quality of care. Findings include: 1. The facility failed to ensure dignity for 4 of 7 residents reviewed for dignity and skin conditions. 2. The facility failed to comprehensively assess the use of a physical restraint for 1 of 6 residents reviewed for accidents. 3. The facility failed to complete comprehensive admission assessment within 14 days of admission and comprehensively assess 2 of 4 residents reviewed for dignity. 4. The facility failed to revise care plans for 4 of 11 residents reviewed for accidents, skin conditions and medications. 5. The facility failed to promptly intervene for 1 resident for acute change of condition, comprehensively evaluate and treat worsening non-pressure wound for 1 resident, which resulted in an immediate jeopardy situation. The facility also failed to follow physician orders [REDACTED]. 6. The facility failed to ensure pressure ulcer wounds were routinely assessed, monitored and treated per physician orders [REDACTED]. 7. The facility failed to ensure care planned safety interventions were in place, residents were assessed and supervised while smoking and to ensure a resident's environment remained free from accident hazards for 4 of 5 residents reviewed for accident hazards. 8. The facility failed to provide respiratory care and services in accordance with residents needs for 4 of 5 residents reviewed for respiratory. 9. The facility failed to provide ordered pain medication and provide efficacy for 6 of 6 residents reviewed for pain management, which resulted in an immediate jeopardy situation. 10. The facility failed to keep medications secure and accessible only to staff for 3 of 4 medication and treatment carts. 11. The facility failed to ensure resident records were complete and accurate for 6 of 12 residents reviewed for accidents, assessments and pain. 12. The facility failed to ensure staff and visitors had a thorough understanding of infection control practices for 2 of 2 staff and 1 of 1 witness who were observed for infection control, which resulted in an immediate jeopardy situation. On 7/3/18 at 10:20 AM Staff 1 (Administrator) he sated there was a change in staff and audits fell through the cracks. Refer to F550, F604, F636, F657, F684, F686, F689, F695, F697, F761, F842 and F880

1. Based interview and record review it was determined the facility failed to promptly intervene in a resident's acute change of condition for a fracture 1 of 4 sampled residents (#1) reviewed for pressure ulcers. As a result of this deficient practice, which was determined to be an immediate jeopardy situation, Resident 1 experienced a delay in treatment for [REDACTED]. Resident 1 was placed on hospice. Findings include: Resident 1 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. A 3/17/18 Incident Accident Report revealed Resident 1 attempted to transfer from the bed to the bedside commode without assistance and was found on the floor. Resident 1 did not have complaints of pain. A Health Status Note dated 3/19/18 at 12:37 PM revealed Resident 1 complained of pain all over her/his body. The resident slept most of the shift and no latent injuries were noted due to the fall on 3/17/18. A Health Status Note dated 3/19/18 at 6:19 PM and 3/26/18 revealed Resident 1's pain level was 10 out of 10 even after Resident 1 received all prescribed pain medication. A physician Phone Note: Recent Fall With Increased Pain dated 3/27/18 from Witness 4's (Previous physician for Resident 1) office revealed the following: received a fax from the facility resident had increased pain to left upper leg since (she/he) fell stated (her/his) leg makes a cracking noise when (she/he) moves (her/his) leg. Request for x-ray to be done. an order for [REDACTED]. A 3/27/18 Radiology Interpretation revealed: Significant Findings Pelvis oblique fracture (bone breaks diagonally) with a butterfly component. (Fractures resulting in multiple fragments) Impression: Possible pathologic fracture left femur (a break that occurs in a bone area that has already been weakened by a disease, a tumor, or an infection.) Staff 8 (LPN) initialed the report 3/27/18 at 3:30 PM. On the top of the document stated from: with a fax number and To: Fax: with a fax number. (The To: Fax number was the facility's fax number) Another copy of Radiology Interpretation with same information as listed above revealed Witness 9 (former LPN) initialed the report 3/29/18 faxed to Witness 4. On the top of the document stated from: with a fax number and To: Fax: with a fax number. (The To: Fax number was the facility's fax number) A Health Status note dated 3/29/18 revealed Resident 1's pain level was 10 out of 10 even after Resident 1 received all prescribed pain medication. A Care Conference-Multidisciplinary report dated 3/30/18 revealed a meeting was held on 3/28/18 and Resident 1 reported a high level of pain. A physician Phone Note 4/5/18 at 3:10 PM from Witness 4's office revealed the office called Witness 17 and informed her the facility was not answering the phone and it was a week since the x-ray orders were sent. Witness 4 had not received the results of the x-ray. The note also stated it was an ongoing issue trying to coordinate or even communicate with the facility. A Progress Note dated 4/10/18 revealed a request for a computed tomography (CT) scan of the left leg of Resident 1 was faxed to Staff 33 (Physician). A 4/13/18 Physician Assistant Note revealed Resident 1 stated her/his pain was 10 out of 10 and stated she/he felt like it may explode. Resident 1 stated she/he cannot take it anymore and she/he was doing illegal drugs due to the pain. Resident 1 had an unspecified [MEDICAL CONDITION] femur. Resident 1 stated she/he fell out of bed several weeks ago and the pain remained. Resident 1 was sent to the emergency department. A Hospital Progress Notes dated 4/23/18 revealed Resident 1 stated it's just crazy pain. There was a delayed presentation of a left femur fracture and left lower extremity abscesses and severe pressure wound requiring debridement (removal of dead, infected and damaged tissue) with escalated abdominal pain. Advancing infection into Resident 1's pelvis. Resident 1 was emotionally overwhelmed and the plan was for hospice. The 4/26/18 hospital's Final Report Discharge Summary revealed Resident 1 had a severe left lower extremity pressure wound which was present on admission with a superimposed infection and abscess.[MEDICAL CONDITION] was present on admission with a delayed presentation of the left leg fracture which was poorly displaced and eventually developed an overlying very significant wound. The quantity of purulence (pus) was marked. It was an unrecoverable wound with no survivable surgical options. On 6/6/18 at 10:24 AM Staff 5 (Nurse Practitioner) stated she came across the x-ray and stated one of the nurses' (who's name she could not remember) told her the physician stated no interventions were needed for the fracture. Staff 5 stated it would be months before an orthopedic appointment so Staff 5 sent Resident 1 to the hospital. On 6/18/18 at 12:13 PM Witness 4 stated on 3/27/18 he had provided orders for increased pain medication and an x-ray for left upper leg. Witness 4 stated he did not receive the results of the x-ray. Witness 4's office called the facility and was told the results would be faxed. Attempts were made to call and the facility did not answer the phone or would not call back. On 6/19/18 at 8:55 AM Staff 8 stated she faxed the results of Resident 1's x-ray on 3/27/18 to the physician. She stated she faxed to the number in the medical record. She stated she cannot be at the facility all of the time and it would be up to the RCM to take care of the follow up. On 6/19/18 at 9:13 AM Resident 1 stated she/he thought her/his leg fractured from the fall on 3/17/18 and reported increased pain. Resident 1 reported her/his concerns to staff with no follow up. On 6/19/18 at 10:00 AM Staff 1 (Administrator) and Staff 4 (LPN Unit Manager) stated after the fax for the x-ray results was sent on the 3/27/18 and on 3/29/18 follow up calls should have been made to the physician. On 6/19/18 at 11:08 AM Staff 7 (RN) stated Resident 1 reported a possible fracture. Staff 7 thought the day shift nurse took care of the concern. Staff 7 stated he administered Resident 1 additional pain medication. On 6/19/18 at 1:15 PM Staff 9 (LPN) stated she heard about Resident 1's fall. Resident 1 reported leg pain after the fall. Staff 9 stated she told another nurse about the fall. Staff 9 stated one day Resident 1 had her/his leg hanging on the side of the bed and when she assisted her/his leg back into the bed there was a pop. Staff 9 stated she reported the popping sound in the leg and believed an x-ray was ordered. On 6/21/18 at 8:44 AM Witness 16 (physician office assistant) provided the number of the fax for the physician office. Asked if any other fax numbers were used and compared numbers. The number Staff 8 used on 3/27/18 was not the correct fax number when she attempted to fax the x-ray results. On 6/21/18 at 8:48 AM Witness 9 (former LPN Unit Manager) stated she remembered Resident 1 but did not remember faxing the x-ray results to the physician on 3/29/18. On 6/20/18 at 11:23 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 4 (LPN Unit Manager) were informed of the failure of current measures used by the facility to ensure promptly intervening in a resident's acute change of condition which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 6/20/18 at 2:02 PM a final immediate plan of correction was received from the facility The facility's immediate plan of correction included: -Current assessment of resident pain, wound, and cares. -Update physician to current condition, follow care updates as indicated. -Assessment of residents with falls in last 90 days to determine if there was pain and/or fracture. -Update physician follow care updates as indicated. -Educate CNAs and nurses on current and ongoing shifts worked regarding management of falls with potential fracture to include but not limited to assessment, monitoring for pain, resident interview, physician notification, implementation of directives, and follow-up. -DNS responsible for assuring compliance. On 6/20/18 at 5:52 PM the plan was verified as implemented removing the immediate risk to residents health and welfare. 2. Based on interview and record review it was determined the facility failed to comprehensively evaluate and treat worsening right leg non-pressure wound, and follow up on wound clinic recommendations for wound culture and antibiotic treatment and to follow physician orders [REDACTED].#s 1, 5, 6, 11, 12 and 18) reviewed for skin conditions and [MEDICAL TREATMENT]. Resident 11 sustained a full thickness wound (skin loss) with muscle exposed with drainage. As a result of this deficient practice, this was determined to be an immediate jeopardy situation. This resulted in an Emergency Department admission for Resident 11 for a wound evaluation and treatment and antibiotic administration. This placed other residents at risk for unmet care needs. Findings include: a. Resident 11 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 2/6/18 Nursing Evaluation/Data Collection noted the resident had [MEDICAL CONDITION] to the lower legs. The 2/26/18 Weekly Body Audit noted bilateral one plus (two millimeter depression with immediate rebound) [MEDICAL CONDITION] (pressure on skin which causes indentation which persists for sometime after the release of the pressure). There was no further documented evaluation and monitoring of the resident's lower extremity [MEDICAL CONDITION] until 3/27/18. The 3/27/18 Weekly Body Audit noted three dressings were placed on the right lower extremity for open weeping wounds due to three plus (six millimeter depression 10 to 12 seconds to rebound) [MEDICAL CONDITION]. There was no comprehensive evaluation of those wounds including the size of the wounds and the status of drainage, odor, wound bed and the surrounding skin. The 3/28/18 Physician Assistant Progress Notes disclosed changes with bilateral areas that were superficially open due to circulatory issues. The resident was diagnosed with [REDACTED]. The 4/3/18 at 4:08 AM Progress Note disclosed the resident's left lower leg was red and slightly warm to the touch. There was an area of approximately 2 cm slightly open and weeping. However, the 4/3/18 Weekly Body Audit documented there was no bleeding or infection of the right foot wound, No signs of worsening of the wound. (Not clear in the resident's record if the resident had two wounds or mis-documentation of left lower leg) The correlating 4/3/18 Physician Assistant Progress Note disclosed nursing staff reported Resident 11 had increased swelling to the right lower extremity and increased drainage to the wound. The physical examination disclosed the resident had a mild increase in redness to the right lower extremity. The 4/3/18 physician order [REDACTED]. The 4/2018 TAR noted the treatment was only completed one time between 4/3/18 and 4/13/18. The 4/12/18 and 4/16/18 Weekly Body Audits did not include comprehensive evaluations of the right lower extremity wound. Weeping [MEDICAL CONDITION] was noted above the ankles with no further description of the [MEDICAL CONDITION]. A 4/13/18 physician order [REDACTED]. Staff were to apply moisturizing lotion before dressing changes on the right leg every three days. The right leg compression wrap treatment included covering the open area with a dressing secured with a self adhesive wrap which were to be changed every three days. The moisturizing lotion was not documented on the 4/2018 TAR to direct staff to complete administration. The 4/13/18 right leg treatment was not documented as completed until 4/18/18. This was five days after physician orders. The 4/18/18 at 11:49 AM Progress Note disclosed there was no drainage, odor or signs/symptoms of infection noted to the right lower extremity wound. The 4/21/18 Wound Consultant Progress Notes documented the right lateral ankle wound with dark green drainage. The wound was assessed as full thickness traumatic wound, muscle is exposed .The wound is deteriorating. The tissue surrounding the wound presented with signs and symptoms of infection. The wound increased in overall size. It is not clear when dressing was changed last. New orders included STAT (emergent) labs and more frequent dressing changes. Antibiotic treatment will be considered pending labs . The 4/21/18 physician orders [REDACTED]. There was no documented follow up from the physician regarding the lab findings. There were no critical lab values related to the wound. New treatment orders for the right lower extremity were obtained on 4/21/18: Apply Vashe (wound cleanser) soaked gauze was to be applied for 10 minutes, then apply a medicated gauze to the right ankle open area, wrap gauze and secure with self adhesive wrap. The dressing was to be changed every day and PRN. The 4/2018 TAR lacked documented evidence the treatment was completed as ordered on [DATE] and 4/28/18. The 4/23/18 and 4/30/18 Weekly Body Audits continued to note the bilateral [MEDICAL CONDITION], weeping above the ankle. There was no comprehensive evaluation of the right lower extremity wound. The 4/24/18 Physician Assistant Progress Note documented per nursing Drainage has increased significantly. The exam revealed the dressings were intact but were moist. The subsequent 5/4/18 Physician Assistant Progress Note documented per nursing everything looks better. The 5/2018 TAR noted the moisturizing lotion was either circled (indicating the treatment was not done) or was blank for 28 of 31 days. There was no documented evidence the right lower extremity treatment was completed as ordered on [DATE] and 5/11/18. The 5/12/18 Wound Consultant Progress Note documented the right ankle wound as a chronic full thickness Bacterial Infection ([MEDICAL CONDITION]) .muscle is exposed .there is a moderate amount of serous drainage noted which has a mild odor .The wound is deteriorating. The periwound skin (tissue surrounding the wound) presents with signs/symptoms of infection. The resident complained of intermittent sharp pain of the right lower extremity, increased drainage, the wound is markedly increased in size; not currently on ABX (antibiotics). A second wound was noted to the front right lower leg and was described as a chronic abrasion. New treatment orders were given and a wound culture was ordered. Staff were directed to contact the physician regarding the resident's change in condition and consideration of antibiotics. There was no documented evidence in the clinical record the wound culture was obtained as ordered. On 6/25/18 at 2:30 PM Staff 12 (LPN) stated Staff 37 (LPN) told her there was an order for [REDACTED]. On 7/3/18 at 11:45 AM Staff 4 (LPN Unit Manager) stated he did not think a wound culture was obtained. On 7/5/18 at 10:21 AM Staff 37 (LPN) stated she did not know a wound culture was ordered. On 7/5/18 at 3:27 PM Staff 8 (RN) stated there was not time for the floor nurses to obtain a wound culture so the culture was handled by the RCM or the DNS. The physician order [REDACTED]. The 5/2018 TAR did not indicate the right ankle treatment was done on 5/13/18 PM, 5/18/18 AM, both treatments on 5/19/18, and 5/23/18 PM. A new physician order [REDACTED]. The 5/14/18 at 6:26 PM Progress Note documented Dressing change complete and DNS interim and corporate DNS took a look at wound and have a plan of action for tomorrow. The 5/14/18 at 6:27 PM Progress Note disclosed there were no signs or symptoms of infection and no red streaks from the wounds. The 5/15/18 at 12:04 PM Progress Note disclosed the resident was sent to the hospital. The wound to the right foot continued to increase in size due to moisture, there was a large amount of drainage which covered 100 percent of the dressing. The correlating physician orders [REDACTED]. On 5/15/18 ED (Emergency Department) Physician Notes described the wound as a large raw area of skin to the right foot and heel. Antibiotics were ordered for potential early underlying cellulite (bacterial skin infection) within the chronic wound and the resident was discharged back to the facility. On 5/16/18 a new treatment to the right lower extremity was obtained. The wound was to be treated with an cream which contained antibiotic and anti-[MEDICAL CONDITION] medications. The treatment was to be completed three times a day and PRN. The 5/2018 TAR indicated the new treatment was not documented as completed from 5/16/18 through 5/23/18. It was also not documented on 5/27/18 at 12:00 PM, and 5/28/18 and 5/29/18 at 8:00 AM and 12:00 PM. The 5/24/18 Weekly Body Audit noted worsening of the right lower leg. The LN was told by RCM not to touch this shift. There was no documented comprehensive evaluation of the wound. There were no additional Weekly Body Audits/skin assessments documented until 6/15/18, more than four weeks after the resident's wound was evaluated in the ED. The 6/2018 TAR indicated the medicated cream treatment to the right lower extremity was not documented as completed on 23 occasions from 6/4/18 to 6/25/18. The 6/15/18 Weekly Non-Pressure Skin Condition Report noted the resident had three wounds on the right lower extremity with serous (yellow) drainage. The evaluation did not include status of odor, the wound bed, nor the surrounding skin of the wounds. An updated Weekly Non-Pressure Skin Condition Report completed on 6/20/18 incorrectly documented the wounds were present upon admission. Three wounds were assessed on the right lower extremity, two of which had purulent drainage (indicated possible infection). There was no documented evidence the physician was notified regarding the possible infection of the wounds. The wound on the right foot was noted as 6.0 ml (milliliters documents volume not size) which was an inaccurate form of measurement of the wound and included two measurements for the width of the wound. The resident's right lower extremity wounds were observed by a RN surveyor on 6/21/18 at 3:13 PM. The gauze wrap had yellow serous drainage. Two wounds were noted, the upper wound was 3 cm in diameter with slough and the lower wound was 2 cm x 4 cm with slough. On 6/25/18 at 10:51 AM Resident 11 was observed sitting in a wheelchair while in the dining room. The right foot dressing had yellow drainage with 6/25/18 at 0000 (midnight) noted on the dressing. The resident stated staff changed the right foot dressing during the previous night at midnight. On 6/25/18 at 11:03 AM Staff 28 (Agency RN) stated the right foot treatment was to be done three times a day and she had not completed the 6/25/18 at 8:00 AM treatment. Staff 28 stated she would complete the resident's treatment after lunch and would pass onto the next shift she did not complete one of the treatments. Staff 28 confirmed there was a large amount of drainage on the dressing which was dated as last changed during the previous night at midnight. Staff 28 stated the resident did not receive one of the 6/24/18 day treatments either and the resident only received two of the three ordered treatments 6/24/18. The lack of evaluating and monitoring the resident's [MEDICAL CONDITION], lack of consistent, accurate and comprehensive evaluation of the resident's right lower extremity wounds, wound consultant documentation regarding the resident's wound status, lack of documented follow up of labs and the resident's status with the physician, no documented wound culture, and lack of following physician orders [REDACTED]. Staff 2 stated a lot of errors were made by agency nurses. No additional documentation was provided. On 6/25/18 at 2:30 PM Staff 12 (LPN) stated the resident's right lower extremity wound had a lot of yellow-brown drainage in April/May (YEAR) which soaked through the gauze. The lower extremity had a lot of open areas with indentations in the wound. Staff 12 did not know how deep the wound was and did not recall muscle exposure, infection, or [MEDICAL CONDITION] to the wound. On 6/26/18 at 1:15 PM Staff 38 (CNA) stated in April/May (YEAR) the resident's right lower extremity wound had yellow drainage with odor which was on the resident's leg and the pillow she/he used under her/his leg during the night. Staff 37 stated the resident's leg was large and during that time she could not put a sock on the resident's foot. On 7/3/18 at 11:45 AM Staff 4 (LPN Unit Manager) stated he was not the resident's RCM during April/May (YEAR) and the resident's prior RCM no longer worked for the facility. The wound consultant reported the resident's legs were weepy, the wound was infected and was treated with an antibiotic. On 7/5/18 at 10:21 AM Staff 37 (LPN) stated in April/May (YEAR) the right lower extremity wound increased in size, the resident was sent out to the hospital for wound evaluation and was treated with an antibiotic. Staff 37 stated she did not see muscle exposure with the wound. Staff 37 stated she was not aware the resident had weeping, [MEDICAL CONDITION] and she did not see [MEDICAL CONDITION] when she completed wound treatments as she was not looking for it and was only focused on the wounds. On 7/5/18 at 3:27 PM Staff 8 (RN) stated the right lower extremity wound was weeping [MEDICAL CONDITION] and she did not recall muscle exposure to the wound. Staff 8 stated she missed completing one of the resident's skin checks and she only documented completing wound treatments. Staff 8 stated she reported treatments were not being completed. Day shift staff signed off on doing the treatments, however, the dressings from the day before had her initials from the previous day. On 6/25/18 at 2:30 PM Staff 1 (Administrator) was informed of the failure of current measures used by the facility to comprehensively evaluate and treat worsening non-pressure wounds which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 6/25/18 at 7:56 PM a final immediate plan of correction was received from the facility. The facility's immediate plan of correction included: -Contract with wound care agency. -Wound culture and/or antibiotic therapy if indicated. -Orders would be transcribed and implemented as physician directs. -Reports and orders reviewed for accurate transcription and implementation. -Omission reports would be completed and physician updated. -Management review of reports and orders during morning clinical meeting. -Nurses will be educated on order transcription, review of reports and physician orders. -Education of Administrator and DNS on timely supervision for wound management details, order transcription, administrative process, use of resources, and development and implementation of quality assurance action plans which impact immediate concerns and long term trending. On 6/26/18 at 12:42 PM the plan was verified as implemented. b. Resident 1 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. 1. The 4/2018 Physician orders [REDACTED]. The 4/2018, 5/2018, 6/2018 TARs instructed staff to complete weekly body audits in the morning every Saturday for skin integrity. Five body audits were not completed during April, (MONTH) and June. A Weekly Body Audit for 4/2018 revealed on 4/28/18 a body audit was completed. The notes stated the wound bed with surrounding tissue beefy pink 1 cm x 1 cm with zero depth and neglected to document of the location of the wound. No other documentation was located for this wound. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (Interim DNS) confirmed body audits were not being completed and the wound was not monitored for Resident 1. 2. A Weekly Non-Pressure Skin Condition Report dated 6/20/18 revealed Resident 1 had a multiple spots on the left shin which were weeping. No other documentation was located in medical records in regard to the wounds on Resident 1's left shin. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed skin checks and treatments were not being completed as needed for Resident 1. 3. The 6/2018 TAR instructed staff to apply [MEDICATION NAME] cream to Resident 1's face two times a day for a rash. On 6/13/18 and 6/19/18 in the evening no treatments were completed. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed treatments were not being completed as ordered for Resident 1. 4. The 6/2018 TAR instructed staff to cleanse Resident 1's right hand with a sensitive skin cleanser, pat dry and apply an antifungal cream two times a day. Out of 46 opportunities treatment was not completed 17 times. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed treatments were not completed as ordered for Resident 1. 5. A contracted wound consulting agency report dated 4/6/18 revealed Resident 1 had a traumatic left groin wound which measured 1 cm x 2 cm x .1 cm depth with an area of 2 cm and a volume of .2 cubic cm. Muscle was exposed. Scant amount of serous (yellow or transparent) drainage and wound bed was 100 percent granulation. A report from a contracted wound consulting agency report dated 4/13/18 revealed Resident 1 had a traumatic groin wound with chronic full thickness (skin loss), which measured 1 cm x 2 cm with no measurable depth with an area of 2 cm and a volume of .2 cubic cm, the muscle was exposed. The wound bed was 100 percent granulation and the wound was deteriorating. Physician order [REDACTED]. -Check dressing integrity and linens twice daily for skin integrity and document in nurses notes with a start date of 4/28/18. No documentation was found in medical records for treatment for [REDACTED]. Physician order [REDACTED]. -Left groin apply dry gauze no tape three times a week and PRN in the morning every three days with a start date of 5/9/18. -Clean all wounds with cleanser of choice and pat dry in the morning every three days with a start date of 5/9/18. The 5/2018 TAR for the left groin revealed the following treatments: -To clean all wounds with cleanser of choice and pat dry every shift with a start date of 5/1/18. No treatment was completed from 5/1/18 through 5/8/18. -Apply gauze with no tape to the left groin three times a week on Monday, Wednesday, and Friday with a start date of 5/2/18. Treatment was not completed on 5/7/18. -To apply dry gauze with no tape to the left groin and change three times per week and as needed in the morning with a start date of 5/9/18. Treatment was not completed on 5/9/18 and 5/12/18. -To clean all wounds with cleanser of choice and pat dry in the morning every three days with a start date of 5/9/18. No treatment was completed on 5/12/18. -Check dressing integrity and linens twice daily for skin integrity and document in nurses notes with a start date of 4/28/18. Monitoring was completed on day shift on 5/1/18. Monitoring was not completed for the remainder of the month. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed treatments were not completed as ordered for Resident 1. 6. The (MONTH) (YEAR) Weekly Body Audit revealed on 3/10/18 Resident 1 had an open wound to the lateral thigh of the leg and to see skin sheets for measurements. The body audit did not identify which leg it was on. A Progress Note dated 3/23/18 at 10:09 PM stated Resident 1's dressings were changed during evening shift since it was not done during day shift due to not enough time. Dressings changed for right outer thigh. No further documentation was found in medical records for Resident 1's right outer thigh. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed wound documentation was not comprehensive for Resident 1. 7. The 3/2018 Weekly Body Audit revealed on 3/10/18 Resident 1 had an open area to the above the knee amputation and to refer to skin sheets for measurements. A Weekly Pressure Ulcer Record for the right above the knee amputation (AKA) (identified on the diagram). No site location or date of onset was documented. On 3/22/18 the size was 1.5 cm x 1 cm with zero depth and exudate (fluid), no odor, the wound bed was red, and the surrounding skin color and wound edges were pink. Stage of the wound was not documented. No measurements for the wound were documented for 3/29/18. On 4/3/18 sloughing (shedding of dead tissue), was identified. No percentage of how much sloughing was documented. The following treatments were documented on the 4/2018 TAR for the residual stump and left knee however there were no correlating physician orders [REDACTED]. -To cleanse the residual limb, and left knee, pat dry apply skin prep to intact skin, use A non adherent wound gauze and tape change daily and as needed in the morning for wound care with a start date of 4/7/18. Treatment was not completed on 4/7/18. -Check dressing integrity and linens twice a day and change as needed every day and evening shift for skin integrity and document in nurses notes with a start date of 7/31/17. No treatment was completed on 4/2/18 day, 4/7/18 both day and evenings, 4/10/18 evening. A report from a contracted wound consulting agency report dated 4/6/18 revealed Resident 1 had a traumatic wound to the left anterior knee which was full thickness (loss of skin) and measured 1 cm x .6 cm x .2 cm depth and area of .6 cm and a volume of .12 cubic cm. The muscle was exposed scant amount of serous drainage was noted there was no odor, and the wound bed had 100 percent slough. The report also indicated a below knee amputation which was .3 cm x .7 cm x .1 cm depth and an area of .21 cm and a volume of .021 cubic cm. the muscle was exposed and the wound bed was 100 percent granulation with a scant amount of serous drainage. A report from a contracted wound consulting agency report dated 4/13/18 revealed Resident 1 had a traumatic wound to the left anterior knee which was covered by eschar which measured 1.3 cm x .8 cm x .1 cm depth and area of 1.04 cm and a volume of .104 cubic cm. The wound bed was 100 percent eschar and the wound was deteriorating. Physician order [REDACTED]. -Apply Opti foam to wound change three times per week and PRN in the morning every three days with start date of 5/9/18. -Clean all wounds with cleanser of (TRUNCATED)

Based on observation, interview and record review it was determined the facility failed to ensure pressure ulcers were routinely assessed, monitored and treated per physician orders [REDACTED].#s 1, 10, 11 and 12 ) reviewed for pressure ulcers. As a result of this deficient practice, this was determined to be an immediate jeopardy situation, Resident 1 developed avoidable Stage 4 pressure ulcers which did not demonstrate signs of improvement, experienced deteriorating wounds and associated systemic infection and a delay in treatment. These deficiencies resulted in an unrecoverable wound and associated systemic infection. Resident 1 was placed on hospice. Resident 10 developed an avoidable Stage 4 pressure ulcer. This placed other residents at risk for worsening pressure ulcers. CMS Appendix PP defined the following pressure ulcer stages: Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: 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 on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. 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 [DIAGNOSES REDACTED] 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. 1. Resident 1 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. Resident 1's care plan dated 12/6/16 indicated the resident would have a weekly skin check completed with any concerns reported to the physician as needed. A 10/14/17 Pressure Ulcer CAA revealed the resident was to have weekly skin checks to monitor for skin integrity, pressure ulcer treatments as prescribed by physician, a wound physician was to observe Resident 1, staff were encourage the resident to turn every two hours and noted the resident sat in a wheelchair for a prolonged amount of time. There was no description of the resident's pressure ulcers, including where they were located or the wound history. The revised 5/3/18 comprehensive care plan revealed Resident 1 had pressure ulcers to the left leg, right hip and mid back. Resident 1's history included multiple unhealed pressure ulcers. Interventions included assisting the resident with transfers, changing her/his position every two hours, a pressure reduction on bed and chair, follow facility protocol for wound care, follow physician orders [REDACTED]. a. A 9/23/16 Weekly Pressure Ulcer Record revealed Resident 1 had a Stage 3 pressure ulcer to the left hip which was present on admission. The report revealed the pressure ulcer resolved on 10/1/16. A 5/15/17 report from a contracted wound consulting agency revealed a Stage 3 pressure ulcer to the left hip measured 2.8 cm length x 1.4 cm width x 1 cm depth, with moderate drainage, no odor and with a dark pink wound base. A 9/14/17 Progress Note document revealed Resident 1 had a left hip Stage 4 pressure ulcer with measurements of 7.5 cm length x 11.5 cm width x .5 cm depth with necrotic muscle and adipose (fat) exposed with wound deteriorating. A 1/4/18 Progress Note revealed Resident 1's left hip wound was 6 cm length x 4 cm width beefy red with no drainage. Resident 1 also had a left upper hip wound measuring 4 cm length x 8 cm width which was beefy red with surrounding pink tissue with no drainage. Staging was not noted. A Physician's visit report dated 1/30/18 revealed a new problem of the left hip. The wound was beefy red measuring 6 cm length x 3.5 cm width x .7 cm depth with tracking and a left hip Stage 4 distal beefy red underlying black eschar 1.5 cm length x 2 cm width x 0 cm depth with no tracking. A Hospital Discharge Summary dated 2/17/18 revealed multiple skin wounds present on admission with a left hip pressure ulcer with a dry wound base and some eschar, and no drainage. The 2/2018 TAR instructed staff to complete the following treatments: -To wash left hip with sensitive skin cleanser pat dry in the morning. -Irrigate left trochanter (upper hip) wound with a medicated wound solution, pack wound bed with gauze moistened in medicated wound solution, cover with pad, and secure with tape. Change two times daily for wound care and the resident refused treatment four times out of 22 times. A Weekly Pressure Ulcer Record with date of the wound onset of 2/20/18 revealed the following for the left hip: (Inaccurately documented for start date of wound 2/20/18) -2/20/18 the wound measured 8 cm length x 3.5 cm width x 1 cm depth with sanguineous (bloody) drainage with no odor, the wound bed with eschar (dead tissue which is being cast off), surrounding skin color is pink and beefy red and surrounding tissue wound edges were pink. There was no staging or description of the wound was documented. A Hospital Discharge Summary dated 2/26/18 revealed Resident 1 had a left hip unstageable pressure ulcer, present on admission 8.5 cm length x 4 cm width. Progress Note dated 3/2/18 stated wound had not been changed since 2/27/18. The day nurse stated the resident had been refusing the dressing changes and the wound had strong odor. A Weekly Pressure Ulcer Record revealed the following for the left hip: -3/6/18 the wound measured 8 cm length x 4 cm width x 1 cm depth with sanguineous drainage, with no odor, with a beefy red wound bed and pink surrounding skin color. There was no staging and description of the wound documented. A Progress note dated 3/17/18 revealed dressing were changed for the left hip and there was moderate amount of blood drainage. There was no signs of infection and the wound was red. A Weekly Body Audit dated 3/2018 revealed a body audit was not completed on 3/17/18. A Weekly Pressure Ulcer Record revealed the following for the left hip: -3/22/18 the wound measured 15 cm length x 6 cm width x .5 depth with no odor, the wound bed was eschar and the surrounding skin was pink. The wound increased in size and there was no staging of the wound or the description documented. A 3/23/18 Progress Note at 10:09 PM indicated dressings were changed during evening shift since it was not completed during the day shift due to not enough time. Dressings were changed for the left hip due to the drainage on the dressing with a moderate amount of serosanguinous (serum and blood) drainage. The 3/2018 TAR instructed staff to complete the following: -To irrigate left hip wound with medicated wound solution, pack wound bed with gauze moisten in medicated wound solution, cover with pad and secure with tape and change twice daily for wound care. Treatments were not completed on the evenings of 3/7/18, 3/10/18, 3/18/18 through 3/22/18 and 3/24/18 through 3/31/18 and the morning of 3/10/18. A Weekly Pressure Ulcer Record revealed the following for the left hip: -4/3/18 the wound measured 14 cm length x 6 cm width x .5 cm depth with a wound bed of eschar and pink surrounding skin. There was no documentation of the stage, description of the wound, or percentage of eschar. The following treatments were documented on the 4/2018 TAR for the left hip: -Wash left hip daily with sensitive skin cleanser, pat dry in the morning. Treatments were not completed for 4/1/18, 4/4/18 and 4/5/18. -Left leg irrigate wound with medicated wound solution, pack wound bed with gauze moistened in medicated solution, cover with pad, and secure with tape, change twice daily. Treatments were not completed on the morning of 4/2/18, 4/4/18 and 4/5/18. A 4/6/18 report from a contracted wound consulting agency revealed Resident 1 had a Stage 4 pressure ulcer on the left hip with measurements of 8.3 cm length x 12.5 cm width x .9 cm depth with necrotic adipose exposed with 30 percent eschar, 70 percent slough and the wound was deteriorating. A 4/13/18 report from a contracted wound consulting agency revealed Resident 1 had a Stage 4 pressure injury to left hip with measurements of 7.5 x 14 x .5 depth with necrotic muscle and necrotic adipose exposed. Wound bed was 100 percent slough and the wound was deteriorating. The wound was found desiccated (extreme dryness). A 4/13/18 Physician Assistant note revealed Resident 1 stated her/his pain was 10 out of 10 and stated she/he felt like it may explode. Resident 1 stated she/he could not take it anymore and she/he was doing illegal drugs due to the pain. The 4/13/18 MDS significant change correction revealed the following pressure ulcers for Resident 1: -Stage 2 pressure ulcer -Has three Stage 3 pressure ulcers all three present on reentry. - One of the Stage 3s measured 15 cm x 6 cm with eschar The 4/13/18 Pressure Ulcer CAA revealed Resident 1 was recently sent to the hospital for surgical debridement of her/his wounds which were not healing well. Resident 1 currently had 11 non-pressure wounds and the following four pressure ulcers: -Stage 4 right buttock ischium -Stage 4 left hip -Stage 3 mid back -Stage 3 sacrum The 4/26/18 hospital's Final Report Discharge summary revealed Resident 1 had a severe left lower extremity pressure wound which was present on admission with a superimposed infection and abscess.[MEDICAL CONDITION] (infection in the blood) was present on admission with a delayed presentation left leg fracture which was poorly displaced and eventually developed an overlying very significant wound. The quantity of purulence (pus) was marked. It was an unrecoverable wound with no survivable surgical options. The resident was transition to hospice and discharged in poor condition. Resident 1 readmitted to the facility on [DATE]. The 5/2018 physician orders [REDACTED]. -To place wound cleanser moistened gauze to the base of the wound for ten minutes, pat dry, apply hydrogel moistened gauze to the wound bed, cover with pad and change daily and PRN in the morning. -Apply calcium alginate sheets to open wound bed (not bone) cover with Opti foam and change every three days a week or PRN for soiling or dislodgement in the morning every three days. -Clean all wounds with cleanser of choice and pat dry in the morning every three days. The following treatments were documented on the 5/2018 TAR for the left hip: -To clean all wounds with cleanser of choice and pat dry. Treatments were not completed from 5/1/18 through 5/8/18. -To cleanse the left anterior hip, pat dry apply skin prep to intact skin, use medicated non adhesive gauze and tape change daily. Treatments were not completed on 5/1/18 through 5/8/18. -To apply calcium alginate sheets to open wound bed (not bone) cover with Opti foam. Treatments were not completed on 5/9/18, 5/11/18 and 5/14/18. -To place wound cleanser moistened gauze to base of the wound times ten minutes. Treatments were not completed from 5/1/18 through 5/8/18. -To clean all wounds with cleanser of choice and pat dry in the morning every three days. Treatment was not completed on 5/12/18. A Weekly Pressure Ulcer Record revealed Resident 1 had a pressure ulcer on the left hip with: -On 6/6/18 and the 6/14/18 revealed the wound was a Stage 4 with measurements of 10 x 8 cm and a depth of 5.5 cm with heavy drainage of exudate, with odor, with a necrotic wound bed, purple surrounding skin color and rolled edges at the wound edge. The 6/14/18 identified the wound had increased in size. On 6/18/18 at 12:13 PM Witness 4 (Physician) stated during visits with Resident 1 the wound dressings were old and not changed timely. Witness 4 stated there were a couple of times the left hip was really nasty and had an odor and required antibiotic treatment. Witness 4 stated he was informed on 3/27/18 of increased pain in the Resident 1's upper leg. A Weekly Pressure Ulcer Record revealed Resident 1 had a pressure ulcer on the left hip, on 6/18/18 and 6/20/18 the wound remained as previously recorded. A Weekly Pressure Ulcer Record dated 6/20/18 revealed Resident 1 had a Stage 4 pressure ulcer on the left hip measuring 12 cm length x 10 cm width with no depth. There was blood and puss with a foul odor, and the wound bed had slough and was moist and pink. The surrounding skin was scarred and the wound edges were round. The broken left hip was protruding from the inner tissue, the wound bed was moist and pink with weeping and surrounding tissue was intact. The 6/2018 TAR instructed staff to complete the following treatments: - The calcium alginate treatment was not completed on 5/12/18. -Weekly body audits were not completed on 6/2/18, 6/9/18 and 6/16/18. On 6/19/18 at 11:08 AM Staff 7 (RN) stated he did not always have time to do wound treatments or wound rounds. On 6/19/18 at 9:13 AM Resident 1 stated she/he asked multiple times to have her/his dressings changed on her/his wounds and staff did not treat her/his wounds regularly. On 6/19/18 at 10:00 AM Staff 1 (Administrator) and Staff 4 (LPN Unit Manager) confirmed treatments were not completed as ordered. On 6/19/18 at 11:24 AM dressing changes to the various wounds were observed for Resident 1's. The left hip was packed with soaked with bloody drainage. The wound was very large with bone sticking out of the wound. On 6/19/18 at 11:57 AM Witness 8 (Former staff LPN) stated the dressing changes were not always completed for Resident 1. Staff 8 also stated Resident 1's wound was infected with drainage and she would report it with no follow up. On 6/20/18 at 1:09 PM Staff 10 (Hospice RN) stated the wounds were not addressed appropriately when she first started working with Resident 1. On 6/20/18 at 2:28 PM Staff 8 (LPN) stated she did not always have enough time to do wound treatments. On 6/21/18 at 12:25 PM Staff 4 (LPN Unit Manager) confirmed the assessments were not comprehensive, accurate and were not completed weekly. On 6/20/18 at 11:23 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 4 (LPN Unit Manager) were informed of the failure of current measures used by the facility to ensure prompt intervention in a resident's acute change of condition related to pressure ulcers which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm to be developed and implemented. On 6/20/18 at 2:02 PM a final immediate plan of correction was received from the facility. The facility's immediate plan of correction included: -Current assessment of resident pain, wound, and cares. -Update physician of the current condition, follow care updates as indicated. -Care plan revision as indicated. -Assessment of residents with current wounds documented to include present condition, infection, and healing/lack of healing. -Educate LNs on current and next shift worked regarding pressure ulcer prevention and management of wounds to include but not limited to stage, characteristics, pain, infection, treatment, physician update, repositioning, pressure reduction, moisture/pressure control, documentation, and care planning. Nurse performing dressing change will mark dressing with date, and initials. -Educate CNAs prior to next shift worked regarding pressure ulcer prevention and management of wounds to include but not limited to reporting, pain, repositioning, pressure reduction, moisture/pressure control, documentation, and plan of care implementation. -DNS responsible for assuring of compliance. On 6/20/18 at 5:52 PM the plan was verified as implemented removing the immediate risk to the resident's health and welfare. b. A 1/4/18 Progress Note revealed Resident 1 had a right buttock open wound which measured approx. 2 cm length x 5 cm width with no drainage noted. A 1/30/18 Physician's visit report revealed Resident 1 had a new right buttock Stage 3 pressure ulcer which measured 6 cm length x 1.5 cm width x 0.5 cm depth with no tracking marks and was beefy red. A 2/17/18 Nurses Note revealed Resident 1 was readmitted from the hospital with multiple wounds and refused to have them observed due to pain. All but two wounds were new to the left foot and the left thigh. A Hospital Discharge Summary dated 2/26/18 revealed Resident 1 had a right buttock, Stage 4 pressure ulcer present on admission 8.5 cm length x 4 cm width. An 2/2018 TAR instructed staff to irrigate the wound at the right ischial (sit bone) tuberosity with antibiotic solution, cover with a pad and secure with tape two times a day. The order was started on 12/19/17. On 2/28/18 Resident 1 refused treatment. A 3/2/18 Progress Note indicated the wounds were not changed since 2/27/18. The day nurse reported the resident refused the dressing changes and the wound had strong odors. A 3/2018 TAR instructed staff to wash the wound daily with sensitive skin cleanser to the right buttocks in the morning. Physician order [REDACTED]. -To irrigate wound with a medicated solution, pack wound bed with gauze moisten in medicated solution, cover with a pad, and secure with tape, twice daily for wound care with start date of 3/28/18. The following treatments were documented on the 4/2018 TAR for the right buttock wound: -Clean with a cleansing solution and leave moistened gauze with cleansing solution in the wound bed to the right buttock wound for 10 minutes, pat dry and apply skin prep to intact skin apply rope alginate to fill cavity, cover with pad secure with medfix and change daily and as needed in the morning for wound care with a start date of 4/7/18. This treatment was not found on the physician orders [REDACTED]. -Wash right buttock daily with sensitive skin cleanser, pat dry in the morning. Treatments were not completed for 4/1/18, 4/4/18 and 4/5/18. -Irrigate the wound with antibiotic solution, pack wound bed with gauze moisten in medicated solution, cover with pad, and secure with tape, twice daily. Treatments were not completed on the morning of 4/2/18, 4/4/18 and 4/5/18. The treatment was not discontinued on the signed physician's orders [REDACTED]. Treatments were not completed from 4/6/18 through 4/13/18. A 4/6/18 report from a contracted wound consulting agency revealed Resident 1 had a Stage 4 pressure ulcer to the right buttock wound with measurements of 3 cm x 5.8 cm x 1 cm depth necrotic muscle and necrotic adipose were exposed. The wound was undermining (wider area of wound beneath the wound) 100 percent bright red granulation. The wound was deteriorating. A 4/13/18 report from a contracted wound consulting agency revealed Resident 1 had a Stage 4 pressure ulcer of the right buttock wound with measurements of 2.8 cm x 5.4 cm x 1 cm depth necrotic muscle and necrotic adipose were exposed. A light amount of serous (pale yellow or translucent) drainage with 100 percent pink granulation. The wound was deteriorating. The 4/13/18 comprehensive MDS significant change correction revealed Resident 1 had the following pressure ulcers: -Stage 2 pressure ulcer -Had three Stage 3 pressure ulcers all three present on reentry. -Stage 3 longest length 15 cm x 6 cm with eschar The Pressure Ulcer CAA dated 4/13/18 revealed Resident 1 was recently sent to the hospital for surgical debridement of her/his wounds which were not healing well. Resident 1 currently has eleven non pressure wounds and the following four pressure ulcers: -Stage 4 Right buttock ischium -Stage 4 Left hip -Stage 3 Mid back -Stage 3 sacrum A Weekly Pressure Ulcer Record for the right buttock a Stage 4 pressure ulcer with measurements of 3.6 x 5 with a 1 cm depth and serous exudate, with an odor, with slough on the wound bed with normal surrounding skin color and dry wound edges. No documentation of how much exudate or percentage of slough. The following treatments were documented on the 5/2018 TAR for the right buttock revealed treatment was not completed the month of (MONTH) except for 5/1/18: A Weekly Pressure Ulcer Record for the right buttock revealed on 6/6/18 Resident 1 had a Stage 4 pressure ulcer on the buttock with an increase of measurements to 7.5 x 3 cm and a depth of 2.5 with moderate exudate, with odor, with a beefy wound bed, the surrounding skin was within normal limits and the wound edges were rolled and dry. No documentation of what type of exudate. A Weekly Pressure Ulcer Record for right buttock documented revealed the following: -6/13/18, 6/18/18, and 6/20/18 the wound was 7.5 x 2.2 with a depth of 2 cm with moderate exudate, with odor the wound bed is red and pink, surrounding skin color within normal limits. There was no documentation of type of exudate or the stage of the pressure ulcer. There was a slight increase in size on 6/18/18. An updated Weekly Pressure Ulcer Record for right buttock, no date of onset documented, dated 6/20/18 revealed Resident 1 had a Stage four pressure ulcer to the right of the rectum with a size of 4 cm x 2 cm with a 1 cm depth which was full thickness (loss of skin) with a pink wound bed with tissue exposed and had scars around the surrounding skin and round wound edges. The two records had a discrepancies in the wound descriptions. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed treatments for Resident 1 were not completed as ordered and monitoring of the wounds was not accurate and comprehensive. c. A 1/4/18 Progress Note revealed Resident 1 had a mid-back bony prominence wound covered with foam dressing, no open areas noted. A 1/30/18 Physician's visit report revealed Resident 1 had a mid-back thin eschar (dead tissue) overlying not measured only preventative care to prevent skin breakdown. (new problem) A 2/17/18 Hospital Discharge Summary revealed there were multiple skin wounds present on admission with a back wound with dry eschar. Progress Note dated 2/20/18 revealed Witness 8 (Former LPN) changed the dressing to the back wound which measured of 1 cm length x 1 cm width and no signs or symptoms of an infection. A Weekly Pressure Ulcer Record for mid back wound: -On 2/20/18 the wound was 1 cm x 1 cm with zero depth no exudate, no odor and the wound bed was beefy red and the surrounding skin color was beefy red and the surrounding wound edges were pink. No stage of the ulcer was documented. A Hospital Discharge Summary dated 2/26/18 revealed Resident 1 had a midline mid-back lumbar Stage 2 pressure ulcer, present on admission to the hospital which measured 1.5 cm length x 1 cm width. A Weekly Pressure Ulcer Record for mid back wound: -No measurements of the wound were completed on 2/27/18. The 3/2018 physician orders [REDACTED]. The 3/2018 TAR instructed staff to complete the following treatments for the mid back: -To wash mid back daily with sensitive skin cleanser and pat dry in the morning. Documentation resident refused seven instances in the month of March. No notes found in medical records of reason for refusals, further attempts to treat or if physician was notified of refusals. Progress Note dated 3/2/18 stated wound had not been changed since 2/27/18. The day nurse stated the resident refused the dressing changes and the wound had strong odor. A Weekly Pressure Ulcer Record for mid back wound: -On 3/6/18 the wound measured was .5 cm x .5 cm with zero depth with no odor with a scab for a wound bed, the surrounding skin was pink and surrounding wound edges were pink. The stage of the wound was not documented. -No measurements of the wound were completed on 3/13/18. A Weekly Pressure Ulcer Record for mid back wound: -On 3/22/18 the wound measured 5 cm x 4 cm with a zero depth with exudate as sloughing, no odor with the wound bed sloughing and surrounding skin color was pink and wound edges were pink. There was no documentation of the stage of the wound and the percentage of sloughing. The wound had increased in size. -No measurements of the wound were completed on 3/27/18. -On 4/3/18 the size of the wound was 3 cm x 4 cm with zero depth with exudate as sloughing, no odor, wound bed was sloughing, surrounding skin color was pink and wound edges were pink. There was no documentation of the stage of the wound and the percentage of sloughing. The 4/2018 TAR instructed staff to complete the following treatments for the mid back: -Apply hydrogel, apply skin prep to surrounding skin, cover with foam in the morning. Treatment was not completed on 4/2/18, 4/4/18 and 4/5/18. -Wash mid back daily with sensitive skin cleanser, pat dry in the morning. Treatment was not completed for 4/1/18, 4/4/18 and 4/5/18. A 4/6/18 report from a contracted wound consulting agency revealed Resident 1 had a Stage 3 pressure ulcer to the mid-back with measurements of 1 cm x .5 cm x .1 depth. Necrotic muscle is exposed no undermining or tunneling. Wound bed has 100 percent granulation and the wound was deteriorating. A 4/13/18 report from a contracted wound consulting agency revealed Resident 1 had an unstageable pressure ulcer to the mid-back measuring of 2 cm x 1 cm and no measurable depth. The Necrotic muscle was exposed with no undermining or tunneling. The wound bed had 100 percent slough and the wound was deteriorating. The comprehensive MDS significant change correction dated 4/13/18 revealed Resident 1 had the following pressure ulcers: -Stage 2 pressure ulcer -Has three Stage 3 pressure ulcers all three present on reentry one measuring the length of 15 cm x 6 cm with eschar The Pressure Ulcer Care Area assessment dated [DATE] revealed Resident 1 was recently sent to the hospital for surgical debridement of her/his wounds which were not healing well. Resident 1 currently has eleven non pressure wound and the following four pressure ulcers: -Stage 4 Right buttock ischium -Stage 4 Left hip -Stage 3 Mid back -Stage 3 sacrum A Weekly Pressure Ulcer Record for the back. On 4/27/18 an Stage 3 pressure ulcer the size of 1 cm x .5 with .1 depth and zero exudate, with no odor, the wound bed was slough and normal surrounding skin color and dry wound edges. The percentage of slough was not documented. The 5/2018 Physician order [REDACTED]. -To apply Opti foam Ag to back wounds every three days and PRN in the morning. -Clean all wounds with cleanser of choice and pat dry in the morning every three days. The following treatments were documented on the 5/2018 TAR for the back: -No treatment was completed for cleaning of the wounds from 5/1/18 through 5/8/18. -To apply Opti foam Ag to the back wounds every three days and PRN in the morning. No treatments were completed on 5/4/18. -To apply Opti foam to lower midline back and change weekly and as needed in the morning every three days. Treatment was not completed on 5/12/18. -To clean all wounds with cleanser of choice. Treatment was not completed on 5/12/18. A Weekly Pressure Ulcer Record dated 6/20/18 revealed Resident 1 had two areas on the middle of her/his back one healing 6 cm length x 5 cm width and an unstageable pressure ulcer 2 cm length x 1.5 width with a necrotic wound bed and scar tissue surrounding the wound. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed treatments for Resident 1 were not completed as ordered, and wound documentation were not accurate and comprehensive. d. A Hospital Discharge Summary dated 2/17/18 revealed wounds which were present on admission was a right hip wound with two skin ulcerations, on 2 cm x 3 cm diameter, with undermining noted, but no drainage. A Progress note dated 3/17/18 revealed dressing were changed for right hip with a scant amount of blood drainage. No current bleeding seen by Staff 7 (RN). The wound appeared fresh red with no signs of infection. A Progress Note dated 3/23/18 at 10:09 PM indicated dressing was changed to the right hip during evening shift since it was not done during day shift due to not enough time. The 3/2018 Physician orders [REDACTED]. -Irrigate right hip wound with a medicated solution, pack wound bed with gauze moistened in a medicated solution, cover with pad and secure with tape two times a day. The 3/2018 TAR revealed the treatment was not completed on the evenings of 3/7/18, 3/10/18, 3/18/18 through 3/22/18 and 3/24/18 through 3/31/18 and the morning of 3/10/18. A handwritten note disclosed on the TAR stated the wound treatment should be completed only once daily to allow for healing the order was clarified on 3/28/18 however there was no documentation in clinical records the order was clarified for once daily treatments. Treatment was not completed the afternoon of 3/29/18. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed treatments for Resident 1 were not completed as ordered, and wound documentation was not accurate and comprehensive. e. A Hospital Discharge Summary dated 2/26/18 revealed Resident 1 had a right elbow unstageable pressure ulcer, present on admission with measurements of 1.5 cm length x 1 cm width. A Progress note dated 3/17/18 revealed the dressing was changed for the right elbow. There was scant blood drainage at the right elbow. No current bleeding seen by Staff 7 (RN). The wound appeared fresh red with no signs of infection. No other documentation was found in clinical records for Resident 1's right elbow. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (2nd Interim DNS) confirmed treatments for Resident 1 were not completed as ordered, and wound documentation was not accurate and comprehensive. f. A 2/20/18 Progress Note revealed Witness 8 (Former LPN) changed the dressing to Resident 1's coccyx wound with measurements of 5 cm length x 3 cm width. With no signs or symptoms of infection. A Weekly Pressure Ulcer Record for the coccyx wound with the date of onset 2/20/18: -On 2/20/18 the size was 5 cm x 3 cm with a depth of 2 cm with no exudate and 1 cm of tunneling and 1 cm of undermining, no odor, beefy red wound bed and surrounding skin color and wound edges pink. No stage of the ulcer was documented. -No measurements of the wound were completed on 2/27/18. Progress Note dated 3/2/18 st (TRUNCATED)

Based on interview and record review it was determined the facility failed to provide ordered pain medication and provide efficacy for 6 of 6 sampled residents (#s 1, 5, 10, 11, 17 and 24) reviewed for pain management. This failure, determined to be an immediate jeopardy situation, resulted in Resident 10 running out of scheduled narcotic pain medication for three days and caused the resident to suffer from narcotic withdrawal and increased pain and Resident 1 running out of scheduled pain medication and requesting to go to the hospital. This placed residents at risk for increased pain. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 10's (MONTH) (YEAR) MAR revealed the following: - The resident was ordered scheduled [MEDICATION NAME] sulfate (narcotic pain medication) 30 mg extended release for moderate to severe pain every day at 6:00 AM and 2:00 PM and the resident's pain level was supposed to be documented with each administration. - The resident's pain level at 6:00 AM from 6/1/18 through 6/13/18 was zero on a scale of one to ten. On 6/14/18 through 6/18/18 the resident's pain level was not documented. On 6/19/18 and 6/20/18 the resident's pain level was a 10 out of 10. - The resident's pain level at 2:00 PM from 6/16/18 through 6/19/18 was not documented. - On the back of the MAR an unsigned note dated 6/18/18 indicated Resident 10 was out of [MEDICATION NAME] sulfate 30 mg extended release and the medication was supposed to be delivered by the pharmacy on 6/18/18. On 6/25/18 at 3:36 PM Resident 10 verified the facility ran out of her/his [MEDICATION NAME] sulfate. When asked about her/his pain level when the medication was not available she/he stated The pain I can take, it was the withdrawal symptoms that had me crawling out of my skin. The resident verified her/his pain level was a 10 out of 10 by the time the medication was available again on 6/19/18. On 6/25/18 at 3:50 PM Staff 14 (LPN) was asked to show this RN Surveyor Resident 10's [MEDICATION NAME] sulfate in the medication cart. She stated Oh you heard about that huh? Staff 14 was asked what her knowledge was regarding the resident's [MEDICATION NAME] sulfate but she refused to provide any additional information or clarify her earlier statement. A review of Resident 10's clinical record revealed no documentation related to running out of [MEDICATION NAME] sulfate, immediate actions taken to obtain the resident's [MEDICATION NAME] sulfate, assessments of the resident's pain as a result of not having the [MEDICATION NAME] sulfate, assessing and monitoring for withdrawal symptoms, or providing alternative pain relief measures. On 6/25/18 at 4:18 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 13 (Corporate regional nurse/Acting DNS) reviewed Resident 10's (MONTH) (YEAR) MAR and were asked to provide an explanation for the resident running out of scheduled [MEDICATION NAME] sulfate. No additional information was provided. On 6/25/18 at 7:15 PM Staff 1 (Administrator) was informed of the failure of current measures used by the facility to provide ordered pain medication which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 6/25/18 at 8:27 PM a final immediate plan of correction was received from the facility. The facility's immediate plan of correction included: -The resident was assessed for pain. -All resident's in the facility with scheduled narcotics were assessed for pain. -Ensured all residents had a sufficient supply of narcotics. -N[NAME] shift nurses will be educated on checking narcotic inventory each shift to ensure sufficient supply was available. -DNS will audit to ensure narcotic supply for each resident. -All nurses educated on ensuring residents have a sufficient supply of narcotics as shown on medication cards, and notifying nursing management if a timely response is not occurring from pharmacy. 2. Resident 1 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. The Comprehensive care plan dated 12/23/17 revealed Resident 1 had chronic pain with interventions including: anticipate resident's need for pain relief and respond immediately, monitor and document side effects, monitor, document, and report signs or symptoms of non-verbal pain, and administer pain medication as prescribed. Physician orders [REDACTED]. With a start date of 2/28/18. The orders also instructed staff to document pain rating scale at the start of each shift using the verbal/nonverbal zero to ten scale every shift. To complete pain assessment every shift if the resident was in pain and to initiate the pain management flow sheet and continue until pain goals were met for 72 hours. The 3/2018 TAR instructed staff to administer [MEDICATION NAME] for pain every four hours PRN. Resident 1 was administered [MEDICATION NAME] 99 times with one instance on 3/8/18 in which effectiveness of the pain medication was monitored. The TAR also instructed staff to document pain rating scale at the start of each shift using the verbal/nonverbal zero to ten scale every shift. On 6/23/18 and 6/24/18 in the evening, 6/25/18 and 6/26/18 at night and 6/27/18 through 6/31/18 in the evening no pain rating scale was completed for Resident 1. The following physician order [REDACTED]. Physician order [REDACTED]. -To complete pain assessment, if Resident 1 was in pain staff were to complete the pain management flowsheet and continue until pain goals were met for 72 hours, complete every shift with a start date of 4/27/18. -Document pain rating scale at the start of each shift using verbal and nonverbal zero to ten scale every shift for monitoring of comfort with a start date of 4/27/18. -[MEDICATION NAME] three times a day for chronic pain with a start date of 4/28/18. -[MEDICATION NAME] 10 ml by mouth every hour PRN for chronic pain with a start date of 4/27/18. -[MEDICATION NAME] 10 ml by mouth every two hours PRN for chronic pain with a start date of 4/27/18. -[MEDICATION NAME] 10 ml by mouth every four hours PRN for chronic pain with a start date of 4/27/18. -[MEDICATION NAME] 20 ml by mouth every four hours PRN for pain with a start date of 4/27/18. -[MEDICATION NAME] 20 ml by mouth every four hours PRN for chronic pain with a start date of 4/27/18. The following medications and monitoring were documented on the 4/2018 MAR for pain: -[MEDICATION NAME] 10 ml by mouth every four hours PRN for pain start date 4/6/18. [MEDICATION NAME] was administered 15 times between 4/9/18 through 4/13/18. -Complete pain assessment, if resident was in pain the nurse must initiate pain management flowsheet and continue until pain goals were met for 72 hours every shift with a start date of 8/17/18. Out of 39 instances Resident 1 was in pain 29 instances A Pain Management Flowsheet revealed on 4/12/18 at 2:00 AM effectiveness was monitored for [MEDICATION NAME] 10 ml. Documentation for monitoring effectiveness or alternative interventions were not completed for all other PRN pain medication and for monitoring of resident's pain from the pain assessment for the month of April. Physician order [REDACTED]. -To complete pain assessment if Resident 1 was in pain. Staff were to complete the pain management flowsheet and continue until pain goals were met for 72 hours, complete every shift with a start date of 8/17/17. -Document pain rating scale at the start of each shift using verbal and nonverbal zero to ten scale every shift for monitoring level of comfort start date of 12/19/17. Physician order [REDACTED]. -To complete pain assessment, if Resident 1 was in pain staff were to complete the pain management flowsheet and continue until pain goals were met for 72 hours, complete every shift with a start date of 8/17/17. -Document pain rating scale at the start of each shift using verbal and nonverbal zero to ten scale every shift for monitoring level of comfort. -[MEDICATION NAME] three times a day for chronic pain with a start date of 7/27/17. Physician order [REDACTED]. -To complete pain assessment, if Resident 1 was in pain staff were to complete the pain management flowsheet and continue until pain goals were met for 72 hours, complete every shift with a start date of 4/27/18. -Document pain rating scale at the start of each shift using verbal and nonverbal zero to ten scale every shift for monitoring level of comfort. -[MEDICATION NAME] three times a day for chronic pain with a start date of 4/23/18. -[MEDICATION NAME] every 4 hours PRN for pain 2 ml with a start date of 5/9/18. -[MEDICATION NAME] every 4 hours for pain 2 ml with a start date of 5/9/18. The following medications and monitoring were documented on the 5/2018 MAR for pain: -Administer [MEDICATION NAME] for pain every four hours with start date of 5/9/18. [MEDICATION NAME] was not administered on 5/14/18 at 4:00 am. -Administer [MEDICATION NAME] every four hours PRN for pain with a start date of 5/8/18. [MEDICATION NAME] was administered 38 times in May. -Administer [MEDICATION NAME] every four hours for chronic pain with a start date of 5/2/18, from 5/2/18 through 5/8/18 medication was not administered two times. (Hand written stating discontinued on 5/8/18) -[MEDICATION NAME] by mouth every two hours PRN for chronic pain with a start date of 5/2/18. From 5/2/18 through 5/8/18 medication was administered 13 times. -Pain assessment if resident was in pain initiate pain management flowsheet and continue until pain goals were met for 72 hours every shift. Out of 93 opportunities Resident 1 report no pain two times, two times the assessment was not completed and two times nurses initials were documented instead of if Resident was in pain or not. -[MEDICATION NAME] three times a day for chronic pain with a start date of 4/23/18. Out of 93 opportunities for administration Resident 1 did not receive schedule pain medication seven times and refused two times. -Document pain rating scale at the start of each shift using verbal and nonverbal zero to ten scale every shift for monitoring comfort with a start date of 4/27/18. Out of 93 opportunities pain rating was not completed five times. A Pain Management Flowsheet for 5/2018 revealed two documentations of effectiveness of [MEDICATION NAME], but no date was listed. Seven entries were documented for [MEDICATION NAME] PRN. Six administrations of [MEDICATION NAME] was not monitored for effectiveness. [MEDICATION NAME] PRN effectiveness was monitored four times out of 38 administrations in May. The 6/2018 TAR instructed staff to administer [MEDICATION NAME] by mouth every 4 hours PRN pain with a start date of 6/15/18 . From 6/15/18 to midday on 6/20/18 Resident 1 was administered [MEDICATION NAME] 11 times with no monitoring of effectiveness of the pain medication. On 6/27/18 at 12:23 PM Staff 1 (Administrator) and Staff 13 (Interim DNS) confirmed the MAR and Flowsheets did not have all of the required documentation, monitoring and efficacy were not being completed as physician ordered. 3. Resident 5 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] revealed Resident 5 received pain medication as needed (PRN) and had a non-medication intervention plan. Resident 5 occasionally had mild pain. Physician orders [REDACTED]. Document pain rating scale at the start of each shift using verbal and not verbal zero through ten scale every shift for monitoring level of comfort. [MEDICATION NAME] sulfate PRN for moderate to severe pain. The comprehensive care plan last revised on 5/9/18 revealed Resident 5 had chronic generalized pain with interventions of anticipating the resident's need for pain relief, call for assistance when in pain, staff would monitor, record and report any signs or symptoms of non-verbal pain. The nurse would monitor and document for side effects of pain medication. Nurses would monitor and record pain characteristics, frequency, quality, severity, location, duration, aggravating and relieving factors. Nurses would also observe and report any changes from usual routine. The (MONTH) (YEAR) MAR revealed the following: -Instructed staff to complete pain assessment and if Resident 5 was in pain to initiate the pain management flowsheet and to continue until pain goals were met for 72 hours for every shift. Out of 90 opportunities there were 30 documentations Resident 5 had pain. Six times no pain assessment was completed. -Document pain rating scale at the start of each shift using verbal and not verbal zero through ten scale every shift for monitoring level of comfort. Out of 90 opportunities eleven times pain rating scale was not completed. -[MEDICATION NAME] sulfate PRN for moderate to severe pain were documented as administered to the resident 20 times. The 4/2018 Pain Management Flowsheet revealed four documentations with no date, had the time listed, three with pain rating scale and one with no rating. Ten total documentations of pain rating for Resident 5 was completed on the flowsheet. On 6/27/18 at 12:21 PM Staff 13 (Interim DNS) confirmed the MAR and flowsheet did not have all of the required documentation and efficacy was not being completed as physician ordered. 4. Resident 11 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 5/4/18 Physician Assistant Progress Note documented Resident 11 had venous stasis ulcers on the right lower extremity. The 6/2018 pain management physician orders [REDACTED]. The 6/2018 MAR noted during the 6/9/18 night shift Resident 11 had pain and received [MEDICATION NAME] at 11:00 PM. There was no documented effectiveness of the [MEDICATION NAME] nor a documented pain assessment for the following 6/10/18 day shift. The 6/23/18 evening and night shift pain assessments documented the resident had pain. The resident had a pain level of 10 when the [MEDICATION NAME] was administered at HS (hour of sleep). The resident received [MEDICATION NAME] at 9:01 PM. There was no documented evidence the resident's pain was treated with a PRN pain medication during the night shift. The 6/24/18 pain assessment noted the resident had pain during all shifts. There was no documented evidence the AM [MEDICATION NAME] was administered as ordered nor was a PRN pain medication administered during the day shift. The resident reported a pain level of 7 when the HS [MEDICATION NAME] was administered and 6/10 when [MEDICATION NAME] was administered at 11:30 PM. There was no documented effectiveness of the [MEDICATION NAME]. The 6/26/18 pain assessment noted the resident had pain during the evening and night shifts. The resident had a pain level of 5 when the HS [MEDICATION NAME] was administered. There was no documented evidence PRN pain medication was administered during the evening/night shifts until [MEDICATION NAME] was documented as given at 1:30 AM on 6/27/18. There was no documented effectiveness of the [MEDICATION NAME]. In interview on 6/27/18 at 9:05 AM Resident 11 stated on 6/26/18 at 10:00 PM staff changed the right lower extremity dressing. The dressing change took an hour to be completed and she/he had pain all night. On 7/2/18 at 1:16 PM Resident 11 was observed sitting in her/his wheelchair and appeared comfortable. The resident's pain management was discussed with Staff 13 (2nd Interim DNS) on 7/2/18 at 10:45 AM. No additional documentation was provided. In interview on 7/3/18 at 11:45 AM Staff 4 (LPN Unit Manager) stated over the previous weekend the resident reported the [MEDICATION NAME] did not address her/his pain. Staff 4 stated he was not aware of pain issues for the resident as no staff reported the resident complained of pain. In interview on 7/3/18 at 1:59 PM Staff 36 (CNA) stated she did not recall the resident's pain management during the 6/26/18 evening shift. Staff 36 stated the resident complained of lower extremity pain related the wound and did not know if pain medications were effective for the resident. In interview on 7/3/18 at 5:15 PM Staff 22 (Agency Nurse) stated on 6/26/18 she could not recall the resident's pain level when she completed the wound treatment, however, her/his pain was typically high at around 6-8 out of 10. Staff 22 stated she did not remember when the resident reported pain during the 6/26/18 evening/night shifts. 5. Resident 24 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 5/2018 and 6/2018 physician orders [REDACTED]. The 5/2018 MAR lacked documented evidence the [MEDICATION NAME] was administered as ordered on [DATE] at 8:00 AM and 12:00 PM, and on 5/21/18 at 8:00 PM. There was no documented pain assessment for the 5/12/18 day shift. The 6/2018 MAR lacked documented evidence the [MEDICATION NAME] was administered as ordered on [DATE] at 8:00 AM and 12:00 PM, and on 6/4/18 at 12:00 PM. The lack of following pain management orders was discussed with Staff 13 (2nd Interim DNS) on 7/5/18 at 12:06 PM. No additional documentation was provided. 6. Resident 17 was readmitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. The 2/1/18 care plan revealed the resident had pain related to immobility and staff were to acknowledge the pain and report increased pain to the licensed nurses. The 4/26/18 annual MDS Section I (Pain) revealed the resident was prescribed PRN and scheduled pain medications and the resident had moderate pain. The 5/26/18 Change of Condition Evaluation revealed the resident had increased pain from a recent catheter change. The pain was acute and at a level 10 out of 10, and urinating made the pain worse. Resident 17 received PRN pain medications. The 6/2018 MAR revealed the following pain medications and directions: -8/14/17: Pain Assessment, if the resident was in pain the nurse must initiate the Pain Management Flowsheet and continue until the pain goals were met within 72 hours every shift. -8/1/17: [MEDICATION NAME] 10 mg two tablets every six hours for chronic pain. -9/20/17: Tylenol 325 mg two every four hours PRN for pain. -5/25/18: [MEDICATION NAME] 5 mg give one every six hours as needed for pain take 1-2 tabs. Resident 17 was administered [MEDICATION NAME] on 15 occasions during 6/2018. The facility staff did not document the resident's pain level, the reason for the pain medication and the efficacy of the pain medication on 10 of the 15 occasions. The facility did not initiate the Pain Management Flow sheet to monitor the resident's pain as ordered. On 7/2/18 at 2:10 PM Staff 7 (RN) indicated he was not familiar on how to document on the Pain Management flow sheet and did not use it. On 7/2/18 at 2:24 PM Staff 18 (RN Director of Clinical Operations) was shown the lack of monitoring for pain and acknowledged it was not done.

Based on multiple immediate jeopardy situations and the number of citations including care and services, treatments and services to prevent pressure ulcers, pain management, infection control and nursing services it was determined the facility was not managed in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This resulted in multiple occurrences of immediate jeopardy and substandard quality of care. Findings include: On 6/25/18 at 2:30 PM Staff 1 (Administrator) was informed of the failure of current measures used by the facility to utilize its resources effectively and efficiently to assure all residents attained or maintained their highest practicable physical, mental and psychosocial well-being which constituted a situation of immediate jeopardy to health and welfare for residents. Surveyors requested a plan of correction to immediately protect the residents from harm to be developed and implemented. On 6/25/18 at 7:58 PM a final immediate plan of correction was received from the facility. The facility's immediate plan of correction included: -Contract with wound care agency. -Mandated training: Monitoring residents for change in conditions and Infection Control Standards for nursing practice. -Utilize Staff 13 (2nd Interim DNS) until permanent RN RCM can be hired. -Hire RNCM to fill current position. -Educate administrator and DNS on timely supervision for wound management, and quality assurance plans which impact immediate concerns and long term trending. -Provide operational oversight to quality implementation of the wound care program, as well as consistent implementation of abatement plan. 1. Resident 1 experienced a delay in treatment of [REDACTED]. Which was comprehensively evaluated and treated. Refer to F-684 2. Resident 1 experienced a deteriorating Stage four pressure ulcer and Resident 10 and 11 were not receiving treatments. Refer to F-686 3. Resident 10 was not administered scheduled narcotic medication and experienced severe withdrawals. Resident 10 experienced narcotic drug withdrawal due to scheduled narcotic medication not being administered. Refer to F-697 4. The facility failed to ensure standard precautions for infection control practices were in place. Staff 10 failed to use personal protective equipment potentially contaminating the facility with an antibiotic resistant organism. Refer to F-880

Based on observation, interview and record review it was determined the facility failed to ensure staff followed standard precautions or have a thorough understanding of infection control practices for 1 of 1 staff observed (#1) observed for infection control. This failure, determined to be an immediate jeopardy situation, resulted from staff not using personal protective equipment (PPE), removing a contaminated beverage container from the resident's room and refilled the contaminated container in the kitchen and returned the container back to the resident's room. This potentially could have contaminated the facility with an antibiotic resistant organism. Findings include: Resident 1 was admitted to the facility in 4/2018 with [DIAGNOSES REDACTED]. a. On 6/21/18 at 9:37 AM Staff 11 (CNA) was observed to enter Resident 1's room with a reusable hot beverage cup. A contact precautions cart was noted outside the room. Staff 11 was not wearing any PPE. Staff 11 exited Resident 1's room without the cup and walked to a handwashing sink next to nurses station. Staff 11 stated Styrofoam cups were normally used but the resident already had the reusable beverage cup in her/his room. Staff 11 obtained the cup from Resident 1's room and re-filled the cup in the kitchen. Staff 11 stated she had not touched anything in the room, so she did not have to wear PPE. On 6/21/18 at 9:42 AM Staff 2 (Interim DNS) confirmed it was not acceptable for the staff to remove a reusable cup from Resident 1's room and refill it in the kitchen with coffee when a resident was on precautions. On 6/21/18 at 10:55 AM Staff 1 (Administrator) was informed of the failure of current measures used by the facility to ensure staff had a thorough understanding of infection control practices which constituted a situation of immediate jeopardy to health and welfare for the residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 6/21/18 at 12:19 PM a final immediate plan of correction was received from the facility, The facility's immediate plan of correction included: -Sanitize the coffee system. -Sanitize contact surfaces to include but not limited to key pads, door knobs, hand rails, drawer handles, cart handles, etc. -Review of other residents to determine need for enhanced precautions. -Educate all staff regarding infection control practices for standard precautions, and enhanced precautions for contact isolation. -Additional education to kitchen staff regarding potential cross contamination from external sources which enter the kitchen. On 6/21/18 at 12:19 PM at 3:57 PM the plan was verified as implemented removing the immediate risk to the residents health and welfare. b. Resident 1 had isolation precautions noted on her/his door and there was a cart next to Resident 1's room with personal protective equipment (PPE). On 6/25/18 at 3:25 PM Witness 11 (hospice bath aid) entered the resident's room with only gloves on. Witness 11 touched the resident's blankets and then left the room. Witness 11 indicated she should have known better, washed her hands and used the proper PPE before re-entering Resident 1's room. On 6/25/18 at 3:30 PM Staff 1 (Administrator) was notified of the infection control breach and acknowledged the error. c. On 6/19/18 at 11:24 AM Staff 4 (LPN Unit Manager) was observed as he performed wound care on Resident 1's pressure ulcers. The facility's Handwashing/Hand Hygiene Policy Statement revised 8/2015 indicated Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: After removing gloves; Throughout the wound care observation Staff 4 failed to perform hand hygiene on five occasions when he changed gloves at various times during the dressing changes. Staff 4 acknowledged he did not use hand sanitizer each time he changed gloves and he was not aware of the facility's policy regarding hand hygiene. In Resident 1's room two signs were posted on the wall which directed staff to dispose of used wound dressing supplies into a red biohazard bag. During Resident 1's pressure ulcer wound treatments Staff 4 disposed of bloody dressings and supplies into a plastic yellow trash bin with a clear liner used for the disposal of PPE (personal protective equipment). Staff 4 acknowledged the signs posted on the wall and used dressings were to be supposed to be disposed of in a biohazard bag.

Based on interview and record review it was determined the facility failed to notify the ordering physician of the results of an x-ray of a fracture for 1 of 5 sampled residents (#1) reviewed for accidents. As a result of this deficient practice Resident 1 experienced a delay in treatment of [REDACTED]. Findings include: Resident 1 was admitted to the facility in 6/2016 with [DIAGNOSES REDACTED]. A signed physicians order dated 3/27/18 revealed STAT (immediately) x-ray left upper leg and hip. A Phone Note: Recent Fall With Increased Pain dated 3/27/18 from Witness 4's (Previous physician for Resident 1) office revealed the following: received a fax from the facility resident had increased pain to left upper leg since (she/he) fell stated (her/his) leg makes a cracking noise when (she/he) moves (her/his) leg. Request for x-ray to be done. an order for [REDACTED]. A Radiology Interpretation dated 3/27/18 revealed: Significant Findings pelvis oblique fracture (bone breaks diagonally) with a butterfly component. (Fractures resulting in multiple fragments) Impression: Possible pathologic fracture proximal left femur. (a break that occurs in a bone area that has already been weakened by a disease, a tumor, or an infection.) Femur oblique fracture with central lucency of medullary cavity (where bone marrow is stored) with butterfly fragment. Impression: Proximal femoral shaft, probable pathologic fracture. In the lower right corner a hand written note was which stated: faxed to the following number with a fax number written below, Staff 8's (LPN) initials with the date of 3/27/18 at 3:30 PM. On the top of the document which was printed out from the fax revealed the following: from: with a fax number and To: Fax: with a fax number. (The To: Fax number was the facility's fax number) Another copy of Radiology Interpretation with same information as listed above revealed a hand written note in lower right hand corner with the following: Faxed to Witness 4 on 3/29/18 with the initials of Witness 9. On the top of the document which was printed out from the fax revealed the following: from: with a fax number and To: Fax: with a fax number. (The To: Fax number was the facility's fax number) A Phone Note 4/5/18 at 3:10 PM from Witness 4's office revealed he called Witness 17 and informed her the facility was not answering the phone and it had been a week since the orders were sent and confirmed they were received. Witness 17 had not returned calls to inform of the x-ray results. Witness 17 was spoken to briefly on 4/3/18 and Witness 17 stated she would call back and never did. The note also stated it was an ongoing issue trying to coordinate or even communicate with the facility. A Hospital Progress Notes dated 4/23/18 revealed Resident 1 stated it's just crazy pain. Resident 1 had a delayed presentation of left femur fracture and left lower extremity abscesses and severe pressure wound requiring debridement (removal of dead, infected and damaged tissue) with escalated abdominal pain. Advancing infection into pelvis. Resident 1 was emotionally overwhelmed. Resident 1 [MEDICAL CONDITION] (infection in the bloodstream) present on admission. The plan for Resident 1 was for hospice transition. On 6/18/18 at 12:13 PM Witness 4 stated on 3/27/18 he had placed an order for [REDACTED]. Witness 4's office called the facility and was told the results would be faxed. Attempts were made to call and the facility did not answer the phone or would not receive calls back. On 6/19/18 at 8:55 AM Staff 8 stated she had faxed the results of the x-ray on 3/27/18 for Resident 1 to the physician. Asked if she had used the number written in the corner and she stated she had faxed to the number in the medical record for the physician. When asked what was the process to make sure the physician was notified. She stated she cannot be at the facility all of the time and it would be up to the RCM to take care of the follow up. Staff 8 stated her main job was to do wound care and administer medications. On 6/19/18 at 10:00 AM Staff 1 (Administrator) and Staff 4 (LPN Unit Manager) stated after the fax for the x-ray results were sent on the 3/27/18 and on 3/29/18 follow up calls should have been made to the physician and confirmed there was a delay in notification to the physician. On 6/21/18 at 8:44 AM Witness 16 (physician office assistant) provided the number of the fax for the physician office. Asked if any other fax numbers were used and compared numbers. The fax number Staff 8 used on 3/27/18 was not the correct fax number when she attempted to fax the x-ray results. On 6/21/18 at 8:48 AM Witness 9 (Previous employee LPN Unit Manager) stated she remembered Resident 1 but did not remember faxing the x-ray results to the physician on 3/29/18. She reported it would be up to the nurse who was administering medications to send the fax.

Based on interview and record review it was determined the facility failed to ensure 1 of 1 sampled resident (# 2) received only medication prescribed to her/him. As a result Resident 2 was hospitalized . Findings include: Resident 2 was admitted to the facility in August 2017 with [DIAGNOSES REDACTED]. On 10/5/17 Nurse's Notes indicated at 2:00 pm a CMA reported to the nurse she gave Resident 2 the wrong medication and identified the medication as 20 mg of [MEDICATION NAME]. The nurse assessed the resident and found the resident sleepy and low in energy but conscious and responsive. The resident's oxygen saturation (O2 sat) was 88% on 4 liters of oxygen. The DNS and physician were notified. A Physician's Telephone Ordered, dated 10/5/17, indicated an order for [REDACTED]. On 10/5/17 nursing notes identified the resident refused to go to the hospital and the risks were explained to the resident and around 3:45 pm the resident departed for [MEDICAL TREATMENT] as scheduled. At 11:09 pm nursing notes indicated the resident was admitted to the hospital from [MEDICAL TREATMENT]. An Incident/Accident Report indicated Resident 2 approached and demanded that Staff 5 (CMA) give her/his indigestion medication. Staff 5 gave Resident 2 [MEDICATION NAME] in error instead which she had popped for another resident. A hospital Discharge Summary Note, dated 10/8/17, identified Resident 2 did not take opiates at baseline and was in acute toxic [MEDICAL CONDITION] upon admission due to inadvertent [MEDICATION NAME] ingestion at the facility. Secondary to the [MEDICATION NAME] ingestion, the resident had acute on chronic hypoxemic (abnormally low concentration of oxygen in the blood) [MEDICAL CONDITION] and was intubated and admitted to the ICU and treated supportively. The resident returned to baseline at the time of hospital discharge. In interview on 11/15/17 at 11:50 am Resident 2 reported she/he could not wake up and was on life support in the ICU after facility staff gave her/him [MEDICATION NAME] in error. The resident reported she/he now makes sure she/he knows what medications the facility is giving her/him before taking it. In interview on 12/18/17 at 1:05 pm Staff 5 (CMA) reported on 10/5/17 she popped out medication for another resident when Resident 2 yelled loudly that she/he wanted her/his medication. Staff 5 stated she asked the resident to wait so she could continue with the other resident's medications, however, Resident 2 would not stop yelling. She reported she thought she had put the other resident's medication aside but realized five to 10 minutes after giving Resident 2 medication, she gave her/him the wrong one. She reported the error to the nurse. In interview on 12/19/17 at 12:18 pm Staff 2 (DNS) confirmed Resident 2 was given [MEDICATION NAME] in error. She reported Resident 2 had severe [MEDICAL CONDITION] and was hospitalized as a result of the incident.

Based on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 4 sampled residents (#1) reviewed for discharge. Resident 1 did not receive medications including insulin and anti-hypertensive medications and was hospitalized . Findings include: Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 3/2017 Physician order [REDACTED]. diuretic), potassium, and [MEDICATION NAME] (a medication used to treat nerve pain). The 3/17/17 Post-Discharge Plan of Care noted the resident's nursing needs included meds & diabetic care. The 3/17/17 at 10:00 am Social Services Progress Notes disclosed Resident 1 was given diabetic supplies, will be given meds on discharge . The 3/17/17 Discharge Orders included the following options regarding the resident's discharge: ___Resident may discharge with current medication and treatments ___Resident may discharge with current medication orders The physician did not select a discharge medication order on the 3/17/17 discharge orders. The 3/17/17 Evening Nurse's Note disclosed Resident 1 was discharged from the facility at 3:05 pm via taxi to a local motel. The 3/19/17 Hospital Emergency Department Report and History and Physical documented Resident 1 was discharged from the facility without medications. The resident presented in the Emergency Department with a symptomatic high blood glucose level of 544, was hypertensive with a blood pressure of 190/101, reported being puffy and appeared to be fluid long. The resident was treated with [MEDICATION NAME], IV insulin and fluids, and was admitted to the hospital. The 3/25/17 at 5:00 pm Nurse's Note disclosed Resident 1 was readmitted to the facility. On 5/23/17 at 10:50 am Resident 1 stated she/he was a diabetic and was discharged from the facility without medications, including insulin. Resident 1 reported she/he had a high blood glucose level and was hospitalized . In interview on 5/23/17 at 12:56 pm Witness 1 (Complainant) reported in preparation of Resident 1's discharge she spoke with the facility's former SSD (Social Services Director) who stated the resident would discharge from the facility with medications. Witness 1 stated Resident 1 was discharged on a Friday (3/17/17) to a local motel. On the following Sunday (3/19/17) the resident was ill and was sent to the hospital. Witness 1 learned Resident 1 was discharged from the facility without medications. Witness 1 contacted the facility's former SSD who stated Resident 1 was discharged without medications because the physician did not mark the box for discharging the resident with medications and the physician was not contacted for clarification as it was the end of the day. In interview on 5/23/17 at 2:40 pm Staff 1 (Administrator) stated the facility completed an investigation and identified significant problems with the discharge. There was a miscommunication between the former SSD and the LN (Staff 6, LPN) working the floor at the time of Resident 1's discharge. Staff 6 thought the resident left for an appointment and the resident was discharged without medications. In interview on 6/8/17 at 2:55 pm Staff 6 (LPN) stated she was aware of Resident 1's pending discharge but did not know when the discharge was taking place. On 3/17/17 Staff 6 checked with the former SSD who initially reported Resident 1 was leaving for a physician appointment and did not report the resident was discharging. Staff 6 stated when a taxi arrived she learned the resident was discharging and did not have a chance to give the resident her/his medications before leaving the facility. When asked about contacting the resident at the motel to provide the medications, Staff 6 stated she thought the resident was returning to pick up her/his belongings. Refer to F225

1. Based on observation, interview and record review it was determined the facility failed to promote skin healing for 1 of 1 sampled resident (#1) reviewed for skin conditions. The lack of assessment, MD notification and lack of change in treatment caused a deterioration the of wounds. Findings include: Resident 1 admitted to the facility in 2016 with [DIAGNOSES REDACTED]. On 9/26/16 at 2:26 pm the left groin dressing change was observed and changed per physician orders. No signs or symptoms of infection were present. Resident 1 declined a formal assessment including measurements. The 6/29/16 Pain Evaluation revealed Resident 1 had a pain level of eight to ten out of ten related to her/his wounds. The 7/29/16 signed Physician order [REDACTED]. Original order was dated 6/29/16. The July, August and September 2016 TARs revealed left groin treatment orders to pack the wound with a damp gauze using saline or [MEDICATION NAME]. Cover with gauze and change daily. The treatment was not completed on 9/15/16. The Weekly Non-Pressure Skin Sheet revealed Resident 1 had a groin wound. The following assessments were completed: * 6/29/16 the wound measured 1 cm x 1 cm x 2.2 cm with serous exudate (thin, watery, blood-tinged drainage) with slight odor, 2.2 cm tunneling was present, the physician was notified and the treatment was continued. * 7/13/16 revealed the wound measured 1 cm x 1 cm x 1 cm with serous exudate with slight odor, the physician was notified on 7/12/16, Dietary (Registered Dietitian or RD) was notified on 7/13/16. * 7/20/16 revealed the wound measured 1 cm x 1 cm x 0 cm with serous exudate, 2 cm tunneling was present and the treatment was continued. * 7/27/16 revealed the wound measured 1 cm x 1 cm x 0 cm, 2 cm tunneling, the physician was notified 7/26/16 and the treatment was continued. * 8/3/16 revealed the wound measured 1 cm x 1 cm x 0 cm, 2 cm tunneling and the treatment was continued. * 8/10/16 revealed the wound measured 1 cm x 1 cm x 0 cm with serous exudate with slight odor, 2 cm tunneling, the surrounding skin was white/gray in pallor, edges with hardness/induration. (This wound had deteriorated from previous assessment). * 8/24/16 there was no change from the 8/10/16 assessment; the physician notified on 8/17/16. * 9/20/16 1 cm x 1 cm x 2 cm with serous exudate with slight odor, the surrounding skin was white/gray in pallor. (This wound had deteriorated from previous assessment). All above assessments were completed by the Staff 2, DNS. *9/23/16 revealed the open wound was most likely an abscess and measured 1.5 cm x 1.8 cm x 2.9 cm with moderate exudate and 2.9 cm of tunneling. The assessment was completed by a facility RN with Staff 4 (Regional RN Consultant). The Weekly Body Audit revealed the following: *9/6/16 revealed the wound measured .8 cm x .4 cm x 1.3 cm with 2.8 cm of tunneling. *9/16/16 revealed the wound measured 1 cm x 1 cm x 2.2 cm. The current Alteration in Skin Integrity Care Plan revealed an open groin wound. Staff were to observe the skin daily with routine care, complete a full weekly skin evaluation, weekly evaluation of wound healing and document the wound dressing changes. The physician was to be notified if the wounds worsened and the treatment plan would be adjusted if there were no documented improvements of the wound within two to four weeks of admission. A review of Resident 1's medical record revealed no physician notification regarding lack of wound healing, no RD notification for follow-up reviews and no weekly wound assessments between 8/24/16 - 9/20/16. On 9/23/16 at 9:03 am and 12:44 pm Staff 2 (DNS) verified the physician and RD were not notified regarding the condition of the left groin wound. Staff 2 stated she inaccurately documented the physician and RD notification on the Weekly Non-Pressure Skin Sheet (they were not notified) and verified no wound assessments were completed from 8/24/16 - 9/20/16. Staff 2 stated the treatment orders had not changed from admission until 9/22/16 and the wound assessments indicated no improvement. 2. Based on interview and record review it was determined the facility failed to provide bowel care for a resident with significant constipation for 1 of 1 sampled resident (#46) whose bowel records were reviewed. This placed residents at risk for fecal impaction. Findings include: Resident 46 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. On 9/20/16 at 1:15 pm Resident 46 revealed when she/he went to the bathroom she/he feels constipated, it hurts to go and she/he does not go very often. Resident 46's Bowel Monitoring records for July 2016 through September 2016 revealed: * 7/26/16 - 8/3/16: 20 consecutive shifts with no BMs (bowel movement); * 8/12/16 - 8/17/16: 15 consecutive shifts with no BMs; * 8/20/16 - 8/27/16: 20 consecutive shifts with no BMs; * 8/27/16 - 9/3/16: 20 consecutive shifts with no BMs; * 9/9/16 - 9/14/16: 14 consecutive shifts with no BMs; and * 9/14/16 - 9/18/16: 11 consecutive shifts with no BMs. The 7/26/16 through 9/17/16 MARs indicated no PRN bowel care medications were administered when Resident 46 experienced extended periods without a BM. On 9/22/16 at 3:23 pm Staff 11 (CNA) indicated Resident 46 required assistance with toileting and she did not recall the resident complained of problems with constipation. In an interview on 9/28/16 at 3:06 pm, Staff 3 (Interim DNS/RNCM) stated the house protocol for initiation of bowel care treatment was after nine consecutive shifts without a BM. Staff 3 further stated Resident 46 did not have specific bowel care guidelines and acknowledged the resident was not provided with PRN bowel care treatment in response to extended periods without BMs.

Based on observation, interview and record review it was determined the facility failed to promote the healing of six pressure ulcers for 1 of 1 sampled resident (#1) reviewed for pressure ulcers. The lack of assessment, lack of physician notification, no change in treatment and missed ordered treatments caused a delay and worsening in pressure ulcer healing. Findings include: Resident 1 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 6/29/16 Nursing Evaluation indicated Resident 1 admitted with the following eight unstaged pressure ulcers: 1. Right flank measured 5 cm x 4 cm x 1.5 cm 2. Right hip measured 2/12 cm x 2 3/4 cm 3. Left thigh 3 cm x 4 cm 4. Left hip 4 cm x 4 cm 5. Upper left hip 2 cm x 3.5 cm x .5 cm 6. Cleft of buttock 8 cm x 4.5 cm x 1.25 cm 7. Low spine 7 cm x 5 cm x 3.25 cm 8. Coccyx 4.5 cm x 3 cm x 3 cm The evaluation indicated Resident 1 had horrible, constant pain to all wounds. The 6/29/16 Pain Evaluation revealed Resident 1 had a pain level of eight to ten out of ten related to her/his ulcers. The 6/29/16 Norton Plus Pressure Ulcer Scale revealed a score of five. (A score of ten or less indicated a high risk for pressure ulcers). The current Alteration in Skin Integrity Care Plan related to multiple pressure ulcers revealed Resident 1 had four stage IV pressure ulcers located on her/his right upper back, right buttocks and right hip and a stage III pressure ulcer to the left hip. Interventions included providing wound care as physician ordered, daily observation of skin with routine care, complete a full weekly skin evaluation, weekly evaluation of wound healing and document the wound dressing changes. The physician was to be notified of worsening of wounds and the treatment plan would be adjusted if no documented improvements of the wound within two to four weeks of admission. The 7/6/16 Admission MDS indicated Resident 1 had four stage III and two stage IV pressure ulcers present on admission. The 7/29/16 Physician order [REDACTED]. 1. Right posterior flank: Gently debrid (clean), then apply Santyl (medication to remove dead skin/tissue) to slough (white/yellow devitalized tissue adhered to wound bed) at base and cover with damp saline dressing every morning. 2. Posterior spine: Apply thick coat of Santyl to necrotic (dead) tissue at base and cover with damp foam every morning. [MEDICATION NAME] 1% gel (antibiotic). Apply to affected area daily. 3. Posterior spine: Cleanse and place damp gauze dressing to base, cover with gauze and secure with tape. 4. Right Ischium: Impregnate gauze with [MEDICATION NAME] (antibiotic) and pack. Cover with gauze and change daily. This is to decrease drainage. 5. Clean and Shallow Wound Areas: Cover with foam and change every three to five days and when saturated. On 9/22/16 new wound treatment orders were obtained. The July 2016 TARs revealed wound care was completed as ordered. Last treatment for [REDACTED]. The August 2016 TAR revealed wound care for the Clean and Shallow Wound Areas was not completed from 8/1/16 - 8/7/16. Resident 1 had no documented treatment for [REDACTED]. The September 2016 TAR revealed the Posterior Spine treatment was not completed on 9/1/16, 9/15/16 and 9/19/16 and the Right Ischium treatment was not completed on 9/19/16. The weekly skin sheets (non-pressure report, which was not an accurate reflection of the wounds) indicated the following: 1. Mid-back pressure ulcer: The admission assessment indicated the wound measured 3.8 cm x 5.3 cm with slough present. On 7/6/16 the wound measured 3.8 cm x 5.3 cm, purulent (pus-like), foul smelling, large amount of exudate (drainage) with slough. Surrounding skin white/gray in color with maceration (softening or breaking down of skin), hardness/induration and rolled edges. Pain present. Wound not changed from previous assessment, physician notified on 7/6/16 and Dietary notified on 7/7/16. Between 7/6/16 - 8/24/16 and on 9/20/16 the wound description did not change, the wound did not improve and no new treatment orders were obtained. The 9/20/16 assessment indicated a change in treatment was needed however the physician and dietary were not notified. The weekly assessment documentation indicated the physician and dietary department were notified weekly. 2. Left thigh pressure ulcer: The admission assessment indicated the wound measured 2 cm x 1 cm with slough present. On 7/6/16 the wound measured 2 cm x 1 cm with purulent, moderate smelling, moderate amount of exudate with slough. The Surrounding skin was white/gray in color with maceration, hardness/induration and rolled edges. Pain was present and both the physician and dietary were notified. Between 7/20/16 - 8/24/16 the wound description did not change, the wound did not improve and no new treatment orders were obtained. The weekly assessment documentation indicated the physician was notified weekly through 8/17/16. The 9/20/16 assessment the wound measured 1 cm x 1 cm with the same description as above and indicated a change in treatment was needed however the physician was not notified. 3. Right hip pressure ulcer: The admission assessment indicated the wound measured 2.3 cm x 1.1 cm with slough present. On 7/6/16 and 7/13/16 the wound measured 2 cm x 1 cm with purulent, moderate smelling, moderate amount of exudate with slough. The surrounding skin was white/gray in color with maceration and hardness/induration. On 7/20/16 the wound measured 2.2 cm x 1.1 cm with the same wound description and the physician was notified. On 7/27/16 - 8/17/16 the wound measurements and description were unchanged except the surrounding skin had rolled edges. The physician was notified on 7/13/16, 8/10/16, 8/17/16. On 8/24/16 the wound had new granulation tissue (new connective tissue). On 9/20/16 the wound measured 2 cm x 1 cm with purulent, moderate smelling, moderate amount of exudate with slough. The surrounding skin was white/gray in color with maceration, hardness/induration and rolled edges. The assessment indicated a change in treatment was needed however the physician was not notified. 4. Cleft of buttocks: The admission assessment indicated the wound measured 2.3 cm x 1.1 cm x .6 cm. On 7/6/16 the wound had the same measurements with a small amount of serous (clear, thin and watery) exudate and slight odor. The wound bed had [MEDICATION NAME] (large sheet of cells covering the body) tissue, the surrounding skin was normal in appearance and pink in color. On 7/13/16 the wound measured 2.3 cm x 1.1 cm x .5 cm with small amount of serous exudate and slight odor. The wound bed and surrounding skin remained the same. Between 7/20/16 - 8/3/16 the wound measured 2 cm x 1 cm x 0 cm with scant amount of serous exudate and no odor. The wound bed and surrounding skin remained the same. Between 8/10/16 - 8/24/16 the wound had the same measurements and drainage but the surrounding skin declined to a white/gray color with maceration and hardness/induration. The documentation indicates the physician was notified on 7/6/16, 7/13/16, 7/27/16, 8/3/16 and 8/10/16. On 9/20/16 the wound measured 2.2 cm x 1.1 cm with a moderate amount of purulent exudate and moderate odor. The wound bed had granulation tissue, the surrounding skin was white/gray in color with maceration, hardness/induration and rolled edges. The assessment indicated a change in treatment was needed however the physician was not notified. A chart review found no documentation the physician had been notified at any time. 5. Right upper shoulder pressure ulcer: The initial observation on 6/29/16 indicated the wound was 2 cm x 2 cm with slough in the wound bed. Between 7/6/16 - 8/24/16 and on 9/20/16 the wound did not improve and measured 2 cm x 2 cm with purulent, moderate smelling, moderate amount of exudate with slough. The surrounding skin was white/gray in color with maceration, hardness/induration and rolled edges. There was no documented evidence the treatment was changed. The documentation indicated both the physician and dietary department were notified weekly. The 9/20/16 assessment indicated a change in treatment was needed however the physician was not notified. Review of Resident 1's medical record indicated no documentation to support Physician or Dietary notification and no weekly wound assessments between 8/24/16 - 9/20/16. The 9/6/16 Weekly Body Audit revealed the following wound measurements: 1. Mid-back 3.8 cm x 5.3 x .6 cm 2. Left thigh 2 cm x 1 cm x .2 cm 3. Right hip 2.3 cm x 1.1 cm x .6 cm 4. Cleft of buttocks 2.2 cm x 1.2 cm x .4 cm 5. Right upper Shoulder 2 cm x 2 cm 6. Left hip 1 cm diameter scab 7. Inner left thigh 2 cm x 1 cm The 9/16/16 Weekly Body Audit revealed the following wound measurements: 1. Mid-back 3 cm x 6 cm x .6 cm 2. Left thigh 3 cm x 2 cm 3. Right hip 3 cm x 2 cm x 2.8 4. Right upper shoulder 7 cm x 4 cm 5. Left hip 1 cm diameter scab The Weekly Pressure Ulcer Records dated 9/23/16 and 9/24/16 revealed the following: 1. Sacral stage IV pressure ulcer present on admission measuring 5 cm x 2.5 cm x .3 cm with moderate amount yellowish sero-sangenious exudate. Undermining present measuring .2 cm. Surrounding skin whitish gray/brown with slightly mascerated edges. 2. Left hip stage III pressure ulcer present on admission measuring 3.5 cm x 2.5 cm x .1 cm with moderate sero-sanguineous exudate. Undermining of 2 cm present. Granulated tissue in wound bed, surrounding skin had scar tissue formation. 3. Left ischium Stage IV pressure ulcer present on admission measuring 1.1 cm x .2 cm. Wound bed 100% epithial tissue, surrounding tissue scarred. 4. Right ischium Stage IV pressure ulcer present on admission measuring 1.8 cm x 3 cm x 4.4 cm with moderate serosangenious drainage and 4.4 cm tunneling present. 5. Right [MEDICATION NAME] spine Stage IV present on admission measuring 6.8 cm x 4 cm x .8 cm with moderate serosangenious exudate and .3 cm tunneling present. 6. Right posterior flank Stage IV pressure ulcer measuring 1.5 cm x 0.7 cm. Comparison of the weekly skin sheets and the Weekly Pressure Ulcer Records revealed the following: 1. Mid-back stage IV pressure ulcer measured 3.8 cm x 5.3 cm on admission and worsened to 6.8 cm x 4 cm x .08 cm on 9/23/16. 2. Left thigh stage III pressure ulcer measured 2 cm x 1 cm on admission and worsened to 3.5 cm x 2.5 cm x .1 cm on 9/23/16. 3. Right hip stage IV pressure ulcer measured 2.3 cm x 1.1 cm on admission and was 1.8 cm x 3 cm x 4.4 cm on 9/23/16. 4. Cleft of buttocks Stage IV pressure ulcer was 2.3 x 1.1 x .6 cm on admission and worsened to 5 cm x 2.5 cm x .3 cm on 9/24/16. 5. Right upper shoulder Stage IV pressure ulcer measured 2 cm x 2 cm on admission and 1.5 cm x .7 cm on 9/23/16. 6. Left ischium not assessed until 9/23/16 measuring 1.1 cm x 0.2 cm. On 9/26/16 at 2:26 pm wound observations were completed with Staff 4 (Regional Nurse Consultant) and Staff 16 (LPN). Dressing changes were completed per physician orders. On 9/23/16 at 8:20 am and 9:03 am Staff 2 stated Resident 1 had new wound care orders including an order for [REDACTED]. On 9/2316 at 12:44 pm Staff 2 verified no treatment orders had changed from admission until 9/22/16 and the wound assessments indicated no improvement and/or worsening of the wounds. Staff 2 verified the three undocumented wounds had no treatment orders and did not improve. On 9/23/16 At 2:18 pm Staff 3 (Interim DNS/RNCM) acknowledged wound assessments were completed for only six of the nine wounds; three wounds were never assessed. Staff 3 stated the low back wound was a stage III pressure ulcer and was unchanged. On 9/26/16 at 8:31 am Staff 4 stated she went back and assessed Resident 1 to get an accurate picture of all the wounds and Resident 1 had six pressure ulcers including the right stump. Staff 4 stated the prior skin documentation was completed on the incorrect sheets (Non-pressure skin.) On 9/26/16 at 11:05 am Staff 4 stated there was no longer an abdominal wound and two additional wounds had resolved. Staff 4 verified the worsening of the right [MEDICATION NAME] spine wound. In Summary, Resident 1 admitted with eight unstaged pressure ulcers. Five of the eight wounds were assessed weekly. Three wounds were not assessed. The Care Plan interventions included the weekly evaluation of wound healing and documented dressing changes. The physician was to be notified of worsening of wounds and the treatment plan would be adjusted if no documented improvements of the wound occurred within two to four weeks of admission. This plan of care was not followed, the physician was not notified and the treatment plan was not adjusted. The treatments were provided as ordered and the assessed wounds indicated either no change or worsening since admission.

Based on observation, interview and record review it was determined the facility failed to timely revise pain management, initiate alert charting and document resident status changes and assess changes in condition in a timely manner for 3 of 5 sampled residents (#s 2, 3 & 4) reviewed for changes in condition. Resident 2 experienced repeated episodes of unaddressed severe pain due to multiple hip dislocations. Residents 3 and 4 were at risk of complications from not receiving care in a timely manner. Findings include: 1. Resident 2 was admitted to the facility in 8/2013 with [DIAGNOSES REDACTED]. The 7/2015 Annual MDS and the Cognitive Loss and Falls CAAs noted the resident was alert to self and others, confused, had impaired decision making and judgement secondary to dementia. The 10/14/15 Day Shift Nurse's Note indicated Resident 2 was found on the floor at approximately 7:20 am. The resident complained of pain to the left hip and was sent to the hospital, where a [MEDICAL CONDITION] was identified. The 10/20/15 Re-admission Physician order [REDACTED]. Resident 2's 10/21/15 Nursing Evaluation/Data Collection and Pain Evaluations noted the resident was confused and forgetful and had a left [MEDICAL CONDITION] that was repaired. The resident had constant bilateral hip pain that was mild. The Pain Assessment noted the pain was 10 out of 10, with an acceptable pain level at 5 out of 10. The undated care plan noted the resident was at risk of dislocating the hip due to non-compliance with ordered hip precautions. Staff were directed to evaluate the resident's pain and monitor for worsening of pain symptoms and report to the physician. The resident had a behavior of yelling My hippie hurts for attention. Staff were directed to assess for actual pain versus behavior and treat accordingly. Per the facility's documented timeline of events, on 11/3/15 the Nurse Practitioner with Physician were updated on the resident's complaints of pain. The Nurse Practitioner suggested post operative pain was to be expected. The 11/5/15 Day Nurse's Note disclosed Resident 2 had noted agitation/yelling throughout the shift, wanting to go to bed, then get back up, yelling ow, ow, my hippy during cares and in the wheelchair. One to one supervision, snacks and PRN [MEDICATION NAME] were given. The resident had frequent calling out and only wanted to be in the wheelchair for very short periods of time. Per the facility's documented timeline of events, on 11/6/15 at 3:00 am Resident 2 complained of left hip pain 7 out of 10. The resident was continuously calling out and yelling for help, pushing the call light even when cares were met. Continued redirection was only helpful momentarily. The resident had continued episodes of agitation and yelling. During the day the resident called out in pain, saying her/his hip was killing her/him. Staff attempted to reposition the resident back into the wheelchair and the resident became more agitated, crying out. The left hip appeared to be more internally rotated. Nursing was informed and an x-ray was scheduled to determine if the hip was dislocated. At 9:30 am Staff 2 (DNS) assessed the resident, who found a contracture to the left leg and rigidity in movement with complaint of pain, 8 out of 10. The 11/6/15 Day Nurse's Note disclosed Resident 2 was given PRN [MEDICATION NAME] once during the shift. The facility ordered an x-ray, however, a family member called an ambulance for the resident stating, this isn't like (Resident 2) . The 11/6/15 Hospital Records noted the resident had a left hip dislocation, which was treated in the ED (Emergency Department). Resident 2 was re-admitted to the facility on [DATE]. Nurse's Notes dated 11/7/15, 11/8/15, 11/11/15 to 11/15/15 documented the resident's non-compliance with hip precautions and the use of pillows or hip abductor cushion. The 11/8/15 1:45 am to 5:30 am Nurse's Note documented the resident called for help most of the shift, complaining of intense pain. [MEDICATION NAME] and [MEDICATION NAME] (an antidepressant) was given PRN. Med. seems to not help with pain because could not sleep and still c/o (complain of) pain. The 11/8/15 Evening Nurse's note documented the resident was calling out for help throughout the shift. PRN [MEDICATION NAME] was administered with minimal effectiveness. According to the facility's documented timeline of events, on 11/8/15 at 4:00 pm, the resident called out for help, complaining of intense left hip pain. On 11/10/15 the resident's status was updated to the Nurse Practitioner, with the physician. The Nurse Practitioner believed the resident's pain complaints were within normal parameters post surgery. The 11/11/15 Day Nurse's Note described Resident 2 as very agitated/yelling out during transfer/shower/changing. The 11/12/15 10:45 pm Nurse's Note documented the resident was on call light entire shift. Staff checked and assisted the resident every 15 to 20 minutes throughout the shift. The resident complained of pain and was administered PRN medication. .unable to determine if real relief is achieved d/t (due to) resident calling out and frequent use of call light. Resident continues to remove hip abductor throughout shift. The 11/13/15 11:15 pm Nurse's Note disclosed Resident 2 complained of hip pain throughout the shift, with the PRN [MEDICATION NAME] administered. The resident was informed the [MEDICATION NAME] for pain was given with verbal understanding expressed. Before the nurse exited the room the resident again asked for pain medication. The resident threw the TV remove, dishes and water bottle and continued to hold the call light button down throughout the shift. The resident was described as very difficult to redirect. The 11/14/15 Day Nurse's Note indicated Resident 2 was up for a shower at 6:30 am, yelling and demanding pain medications. The PRN [MEDICATION NAME] was administered at 6:00 am and should be helping soon. The resident received the shower, demanded to be laid down and still yelling for more pain meds. It was explained to the resident the [MEDICATION NAME] could not be given again until 10:00 am. The resident was placed back in bed and removed the hip abductor stating No! You're hurting hippie. The resident threw a cup of water on the floor and was uncooperative with staff. The 11/14/15 8:30 pm Nurse's Note documented Resident 2 was uncooperative with cares, screaming with all cares provided, removing the hip abductor as soon as it was placed. The resident threw the water bottle across the room with each offer of water. The PRN [MEDICATION NAME] was administered once during the shift with relief noted. The 11/15/15 4:00 pm Nurse's Note disclosed a family member reported the resident was in pain and agitated. When the LN checked on the resident, she/he was lying comfortably in bed. The family member stated the resident's hip was dislocated again and wanted the resident sent to the hospital. The facility spoke with the Nurse Practitioner, who asked for staff to try the hip abductor first and wait 15 minutes to see if the resident improved. The family member refused and the resident was sent to the hospital. The 11/15/15 Hospital Records noted the resident's left lower extremity appeared to be internally rotated and was slightly shorter. Hip x-rays revealed a left hip dislocation. A week prior the resident was noted to have a dislocation of the same hip. The resident required surgical intervention The hospital physician noted the resident would probably need a scheduled opiate medication secondary to the resident's dementia. According to the facility's timeline of events, it was reported the orthopedic surgeon stated after reviewing the 11/6/15 x-rays, the hip was never actually reset, so resident had been nine days with a dislocated hip. The 11/2015 MAR indicated [REDACTED]. After the medication was administered the resident reported pain levels between two and five. In interview on 2/25/16 at 12:23 pm Witness 2 (Complainant) stated in 11/2015 (date unknown) it was reported Resident 2's hip was dislocated, however, staff did not call for an ambulance and let the resident sit in bed, in pain. Witness 2 stated she could see the resident's hip was dislocated and she called for an ambulance herself. After the resident was readmitted to the facility, the resident was in pain, which was reported to staff. It was thought the hip was back in place, however, it was not. On 11/15/15, the resident was in pain. Staff reported the resident had pain medication at 9:00 am and she had staff give pain medication to the resident at 3:00 pm. Staff stated they would put the hip abductor in place, however, Witness 2 insisted they call for an ambulance. The resident went to the hospital and required surgical intervention for the dislocated hip. In interview on 3/24/16 at 5:17 am Staff 14 (LPN) stated from 11/5/15 to 11/15/15 Resident 2 had increased pain. The resident crunched her/his knees so tight it was impossible to place the hip wedge. The resident yelled and would not let staff move her/him around. In interview on 3/24/16 at 8:28 am Staff 15 (CNA) stated from 11/5/15 to 11/15/15 Resident 2 was in a lot of pain. The resident tried to move herself/himself all over the place. The resident was more vocal and exhibited behaviors of name calling and hitting. The resident had those behaviors prior, but they increased during that timeframe. Staff 15 informed the LNs, who tried to stay on top of administering pain medications to the resident. In interview on 3/24/16 at 9:16 am Staff 9 (LPN) stated Resident 2 complained of hip pain, which increased before being sent to the hospital on [DATE]. In interview on 3/24/16 at 10:53 am Staff 12 (LPN) stated from 11/6/15 to 11/15/15 Resident 2 had a lot of discomfort and staff could not get the resident to keep the hip abductor in place. The resident was very anxious, pulling off blankets and repositioning herself/himself, which was different for the resident. The resident had an increase in behaviors and throwing objects. Staff 12 stated it was hard to tell if the increase in behaviors was due to increased confusion or pain. Staff 12 stated she spoke about it with Staff 2 (DNS) and the resident's family member. In interview on 3/24/16 at 2:54 pm Staff 7 (LPN) stated on 11/6/15 Resident 2 was screaming and had unbearable pain. Staff 7 called the Nurse Practitioner for an x-ray, however, a CNA reported to her the resident called a family member, informed the family member about her/his pain and the family member called 911. A couple of weeks later the family member wanted the resident sent back to the hospital due to feeling the facility was not doing enough for the resident and the resident was sent to the hospital. In interview on 3/21/16 at 11:09 am Staff 2 (DNS) stated Resident 2 had a history of [REDACTED]. which indicated an increase in the resident's pain. Resident 2's pain management was not revised when the resident exhibited signs and symptoms pain, including the resident's verbal reports of pain and behaviors. Even though the pain was documented at a level between two and five after pain medication was administered, there was also documentation of the resident reporting intense pain, behaviors which indicated pain, and staff being unable to determine if the pain medication was effective due to the resident's behaviors. There was no documented consideration of a scheduled pain medication secondary to the resident's dementia and continued reports of pain. While the Nurse Practitioner/Physician was updated regarding the residents pain on 11/3/15 and 11/10/15, at the time of the survey there was no documented assessment by either the Nurse Practitioner or the Physician on those dates. The facility did not continue to advocate for pain management or further follow up of the resident's pain with the physician after 11/10/15. The facility failed to re-asses the potential for a hip dislocation in a timely manner when the resident was non-compliant with hip precautions with signs and symptoms of hip pain. The resident was sent to the hospital on [DATE] and 11/15/15 after family intervention. On both occasions a hip dislocation was identified. 2. Resident 3 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The 7/2015 Annual MDS/CAAs indicated Resident 3 was alert and oriented and accurately communicated needs. The 1/2016 MAR indicated [REDACTED]. and on 1/2/16 at 7:00 am. There were no documentation of the resident's complaints nor assessments of the resident's status when the medication was administered. The 1/2016 TAR noted the resident's lung sounds were monitored on 1/2/16 day shift, however, the findings of that monitoring were not documented. The facility's investigation noted on 1/2/16 at around 3:00 am to 4:00 am Resident 3 reported becoming ill and throwing up. The resident notified the CNA and Staff 33 (LPN) and requested [MEDICATION NAME]. Staff 33 requested the CNA to obtain vital signs on the resident. Per the investigation, this was not documented. The resident again asked for [MEDICATION NAME] at 7:00 am, which was administered. Per the investigation the resident's oxygen was assessed at around 10:00 am and was 97%. At 12:20 pm Resident 3 reported right sided [MEDICATION NAME] pain. At the time of the survey there was no documented assessment of the resident's oxygen saturation level and the resident's pain in the clinical record. The resident wanted to wait to see if she/he improved and later requested to be sent to the hospital. The facility's investigation did not address the lack of documentation regarding the resident's status during the 1/1/16 evening and 1/2/16 day shifts. The 1/2/16 9:20 pm Nurse's Note documented Resident 2 complained of nausea, stating I threw up last night, am still nauseated, feeling really ill. The resident had audible wheezing and an oxygen saturation of 77% while on oxygen. A chest x-ray came back positive for pneumonia and the resident was sent to the hospital at 2:30 pm. The 1/2/16 SBAR (Situation, Background, Appearance, Review) Communication Form noted the resident's change of condition started on 1/1/16. The resident appeared dehydrated, had lung sounds with wheezing and crackles and the resident reported vomiting. The facility's Alert Charting Guidelines noted residents were placed on alert charting for noticeable changes in condition. On 2/25/16 at 12:54 pm Resident 2 was observed sitting in bed, with oxygen in place. Resident 2 stated during the middle of the night on 1/1/16 she/he threw up. During the day she/he developed a severe side pain which was indicative of pneumonia. The resident was sent to the hospital, where she/he was diagnosed with [REDACTED]. In interview on 3/24/16 at 5:30 am Staff 31 (CNA) stated Resident 3 reported not feeling well and spitting out during the 1/1/16 night shift. Staff 31 stated she reported the resident's concerns to Staff 33 (LPN). In interviews on 2/26/16 at 10:57 am and 3/24/16 at 9:16 am Staff 9 (LPN) stated she worked with Resident 1 on the 1/1/16 evening shift. Staff 9 stated Resident 3 complained of nausea and not feeling well and she administered the resident [MEDICATION NAME]. Staff 9 stated she assessed the resident's lungs, which were clear, but performed no further assessment. At the start of the 1/2/16 day shift at 6:00 am, Staff 33 (LPN) told her Resident 3 did not feel well and reported vomiting. The resident had intermittent nausea at 6:00 am. Staff 9 stated she did not know if the physician was contacted regarding the resident's status during the night and she texted the Nurse Practitioner about the nausea at around 6:30 am to 7:00 am. Staff 9 stated when she checked with the resident between 9:00 am and 10:00 am, the resident reported being nauseous and having rib pain. Staff 9 stated she assessed the resident's oxygen saturation level and lungs but did not document her findings. She administered [MEDICATION NAME] to the resident and contacted the physician for a chest x-ray. At around 2:00 pm the x-ray results were positive for pneumonia and the physician was contacted. At that time the resident requested to go to the hospital. When asked about the lack of documentation regarding assessing the resident's status, Staff 9 stated it should have been documented. In interview on 3/24/16 at 11:06 am Staff 33 (LPN) stated she did not receive any reports from the 1/1/16 evening shift nurse regarding the resident's status. During the 1/1/16 night shift Resident 3 reported nausea and vomiting. Staff 33 stated she told one of the CNAs to obtain vital signs on the resident, which was documented on a piece of paper. Staff 33 stated she could not recall if the resident's vital signs were documented in the resident's chart. Staff 33 sated she checked the resident's oxygen saturation level, which was at 93%, however, she could not recall if she assessed the resident's lungs. No further assessment was done. Staff 33 stated she did not inform the physician and reported it to the day shift nurse. In interview on 2/26/16 at 10:23 am Staff 2 (DNS) stated Staff 9 (LPN) should have documented regarding Resident 2's status and Staff 33 (LPN) did not give appropriate care or assessment during the 1/1/16 night shift. In interview on 3/21/16 at 2:27 pm Staff 1 (Administrator) stated he did not know if Staff 33 (LPN) did a full assessment on the resident as it was not documented. 3. Resident 4 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 11/24/15 Wound Care After Visit Summary noted if Resident 3 developed a fever, staff were to seek medical attention for the resident. There was no documented Nurse's Notes for Resident 4 on 2/14//16 to 2/18/16. The 2/19/16 12:05 pm Nurse's Note documented the resident had a temperature of 101 F at 9:00 am. The resident complained of shivering, pain to a buttock wound, shortness of breath, dyspnea (difficult or labored breathing), rib pain and a red rash on the bilateral thighs from the hips to knees with goose bumps. The physician was contacted, who sent the resident to the hospital. The correlating SBAR (Situation, Background, Appearance, Review) Communication Form noted the resident's change of condition started on 2/17/16. The 2/19/16 Hospital Records noted the resident, who was alert and oriented, reported having a fever for two days, felt poorly, had increased weakness and malaise and now developed redness and rash on the bilateral legs. The resident was diagnosed with [REDACTED]. On 3/4/16 at 8:00 am Resident 4 was observed in bed. The resident stated prior to going to the hospital on [DATE] she/he had sweats and chills and a temperature for two or three days before the hospitalization . The resident noticed red bumps on the legs on 2/19/16, which the hospital said was [MEDICAL CONDITION]. In interview on 3/4/16 at 6:09 am Staff 18 (CNA) stated Resident 4 was sick for a couple of days before the 2/19/16 hospitalization . Staff 18 stated he did not know if the resident had a rash before going to the hospital. In interview on 3/4/16 at 4:46 pm Staff 28 (CNA) stated Resident 4 reported being ill the week prior to the 2/19/16 hospitalization . In interviews on 3/24/16 at 1:58 pm and 3/28/16 at 5:31 pm Staff 13 (LPN) stated during the 2/18/16 night shift he was not the resident's charge nurse. The resident requested pain medication during the night shift and he went with Staff 10 (LPN) to administer the medication. Resident 4 looked like she/he was trying to get words out and had trouble talking and was very agitated. The resident's face was like oil, she/he looked like someone with an elevated temperature and she/he had a fever. Staff 13 stated this was new as he had never seen the resident look that way before. Staff 13 stated he and Staff 10 discussed the resident's condition and did not know if the resident's vital signs were obtained. In interview on 3/4/16 at 10:42 am Staff 10 (LPN) initially stated when she worked the 2/8/16 night shift, the resident reported not feeling well at around 11:00 pm and had a low grade temperature of 98.9. When asked what the resident wanted to do, the resident stated she/he did not know. Staff 10 stated she told the next shift about the resident's status and if the resident had an increase in temperature she/he would need to be sent to the hospital. There was no rash or heat on the resident's legs. In a subsequent interview on 3/28/16 at 4:58 pm Staff 10 stated during the 2/18/16 night shift the resident had a slight fever which responded to Tylenol. When asked about a documented assessment of the resident's status, Staff 10 stated it's got to be in there somewhere. Staff 10 stated she did not notify the physician as the temperature was only 99.2 F and the resident did not want to go to the hospital. Staff 10 stated she informed Staff 8 (RN) at shift change of the resident's slight fever. In interview on 3/3/16 at 10:40 am Staff 12 (LPN) stated prior to the 2/19/16 hospitalization , Staff 10 (LPN) reported to the next shift the resident had a temperature all night and might need to be sent to the hospital. Afterwards she and Staff 8 (RN) assessed the resident. The resident was shivering, looked flushed, reported not feeling well and had a temperature. Staff 8 obtained the resident's vital signs. In interview on 3/4/16 at 10:18 am Staff 8 (RN) stated Resident 4 was normally alert and oriented times four. When she came on shift on 2/19/16 staff reported the resident was not herself/himself, something was different and the resident had a fever. The resident was a little confused, forgetful, very sleepy, had a temperature and the resident's hip discoloration concerned her, so she called the physician and the resident was sent to the hospital. In interview on 3/28/16 Staff 2 (DNS) stated she expected staff to document the resident's status during the 2/18/16 night shift.

Based on observation, interview and record review it was determined that the facility failed to implement individualized approaches to prevent falls for 1 of 1 sampled resident (#75) who had experienced multiple falls previous to admission. The failure to individualize and implement approaches to prevent falls, of a similar nature, upon admission resulted in a fall with injury for Resident 75. Findings include: Resident 75 was admitted on [DATE] with [DIAGNOSES REDACTED]. Hospital records, available to staff upon admission, identified three falls had occurred between 2/1 and 2/5/13. The first fall on 2/1/13 was the result of the resident taking off his hospital gown which had a bed alarm attached to it and falling from bed. The second fall on 2/2/13 (also in his room) resulted in a laceration on the left front of the head which required seven sutures. The third fall on 2/5/13 was also from bed. A 2/6/13 Nurses Note identified the resident had been admitted around 1:00 pm that day and was alert, oriented to person and place, but generally considered confused. Resident 75 was non-ambulatory, had sutures above his left eyebrow and knew how to use his call light. The Initial Nursing Summary, completed 2/6/13, noted falls within the last 30 days and in the past 6 months with injury. The corresponding Initial Care Plan identified that appropriate footwear was in place, they had considered a wheelchair alarm, the environment was free of clutter and the bed was in the lowest position. A SBAR (Situation, background, assessment or appearance, request) form identified that on 2/6/13 at 7:45 pm (less than 7 hours after admission) the resident was found on the floor of his room, on the left side, next to his bed. The resident had taken his hospital gown off which had a tab alarm attached and so, the alarm did not sound. The resident reopened the head laceration and it was now approximately 1.5 cm longer. The family and the physician were notified with an order to transfer to the emergency room received. The incident investigation, completed 2/7/13 at 11:00 am, identified that a CNA had seen the resident a half an hour prior and the nurse saw him 10 minutes prior to the fall. Both reported the resident had been calm and sleeping. Non-skid socks had been worn, a tab alarm was attached to his hospital gown, the bed was in the low position and the call light was within reach. The CNA walked past the room and observed the resident laying on the floor with his hospital gown off. When the gown was found, the alarm was still attached. After the fall, a 2/7/13 Temporary Care Plan identified approaches of bed in lowest position, use of a fall mat and use of a tab alarm. In observation on 2/7/13 at 4:14 pm and 2/8/13 at 12:23 pm, the resident was dressed in a hospital gown with a tab alarm attached to it. On 2/8/13 at 1:50 pm 3:53 pm and 2/11/13 at 10:03 am, the resident was dressed in a sweatshirt with the tab alarm attached to the shirt. On 2/11/13 from 3:14 pm to 3:51 pm, the resident was observed up in his wheelchair in his room. The care planned tab alarm was not observed to be attached to the resident and when a CNA asked the nurse on duty if the resident had a tab alarm, the nurse responded "I don't think so." In a 2/8/13 interview at 4:20 pm and 2/12/13 interview at 3:05 pm, Staff 9, LPN, stated that the resident had been admitted during the afternoon, prior to her coming on duty. He had a tab alarm attached to his hospital gown and she had lowered the bed in order to stablize it. No fall mat had been in use. When asked if she would have done anything differently if she had known about the resident's history of a fall after taking his hospital gown off in the hospital; she replied "Probably." Staff 9 stated that she had gotten to work late that day and the nurse going off duty said that he didn't know much about the resident. According to Staff 9, the resident now had both old sutures from admission and new sutures from the most recent fall on his forehead. When interviewed on 2/11/13 at 3:40 pm and 4:23 pm, Staff 2, DNS, stated that the hospitals sometimes did not give the facility all the information about a resident prior to admit. When the resident arrived, a stack of information came with them and they did not always have time to review the hospital notes immediately. Resident 75 had been identified as a fall risk on admission and so, a tab alarm had been placed and his bed had been put in the low position. After his fall, a fall mat had been placed at the bedside. The IDT also reviewed his fall and later identified that the hospital gowns did not work for the resident and so, they learned if he wore a shirt, he would leave it alone. The resident was wearing a t-shirt in bed and a sweatshirt when up with the tab alarm attached. The care plan was reviewed with Staff 2 and did not reflect the current approach to wear shirts rather than a hospital gown. The failure of the facility to identify on admission the resident's falls in the hospital and assure individualized approaches were in place to decrease the risk of falls contributed to a similar fall in the facility with injury. The facility then failed to update the care plan to reflect new approaches to minimize the risk of falls; and to assure that all staff who worked with Resident 75 understood the interventions required to keep him safe which placed him at further risk for falls.