Every finding on record at Sheboygan Health Services

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 42 residents residing in the facility.The facility did not ensure food prep areas and equipment were in clean and sanitary condition.The facility did not have internal thermometers in the reach-in cooler and walk-in freezer to accurately monitor temperatures.Findings include:Food Prep Areas/Equipment: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 4-602.12 Cooking and Baking Equipment: (A) The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours.The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue.During an initial self-guided kitchen tour that began at 8:40 AM on 3/16/26, Surveyor observed the following:~ The reach-in cooler contained brown and white splashes on the front of both doors.~ The oven doors contained eggs, yellow and white splashes, and grease on both doors.~ The top and side of the double door oven contained dust and grease with matter that appeared to be food particles.~ A shelf next to the double door oven, a vinegar bottle, and seasonings contained brown/black grease.~ A peanut butter container on a shelf next to the double door oven contained peanut butter on sides, lid, and around the lid of the container.~ The dry storage room floor contained crushed crackers, cardboard pieces, and condiments under the shelving.During a continuous kitchen observation that began at 1:38 PM on 3/18/26, Surveyor noted the above items were in the same unclean condition. Surveyor interviewed Dietary Manager (DM)-D who indicated the kitchen had an issue with cleaning. DM-D stated DM-D spoke to staff frequently and attempted to correct the concerns. DM-D stated DM-D completed most of the kitchen cleaning while working and was unable to keep up with the tasks. DM-D confirmed the kitchen was not cleaned every 24 hours and the areas identified were not cleaned per policy. Internal Thermometers:The 2022 FDA Food Code documents at 3 202.11 Temperature: Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41 Fahrenheit (F) (5 Celsius (C)) and freezers at or below 0 F (-18 C).During an initial self-guided kitchen tour that began at 8:40 AM on 3/17/26, Surveyor noted the reach-in cooler and walk-in freezer did not contain internal thermometers. Outside temperature gauges indicated the reach-in cooler was 56.6 degrees F and the walk-in freezer was 0 degrees F. During a continuous kitchen observation that began at 1:38 PM on 3/18/26, Surveyor interviewed DM-D who confirmed the reach-in cooler and walk-in freezer did not contain internal thermometers. DM-D stated the walk-in freezer used to have an internal thermometer, but DM-D couldn't find it. DM-D indicated staff relied on the outside temperature gauge for the reach-in cooler. Surveyor noted the outside temperature gauge for the reach-in cooler indicated the cooler was 46.5 degrees F at the time of the interview.

Based on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 4 residents (R) (R23, R37, R1, and R6) of 5 sampled residents.The facility did not contact the state mental health authority when R23, R37, R1, and R6's PASRR Level I 30-day exemption expired or pursue further PASRR Level II screening.Findings include: The facility's Resident Assessment: Coordination with PASARR Program policy, dated [DATE], indicates: This facility coordinates assessments with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs .ii. Positive Level I Screen necessitates a PASARR Level II evaluation prior to admission .2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has determined as appropriate for admission .4. Exceptions to the pre-admission screening program include those individuals who are .b.admitted directly from a hospital, require nursing facility services for the condition for which the individual received care in the hospital, and have been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services .5. If a resident was not screened due to an exception above (section 4) and the resident remains in the facility for longer than 30 days: a. The facility must screen the individual using the state Level I screening process and refer any resident who has or may have a mental health diagnosis or intellectual disability or a related condition to the appropriate state designated authority for Level II PASARR evaluation and determination. B. The Level II resident review must be completed within 40 calendar days of admission. 1. On [DATE], Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had diagnoses including depression, anxiety, and dementia with agitation. R23's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R23 had severe cognitive impairment. R23 had an activated decision maker for healthcare decisions. R23's medical record indicated the the following: ~ A PASRR Level I Screen, dated [DATE], completed upon admission indicated R23 had a 30-day hospital exemption. ~ A PASRR Level I Screen, dated [DATE], indicated R23 had a 30-day hospital exemption. R23's medicasl record did not contain any other PASRR Screens, including a required PASRR Level II. (See interview under example 4.) 2. On [DATE], Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, anxiety disorder, and dementia with behavioral concerns and psychotic features. R37's MDS assessment, dated [DATE], had a BIMS score of 11 out of 15 which indicated R37 had moderately impaired cognition. R37 had an activated healthcare decision maker. R37's medical record indicated the following: ~ A PASRR Level I Screen, dated [DATE], indicated R37 had a 30-day hospital exemption. R37's medical record did not contain any other PASRR Level I or II Screens. (See interview under example 4.) 3. On [DATE] at 12:45 PM, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including cerebral palsy, cognitive communication deficit, and unspecified mental disorder due to known physiological condition. R1's MDS assessment, dated [DATE], had a BIMS score of 14 out of 15 which indicated R1 had intact cognition. R1 had an activated Power of Attorney for Healthcare (POAHC). R1's medical record included a PASRR Level I Screen that indicated R1 had an intellectual disability and a 30-day hospital discharge exemption that indicated R1 was expected to be in the facility for less than 30 days. A County Review of Nursing Home, Institution for Mental Disease (IMD) or Intermediate Care Facilities/Individual with Intellectual Disability (ICD/IID) Referrals document, dated [DATE], included a recommendation of institutional placement for R1 as nursing facility admission and hospital discharge exemption-30 day maximum. The form indicated a short-term exemption form Level II Screen applied and short-term exemptions may not be used consecutively to extend the time in a facility with a PASRR Level II Screen. R1's medical record did not contain any other PASRR Level I or Level II Screens. On [DATE] at 3:28 PM, Surveyor requested additional PASRR screening documents for R1 since R1's 30-day exemption had expired. No further PASRR screens were provided. (See interview under example 4.) 4. On [DATE], Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including anxiety, depression, mild cognitive impairment, and alcohol-induced dementia. R6's MDS assessment, dated [DATE], had a BIMS score of 14 out of 15 which indicated R6 had intact cognition. R6 had an activated POAHC. R6's medical record included a PASRR Level I Screen that indicated R6 had a diagnosis of a major mental disorder and a 30-day hospital discharge exemption which indicated R1 was expected to be in the facility for less than 30 days. R6's medical record did not contain any other PASRR Level I or Level II Screens. On [DATE] at 3:28 PM, Surveyor requested additional PASRR screening documents for R6 since R6's 30-day exemption had expired. No further PASRR screens were provided. On [DATE] at 9:26 AM, Surveyor interviewed Social Services Designee (SSD)-C who indicated R23, R37, R1 and R6 were all admitted prior to SSD-C's employment in October of 2025. SSD-C stated R23, R37, R1, and R6 had PASRR Level I Screens; however, it was discovered after SSD-C started that PASRR Level I Screens were not referred for PASRR Level II Screens as required. SSD-C indicated a performance improvement plan was initiated, including an audit to ensure all residents who required a PASRR Level II Screen received screening. SSD-C confirmed R23, R37, R1, and R6 should have had PASRR Level II Screens. On [DATE] at 4:05 PM, Surveyor interviewed [NAME] President of Success (VPS)-G who confirmed despite the initiation of a performance improvement plan, the facility did not submit the required PASRR Level II Screens for R23, R37, R1, and R6.

Based on observation, staff and resident interview, and record review, the facility did not ensure meals were served at regular times and in accordance with residents' preferences. This practice had the potential to affect more than 4 of the 42 residents residing in the facility.The facility consistently served meals later than posted mealtimes and residents' preferences.Findings include:On 3/17/26, Surveyor observed a document titled Meal Times posted in the dining room and outside the activity room that indicated the following: ~ Breakfast: 8:30 AM - Dining room; 8:45 AM - Room trays~ Lunch: 12:30 PM - Dining room; 12:45 PM - Room trays~ Dinner - 5:30 PM - Dining room; 5:45 PM - Room traysOn 3/17/26, Surveyor observed lunch in the dining room which started at 1:05 PM. The last resident seated in the dining room was served at 1:26 PM. Surveyor noted room trays left the dining room at 1:45 PM and the last tray was delivered at 2:00 PM. On 3/18/26 at 8:29 AM, Surveyor observed breakfast in the dining room. A beverage cart arrived at that time and residents were served beverages. Staff began to serve breakfast at 8:50 PM and began to deliver room trays at 9:06 AM. The last room tray was delivered at 9:24 AM.On 3/18/26 at 12:28 PM, Surveyor observed lunch in the dining room. A beverage cart arrived at that time and residents were served beverages. Staff began to serve lunch at 12:50 PM and began to deliver room trays at 1:02 PM. The last room tray was delivered at 1:13 PM. On 3/18/26, Surveyor reviewed the facility's grievance file. A grievance, dated 2/16/26, contained a complainant from a Resident Council meeting. The grievance indicated meals were not served as scheduled, meals were early or late, and residents were not always aware when meals would be served. The grievance form indicated Dietary Manager (DM)-D had trained a new Dietary Aide which was why meals were not served according to the posted times. The follow-up section of the grievance (dated 2/17/26) indicated meal times were getting better.On 3/18/26 at 11:31 AM, Surveyor interviewed R15 who stated R15 ate breakfast and dinner in the dining room and ate lunch in R15's room. R15 stated meal times in the dining room were 8:30 AM for breakfast and 5:30 PM for dinner. R15 stated serving times were not adhered to which was a concern. R15 stated room trays for lunch were served over an hour late at times. Dinner was served early at times and R15 had to wait until 9:00 AM or later for breakfast the next morning. R15 received insulin prior to meals and felt R15's blood glucose was too low at times when R15 waited a long time for meals to be served. R15 stated R15 regularly attended Resident Council meetings and reported the concern to staff who attended the meeting; however, meal service had not improved. (Surveyor reviewed 15's medical record and noted R15 had diagnoses including type 2 diabetes and chronic kidney disease. R15's Minimum Data Set (MDS) assessment, dated 1/25/26, indicated R15 had intact cogntion.)R15's medical record contained an order for 13 units of Humalog (a fast-acting insulin) at noon prior to meals.On 3/18/26 at 1:38 PM, Surveyor interviewed DM-D who was aware meals were not served at the posted times and residents had previously reported concerns at Resident Council meetings and during discussions about meal service. DM-D stated kitchen staff were allowed to be 15 minutes late with service.On 3/19/26 at 8:59 AM, Surveyor observed staff begin breakfast service in the dining room. Surveyor interviewed Regional Dietary Manager (RDM)-E who stated DM-D was instructed to start meal service on time because residents requested meals be delivered within the posted time frames. RDM-E indicated staff should start serving breakfast at 8:30 AM.

Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R19) of 3 sampled residents.R19 was at risk for elopement and had an intervention for a WanderGuard. The intervention was not consistently implemented.Findings include:The facility's Elopment/Unsafe Wandering policy, revised 8/9/22, indicates: This facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care, addressing the unique factors contributing to wandering or elopement risk .2. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions as necessary .f. Supervision per the plan of care should be provided to help prevent accidents or elopement. g. Licensed nurses will monitor the implementation of interventions, response to interventions, and document accordingly.From 3/17/26 to 3/19/26, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, obsessive compulsive disorder, and anxiety. R19's Minimum Data Set (MDS) assessment, dated 2/11/26, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R19 had intact cognition. R19 had an activated Power of Attorney for Healthcare (POAHC).R19's care plan, initiated 4/20/25 and revised 6/25/25, indicated R19 was at risk for behavior symptoms related to unspecified schizophrenia and fixated on certain ideas/thoughts, especially related to personal belongings. The care plan contained a goal to reduce the risk of behavioral symptoms and remain safe within the environment. The care plan contained the following interventions: Alert bracelet to walker for safety; Check alert bracelet functioning per facility guidelines; Check alert bracelet placement per facility guidelines.R19's medical record contained the following orders:~ Okay to place wander alert bracelet for elopement risk (dated 6/2/25).~ Check wander alert bracelet placement to walker every shift (dated 6/2/25).~ Check wander alert bracelet function and expiration date once daily (6/3/25).An Elopement Assessment, dated 3/15/26, indicated R19 was at moderate risk for elopement and had a WanderGuard (WG) in place. R19 had not attempted to elope and no longer fixated on the storage unit. An Elopement Assessment, dated 12/15/25, indicated R19 was at high risk for elopement and had a WG in place.R19's Treatment Administration Record (TAR) for December 2025 through March 2026 indicated the following:~ WG placement was not documented on the 12/30/25 evening shift.~ WG placement was not documented on the 1/24/26 night shift.On 3/17/26 at 12:26 PM, Surveyor noted R19 did not have a WG.On 3/18/26 at 11:44 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated there was a WG on R19's walker. LPN-I stated nursing staff test the WG and verify its placement once per shift and document in R19's medical record. On 3/18/26 2:44 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R19 had a history of attempting to leave the facility. DON-B stated an Elopement Assessment is completed every 3 months. DON-B stated R19's most recent Elopement Assessment indicated R19 was at moderate risk for elopement which had decreased from high risk. DON-B stated there was a WG on R19's walker and DON-B planned to discuss WG removal with R19's POAHC. DON-B stated R19 did not ambulate without the walker. DON-B stated staff attempted multiple times to put a WG on R19's ankle or wrist but R19 would not allow it. DON-B indicated staff decided to put a WG on the walker because R19 could not ambulate without the walker.Following the interview with DON-B, Surveyor observed R19 return from an activity with R19's walker. Surveyor did not observe a WG on the walker. Surveyor interviewed R19 who stated R19 was sick of the red light on the WG and removed the WG from the walker. A progress note, dated 3/18/26 at 3:07 PM by DON-B, now indicated R19 had not made any attempts to elope since the summer and no longer obsessed about personal belongings that were stored at R19's POAHC's house. The note indicated R19's POAHC was leery but approved of a trial to remove the WG. An order was received to remove the WG (Of note: R19's medical record did not contain an order to remove the WG.) The note indicated staff would assist R19 to R19's room from meals and activities for no less than 7 days.On 3/18/26 at 3:48 PM, Surveyor interviewed DON-B regarding R19's WG. DON-B stated DON-B observed a WG on R19's walker on 3/17/26. DON-B indicated R19 had a history of cutting off the WG and could have done so again.On 3/19/26 at 11:48 AM, Surveyor interviewed Registered Nurse (RN)-H who stated the WG was located on the horizontal bar of R19's walker because R19 refused to wear a WG on R19's person. RN-H verified R19 cut off the WG multiple times.

Based on staff interview and record review, the facility did not ensure weight monitoring was provided for 1 resident (R) (R7) of 5 sampled residents.R7's weights were not obtained using a consistent device and re-weights were not obtained for weight loss/gain of greater than 5 pounds (lbs). In addition, R7's physician and Power of Attorney (POA) were not notified regarding R7's weight loss/gain of greater than 5 lbs.Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: The Interdisciplinary Team (IDT) will strive to prevent, monitor, and intervene for undesirable weight change for our residents .5. Team members will follow a consistent approach to weighing and use an appropriately calibrated and functioning scale (e.g., wheelchair scale or bed scale). Since weight varies throughout the day, a consistent process and technique (e.g., weighing the resident wearing a similar type of clothing, at approximately the same time of the day, using the same scale, either consistently wearing or not wearing orthotics or prostheses, and verifying scale accuracy) can help make weight comparisons more reliable. 6. Any weight change of five pounds or more since the last weight assessment will be taken for confirmation .8. The threshold for significant weight change will be based on the following criteria where percentage of body weight change = (usual weight - actual weight)/(usual weight) x 100): a. 1 month - 5% weight change is significant; greater than 5% is severe. b. 3 months - 7.5% weight change is significant; greater than 7.5% is severe. c. 6 months - 10% weight change is significant; greater than 10% is severe .10. Nursing staff will notify the individual or responsible party, physician and Registered Dietitian (RDN) or designee of any individual with an unintended significant weight change .2. The undesired weight change will be discussed with the resident and/or responsible party.From 3/17/26 to 3/19/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dysphagia following other non-traumatic intracranial hemorrage, hemiplegia and hemiparesis, type 2 diabetes, and Body Mass Index (BMI) of 19.9 or less. R7's Minimum Data Set (MDS) assessment, dated 2/16/26, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R7 had intact cognition. R7 had an activated Power of Attorney for Healthcare (POAHC).A care plan, initiated 12/15/25, indicated R7 was at risk for nutritional status change related to increased fluid demands as evidenced by constipation, protein/calorie malnutrition, type 2 diabetes, iron deficiency anemia, significant weight gain (+6%, -8#) over 1 month (dated 3/16/26), and significant weight loss (-7%, -10#) over 1 month (dated 1/14/26). The care plan contained a goal to gain weight and maintain as evidenced by no significant weight changes. The care plan contained the following interventions: Review weights and notify Registered Dietitian, provider, and responsible party of significant weight change; Record weight per facility protocol/provider orders; Parenteral nutrition per provider orders; Provide additional calories/protein at meals per R7's preference.R7's medical record contained the following orders:~ Weight on admit, daily x 2, weekly x 3, monthly; obtain re-weight if change of 5 lbs since last weight (dated 1/5/26)~ Boost two times daily for supplement 120 milliliters (ml) (dated 1/6/25)~ Tube feed - 480 ml Osmolite 1.2 calorie at 320 ml/hour (hr) at bedtime (dated 1/6/26)~ Weekly weights in the morning every Monday for history of weight loss (dated 3/2/26)A provider note, dated 3/12/26, indicated R7 was initially admitted in September of 2025 following a left basal ganglia intracranial hemorrhage in July of 2025 complicated by right hemiparesis, dysphagia requiring a percutaneous endoscopy (PEG) tube, urinary retention requiring a Foley catheter, and insulin-dependent type 2 diabetes with recurrent hypoglycemia.~ On 3/5/26 at 2:33 PM, R7 weighed 135.0 lbs (wheelchair scale) ~ On 2/11/26 at 1:25 PM, R7 weighed 142.4 lbs (standup scale) (3/5/26 at 1:33 PM disputed value; No re-weigh 2/11/26)~ On 2/10/26 at 1:47 PM, R7 weighed 133.0 lbs (standup scale) ~ On 2/2/26 at 2:51 PM, R7 weighed 132.8 lbs (wheelchair scale) A Nutrition Assessment, dated 2/23/26, indicated R7's average meal intake was between 51-100% with several refusals. R7 received nutritional supplements (including Boost twice daily) and/or fortified foods. R7's weight on 2/11/26 was 142.4 lbs via standup scale. R7's BMI was 19.9. R7 had a significant weight gain of 6.8% in 1 month that was an increase of 9 lbs. The note contained an instruction to obtain re-weight for 3 consecutive days related to recent significant weight gain in one day (2/11/26). ~ On 2/1/26 at 12:54 PM, R7 weighed 141.6 lbs (standup scale) (2/3/26 at 9:48 AM disputed value; No re-weigh 2/1/26)~ On 1/31/26 at 10:20 AM, R7 weighed 133.2 lbs (standup scale) ~ On 1/29/26 at 3:06 PM, R7 weighed 134.0 bs (standup scale) ~ On 1/24/26 at 11:31 AM, R7 weighed 133.0 lbs (wheelchair scale) (weight down 9 lbs) ~ On 1/23/26 at 1:14 PM, R7 weighed 142.0 lbs (standup scale) ~ On 1/22/26 at 2:48 PM, R7 weighed 139.8 lbs (standup scale) ~ On 1/21/26 at 2:47 PM, R7 weighed 140.6 lbs (wheelchair scale) (weight up 7.2 lbs) ~ On 1/20/26 at 2:01 PM, R7 weighed 133.4 lbs (wheelchair scale) ~ On 1/16/26 at 2:25 PM, R7 weighed 131.4 lbs (wheelchair scale) ~ On 1/15/26 at 1:37 PM, R7 weighed 134.2 lbs (wheelchair scale) (weight up 6.2 lbs) ~ On 1/13/26 at 1:42 PM, R7 weighed 128.0 lbs (standup scale) (weight down 5.4 lbs) ~ On 1/12/26 at 11:05 AM, R7 weighed 133.4 lbs (wheelchair scale) ~ On 1/11/26 at 2:41 PM, R7 weighed 132.0 lbs (standup scale) (weight down 5.2 lbs) ~ On 1/10/26 at 1:45 PM, R7 weighed 137.2 lbs (wheelchair scale) On 3/19/26 at 11:37 AM, Surveyor interviewed Registered Nurse (RN)-H who indicated Certified Nursing Assistants (CNAs) complete weights and give them to the nurses. RN-H stated it is the nurses' responsibility to compare daily weights to previously documented weights. RN-H stated a re-weigh is required if there is a 3 to 7 lb weight variation. RN-H stated if the re-weight is greater or less than 3 lbs from the previous weight, the nurse is required to call the physician. RN-H stated the nurse then writes a progress or assessment note in the resident's medical record. RN-H acknowledged the weight discrepancies in R7's medical record and verified re-weighs were not completed. RN-H stated RN-H did not observe any nursing notes related to weight in R7's medical record.On 3/19/26 at 12:04 PM, Surveyor interviewed [NAME] President of Success (VPS)-G who stated R7's weights were obtained with a wheelchair or stand-up scale and verified the method of obtaining R7's weights was inconsistent. VPS-G confirmed staff are required to contact the physician and POA if there is a change in weight of 5 lbs in one week. VPS-G confirmed R7's medical record did not indicate re-weights, physician, and POAHC notifications were completed.

Based on observation, staff and resident interview, and record review, the facility did not serve meals consistently at regular meal times. This practice had the potential to affect more than 4 of the 36 residents residing in the facility. On 12/2/24, breakfast service started approximately 38 minutes after the posted meal time. Staff served the last breakfast tray 1 hour and 12 minutes after the posted meal time. On 12/2/24, lunch service started approximately 30 minutes after the posted meal time. Staff served the last lunch tray 1 hour and 16 minutes after the posted meal time. Findings include: The facility's Frequency of Meals policy and procedure, revised 9/2017, indicates: The Dining Services Director will ensure that each meal is served within the designated time frame unless there is an emergency situation or resident request. Between 12/2/24 and 12/4/24, Surveyor reviewed the facility's Resident Council minutes. The Resident Council minutes from 9/10/24 indicated: Cold food on hot plate. Progress of concern: Ongoing. New concerns: Late meals. On 12/2/24 at 12:05 PM, Surveyor interviewed R24 who indicated R24 waited too long for meals. On 12/2/24 at 1:55 PM, Surveyor interviewed R31 who indicated meals arrived an hour after the posted meal times. On 12/2/24, Surveyor observed a posting outside the dining room that indicated: Breakfast 8:00 AM, Lunch 12:00 PM, and Supper 5:00 PM. On 12/2/24 at 8:14 AM, Surveyor began observing breakfast service in the dining room. On 12/2/24 at 8:32 AM, Dietary Manager (DM)-G completed food temperatures. On 12/2/24 at 8:38 AM, DM-G started plating meal trays. Surveyor noted breakfast service started 38 minutes after the posted meal time. On 12/2/24 at 8:53 AM, Surveyor noted the last dining room meal tray was completed. On 12/2/24 at 9:12 AM, Surveyor noted the last room tray was delivered 1 hour and 12 minutes after the posted meal time. On 12/2/24 at 12:27 PM, Surveyor began observing lunch service in the dining room. On 12/2/24 at 12:29 PM, DM-G completed food temperatures. On 12/2/24 at 12:30 PM, DM-G started plating meal trays. Surveyor noted lunch started 30 minutes after the posted meal time. On 12/2/24 at 12:47 PM, Surveyor noted the last dining room meal tray was completed. On 12/2/24 at 12:58 PM, Surveyor noted room room trays were plated and ready to deliver. On 12/2/24 at 1:16 PM, Surveyor noted the last room tray was delivered 1 hour and 16 minutes after the posted meal time. On 12/3/24 at 12:53 PM, Surveyor interviewed DM-G regarding meal timeliness. DM-G indicated breakfast in the dining room was at 8:15 AM and room trays were delivered at 8:30 AM. DM-G indicated lunch in the dining room was at 12:15 PM and room trays were delivered at 12:30 PM. When Surveyor asked about the posted meal times, DM-G indicated there was a communication problem and stated DM-G notified Nursing Home Administrator (NHA)-A who would take care of it. On 12/4/24, Surveyor observed a posting outside the dining room that still indicated: Breakfast 8:00 AM, Lunch 12:00 PM, and Supper 5:00 PM.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents received the appropriate care and services to prevent urinary tract infections (UTIs). On 12/2/24, R2's uncovered nephrostomy tube drainage bag was observed on the floor. Findings include: The facility's Nephrostomy and Cystostomy Tube Care Policy, dated 7/21/22, indicates: A nephrostomy tube is a catheter or tube surgically inserted into the kidney to divert urine from the ureters or bladder .d. Interventions to prevent complication or promote dignity associated with the tube(s): .iv. Physical management of tubing and collection bag to prevent infection or dislodgement .7. Considerations for care .b. Maintain the drainage bag below the level of the kidney. Keep bags covered for dignity. From 12/2/24 to 12/4/24, Surveyor reviewed R2's medical record. R2 was hospitalized from 11/15/24 to 11/19/24 and had diagnoses including severe sepsis due to UTI, large staghorn right renal calculus (kidney stone) with mild hydronephrosis status post bilateral nephrostomy tube placement, multiple sclerosis (MS), diabetes, and neuromuscular dysfunction of the bladder. R2's Minimum Data Set (MDS) assessment, dated 11/23/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 was not cognitively impaired. R2 made R2's own healthcare decisions. On 12/2/24 at 1:36 PM and 1:53 PM, Surveyor noted R2's left uncovered nephrostomy bag was on the floor behind R2's wheelchair. On 12/2/24 at 1:54 PM, Surveyor interviewed Registered Nurse (RN)-F who verified R2's left uncovered nephrostomy bag was on the floor which could cause contamination. RN-F indicated R2's nephrostomy bags were usually covered under R2's sweater. RN-F indicated nephrostomy tubes should be in a dependent position and nephrostomy bags should be off the floor for infection control purposes.

Based on staff interview and record review, the facility did not ensure medical records contained accurate and complete documentation for 2 residents (R) (R16 and R31) of 14 sampled residents. R16's Medication Administration Record (MAR) indicated six doses of Artificial Tears were provided when the medication was unavailable for administration. R31 received dialysis three times per week. R31's medical record did not contain a physician's order for dialysis. Findings include: The facility's Medication Administration policy, dated 1/2023, indicates: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so .Documentation: 1. The individual who administers the medication dose records the administration on the resident's MAR immediately following the medication being given .4. The resident's MAR/Treatment Administration Record (TAR) is initialed by the person administering the medication in the space provided under the date and the on the line for that specific medication dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log . 1. On 12/3/24, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including spastic quadriplegic cerebral palsy, bipolar disorder, anxiety, and depression. R16's Minimum Data Set (MDS) assessment, dated 10/26/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 was not cognitively impaired. R16 was responsible for R16's healthcare decisions. Surveyor reviewed R16's medication orders and noted R16 was prescribed Artificial Tears ophthalmic solution 1 drop per eye 3 times per day for dry eyes on 8/13/24. Surveyor reviewed R16's MAR which indicated the following: ~On 11/26/24, all three doses were not administered (medication not available). ~On 11/27/24, all three doses were not administered (medication not available). ~On 11/28/24, all three doses were administered. ~On 11/29/24, all three doses were administered. ~On 11/30/24, one dose was administered and two doses were not administered (medication not available). ~On 12/1/24, one dose was administered and two doses were not administered (medication not available). ~On 12/2/24, all three doses were administered. ~On 12/3/24, one dose was administered. On 12/3/24 at 12:43 PM, Surveyor interviewed Registered Nurse (RN)-H who indicated RN-H did not provide Artificial Tears to R16 on 12/3/24 or on the previous weekend because the facility was waiting on a pharmacy shipment. RN-H verified RN-H documented in error that RN-H had administered the doses and R16's MAR was inaccurate. On 12/3/24 at 12:56 PM, Surveyor interviewed Director of Nurses (DON)-B who indicated DON-B expects staff to provide accurate documentation in a resident's MAR. 2. On 12/3/24, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease-dialysis dependent, diabetes, and coronary artery disease. R31's MDS assessment, dated 9/15/24, had a BIMS score of 15 out of 15 which indicated R31 was not cognitively impaired. R31 was responsible for R31's healthcare decisions. Surveyor reviewed R31's physician orders and noted R31 did not have an order for dialysis, however, R31 received dialysis three times per week on Tuesdays, Thursdays, and Saturdays. On 12/3/24 at 2:07 PM, Surveyor interviewed DON-B who reviewed R31's physician orders and verified R31 did not have a physician's order for dialysis. DON-B indicated R31 should have a dialysis order.

Based on staff interview and record review, the facility did not ensure the state mental health authority was notified in a timely manner following a significant change in mental illness for 2 residents (R) (R7 and R22) of 5 sampled residents. R7 was admitted to the facility on [DATE] with a diagnosed mental illness with corresponding medication. The facility did not update and submit R7's Preadmission Screen and Resident Review (PASRR) Level I for additional Level II screening following changes to R7's medications. R22 was admitted to the facility on [DATE] with a diagnosed mental illness with corresponding medication. The facility did not update and submit R22's PASRR Level I for additional Level II screening following changes in R22's medications. Findings include: According to the Centers for Medicare and Medicaid Services' (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User Manual, dated October 2023, if a significant change in status (SCSA) occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act .The nursing facility must provide the SMH/ID/DDA authority with referrals as described below, independent of the findings of the SCSA. PASRR Level II is to function as an independent assessment process for this population with special needs, in parallel with the facility's assessment process. Nursing facilities should have a low threshold for referral to the SMH/ID/DDA so that these authorities may exercise their expert judgment about when a Level II evaluation is needed .Referral should be made as soon as the criteria indicating such are evident - the facility should not wait until the SCSA is complete. In addition, a referral for Level II Resident Review Evaluations is required for individuals previously identified by PASRR to have mental illness, intellectual disability/developmental disability, or a related condition in the following circumstances: note: .A resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where dementia is not the primary diagnosis) .A resident transferred, admitted , or readmitted to a nursing facility following an inpatient psychiatric stay or equally intensive treatment. 1. On 12/4/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, and major depressive disorder. R7's Minimum Data Set (MDS) assessment, dated 12/9/24, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R7 was severely cognitively impaired. R7 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. A PASRR Level I Screen, dated 12/14/21, indicated R7 had a serious mental illness with corresponding medication of Zoloft (an antidepressant medication). R7 had a physician order for Zoloft 75 milligrams (mg) one time a day for depression (dated 7/4/24) and an order for quetiapine fumarate (an antipsychotic medication) 12.5 mg two times a day for major depressive disorder (dated 10/22/24). R7's medical record did not contain an updated PASRR Level I that included the addition of R7's antipsychotic medication. R7's medical record did not include a PASRR Level II Reevaluation for R7's mental illness with changes to R7's medications. 2. On 12/4/24, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including generalized anxiety disorder, major depressive disorder, and delusional disorder. R22's MDS assessment, dated 9/10/24, had a BIMS score of 9 out of 15 which indicated R22 had moderate cognitive impairment. R22 was responsible for R22's healthcare decisions. A PASRR Level I Screen, dated 8/19/21, indicated R22 had a serious mental illness with corresponding medications of Ativan (an antianxiety medication), and fluoxetine (an antidepressant medication). R22 had physician orders for buspirone (an antianxiety medication) 5 mg two times a day for anxiety (dated 10/8/24), escitalopram (an antidepressant medication) 10 mg one time a day for depression (dated 7/21/23), and Abilify (an antipsychotic medication) 2 mg one time a day for depression. R22's medical record did not contain an updated PASRR Level I that included the addition of R22's antipsychotic medication. R22's medical record did not include a PASRR Level II Reevaluation for R22's mental illness with changes to R22's medications. On 12/4/24 at 1:06 PM, Surveyor interviewed Social Service Coordinator (SSC)-I who had worked in SSC-I's current role for one month with no prior experience in Social Services. SSC-I verified SSC-I was responsible for completing PASRR requirements but had limited knowledge on PASRR requirements including when a Level I should be updated and when a Level II should be resubmitted. SSC-I confirmed SSC-I was not aware R7 and R22 needed an updated Level I and reevaluation of Level II by the state mental health authority. On 12/4/24 at 1:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and [NAME] President of Success (VPS)-C regarding PASRR expectations. VPS-C stated VPS-C was not aware R7 and R22's Level I Screens should have been resent for review for Level II Screens until Surveyor requested the documents. VPS-C stated it was the previous SSC's responsibility to ensure PASRRs were up-to-date with their quarterly review and confirmed it was also an expectation of SSC-I.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R16) of 4 sampled residents. R16 had an order for Artificial Tears ophthalmic solution 1 drop per eye 3 times per day for dry eyes. R16 did not receive 16 doses of the scheduled medication and was told the medication was unavailable. Findings include: The facility's Medication Administration policy, dated 1/2023, indicates: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .14. Medications are administered within 60 minutes of scheduled time . On 12/3/24, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including spastic quadriplegic cerebral palsy, bipolar disorder, anxiety, and depression. R16's Minimum Data Set (MDS) assessment, dated 10/26/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 was not cognitively impaired. R16 was responsible for R16's healthcare decisions. On 12/2/24 at 1:35 PM and on 12/4/24 at 9:20 AM, Surveyor interviewed R16 who wore glasses and indicated staff had not provided R16's eye drops for 7 days. R16 indicated staff informed R16 that the facility was waiting on a pharmacy shipment. R16 indicated R16 cannot see the print on the television without the drops due to dryness which causes pain. R16 indicated on the third day without the eye drops, R16 reported to staff that R16's eyes hurt. Surveyor reviewed R16's medication orders and noted R16 was prescribed Artificial Tears ophthalmic solution 1 drop per eye 3 times per day for dry eyes on 8/13/24. Surveyor reviewed R16's November and December 2024 Medication Administration Records (MARs) which indicated the following: ~On 11/26/24, all three doses were not administered (medication not available). ~On 11/27/24, all three doses were not administered (medication not available). ~On 11/28/24, all three doses were administered. ~On 11/29/24, all three doses were administered. ~On 11/30/24, one dose was administered and two doses were not administered (medication not available). ~On 12/1/24, one dose was administered and two doses were not administered (medication not available). ~On 12/2/24, all three doses were administered. ~On 12/3/24, one dose was administered. On 12/3/24 at 12:43 PM, Surveyor interviewed Registered Nurse (RN)-H who indicated RN-H did not provide Artificial Tears to R16 on 12/3/24 or the previous weekend because the facility was waiting on a pharmacy shipment. RN-H indicated Director of Nursing (DON)-B ordered the medication, but it had not arrived and the facility was out. RN-H verified RN-H documented in error that the doses were administered. On 12/3/24 at 12:56 PM, Surveyor interviewed DON-B who indicated DON-B expects ordered medications to be provided as prescribed and MAR documentation to be accurate. On 12/3/24 at 2:00 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who retrieved a box of Artificial Tears from downstairs which was shown to Surveyor. VPS-C was unsure why staff did not know to go downstairs to obtain the medication.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R22) of 2 sampled residents received the necessary care and treatment for respiratory therapy. On 12/3/24, R22 received oxygen at a rate that was above the rate ordered by R22's provider. Findings include: The facility's Oxygen Concentrator policy, dated 6/27/22, indicates: To provide oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration level of oxygen. It is commonly used to provide oxygen therapy .9. Adjust the flow meter control knob to the flow setting prescribed by the physician. From 12/2/24 to 12/4/24, Surveyor reviewed R22's medical record. R22 had diagnoses including chronic obstructive pulmonary disease (COPD), thrombotic pulmonary embolism, pulmonary hypertension, anxiety, and dependence on supplemental oxygen. R22's Minimum Data Set (MDS) assessment, dated 9/10/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R22 had moderate cognitive impairment. R22 made R22's own healthcare decisions. R22 had a physician order, dated 11/3/24, for oxygen via stationary system for in-room activities at 1-4 liters per minute via nasal cannula daily to keep oxygen saturation level equal to or greater than 90% every shift. On 12/3/24 at 8:22 AM, Surveyor noted R22 was receiving 4.5 liters of oxygen via nasal cannula. On 12/3/24 at 2:12 PM, Surveyor and Licensed Practical Nurse (LPN)-E observed R22's oxygen concentrator and noted R22 was receiving oxygen at 5 liters. LPN-E indicated R22's flow rate was usually set at 3 liters. LPN-E adjusted R22's oxygen incrementally to 4 liters until R22's oxygen saturation level was at 92%.

Based on observation, staff and resident interview, and record review, the facility did not ensure oral care was consistently completed for 1 resident (R) (R3) of 14 sampled residents. Oral care was not consistently documented as completed, unavailable, or refused in R3's medical record. Findings include: The facility's Oral Care Policy, dated 8/5/22. indicates: It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases. From 12/2/24 to 12/4/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including metastatic kidney cancer to pancreas status post pancreatectomy, status post left nephrectomy, status post thyroidectomy for thyroid gland metastasis, schizophrenia, and diabetes. R3's Minimum Data Set (MDS) assessment, dated 11/20/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R3 had moderate cognitive impairment. R3 had an activated Power of Attorney for Healthcare (POAHC). R3's activities of daily living (ADL) care plan, dated 3/30/24, indicated R3 had a self-care deficit related to decreased mobility and an inability to care for self. The care plan contained interventions to offer teeth brushing to R3 and assist as necessary. In addition, R3's plan of care indicated R3 had dental or oral cavity health problems as evidenced by dentures and contained interventions to assist with upper dentures and oral hygiene as needed. A provider note, dated 6/12/24, indicated R3 complained of oral pain but there was no obvious abnormality. Surveyor reviewed Certified Nursing Assistant (CNA) documentation related to the completion of oral care and noted the following: ~On 10/1/24, oral hygiene was not documented on the AM shift. ~On 10/4/24, oral hygiene was not documented on the PM shift (agency staff worked the PM shift). ~On 10/10/24, oral hygiene was not documented on the AM and PM shifts (agency staff worked both shifts). ~On 10/18/24, oral hygiene was not documented on the AM shift (agency staff worked the AM shift). ~On 10/20/24, oral hygiene was not documented on the AM or PM shifts. ~On 11/30/24, oral hygiene was not documented on the AM and PM shifts (agency staff worked both shifts). ~On 12/1/24, oral hygiene not documented on the AM or PM shifts. ~On 12/3/24, oral hygiene was not documented on the PM shift. On 12/2/24 at 10:00 AM, Surveyor interviewed R3 who indicated food was stuck in R3's bottom teeth and staff had not yet offered to help R3 brush R3's teeth. Surveyor observed a dry toothbrush in a basin by R3's sink. On 12/3/24 at 11:01 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects staff to brush residents' teeth during AM and PM cares and offer to brush residents' teeth after meals. DON-B indicated R3 often refused oral hygiene. On 12/4/24 at 9:40 AM, Surveyor and Registered Nurse (RN)-F observed food debris in R3's lower teeth. R3 stated R3's teeth were not brushed. RN-F indicated the food debris was probably from breakfast and RN-F would have a CNA provide oral care. On 12/4/24 at 11:46 AM, Surveyor interviewed DON-B who reviewed R3's oral hygiene documentation for October, November, and December (2024) and verified oral hygiene on the above dates was not documented. DON-B indicated if oral hygiene was not documented it indicated oral hygiene was not completed. DON-B indicated agency staff may have worked the shifts when oral hygiene was not documented. DON- B indicated agency staff don't have access to document in residents' electronic medical records. On 12/4/24 at 2:02 PM, Surveyor interviewed DON-B who indicated the facility did not complete the documentation review for agency staff who may have completed R3's oral hygiene because it was discovered the facility's own staff also did not complete the task.

Based on observation, staff and resident interview, and record review, the facility did not maintain a home-like environment with a comfortable temperature for 1 resident (R) (R6) of 14 sampled residents. The heating/air conditioning unit in R6's room did not work which resulted in an inability to control the temperature in R6's room. Findings include: The facility's Safe and Homelike Environment policy, dated 6/2022, indicates: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belonging to the extent possible .comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents .7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit (F) . From 12/2/24 to 12/4/24, Surveyor reviewed R6's medical record. R6 was admitted to facility on 12/8/11 and had diagnoses including venous insufficiency, chronic obstructive pulmonary disease (COPD), lymphedema, gout, and morbid obesity. R6's Minimum Data Set (MDS) assessment, dated 10/20/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 was not cognitively impaired. R6 was responsible for R6's healthcare decisions. On 12/2/24 at 12:39 PM, Surveyor interviewed R6 in R6's room. R6 indicated the heating/air conditioning unit did not work and R6's room got very cold in the winter. Surveyor noted the room felt cold and did not see a temperature control panel in the room. On 12/3/24 at 2:57 PM, Surveyor interviewed Maintenance Director (MD)-J who verified the heating/air conditioning unit in R6's room did not work and the temperature in R6's room was dependent on hall heat that filtered into the room and wall water heat. MD-J indicated the facility's heating/air conditioning units controlled two rooms. The unit that serviced R6's room also serviced a lounge next to R6's room. The lounge contained a temperature control unit for the two rooms. MD-J indicated the facility replaced 6 heating/air conditioning units in residents' rooms in 2024 and were budgeted in 2025 to replace 6 additional heating/air conditioning units that did not work. On 12/3/24 at 3:14 PM, Surveyor interviewed R6 who indicated R6 only received heat when the sun shone in R6's room. R6 stated the wall water heat register only worked when it was bitter cold. R6 stated the heating/air conditioning unit had not worked since last winter. R6 stated when R6 gets cold, R6 wears sweaters and crawls under the covers to warm up. R6 indicated R6 did not want to change rooms and would rather tolerate the cold. On 12/4/24 at 8:13 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and [NAME] President of Success (VPS)-C. NHA-A and VPS-C verified the heating/air conditioning unit in R6's room was not functional and indicated staff offered to move R6 to another room but R6 declined.

Based on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable temperature for 1 resident (R) (R18) of 1 sampled resident. On 12/2/24, Dietary Manager (DM)-G reheated a bowl of soup in the microwave and served the soup to R18 without checking the temperature. Approximately 14 minutes after being served, R18 indicated the soup was still too hot to eat. Findings include. The facility's Food Temperatures policy and procedure, revised 8/16/22, indicates hot food items may not fall below 135 degrees Fahrenheit (F) after cooking unless it is an item which is to be rapidly cooled to below 42 degrees F and reheated to at least a minimum of 165 degrees F (for a minimum of 15 seconds) prior to serving. Caution should be taken when serving food and liquids to avoid the risk of burns. On 12/2/24 at 1:00 PM, Surveyor observed DM-G microwave a bowl of soup for 1 minute and 30 seconds. DM-G removed the bowl from the microwave and handed the bowl to a Certified Nursing Assistant (CNA) to serve to R18. DM-G did not stir or temp the soup before the CNA served the soup to R18. Surveyor noted R18 was hesitant to eat the soup. On 12/2/24 at 1:14 PM, Surveyor interviewed R18 who indicated the soup was still too hot to eat. On 12/3/24 at 2:30 PM, Surveyor interviewed DM-G who indicated DM-G did not record the temperature of R18's reheated soup on the facility's temperature log. Surveyor reviewed the temperature log and verified there were no temperatures documented on 12/2/24 for R18's reheated soup. DM-G indicated the temperature was obtained after DM-G reheated the soup in the microwave but was not recorded. Surveyor did not observe DM-G obtain the temperature of the soup. On 12/3/24 at 3:03 PM, Surveyor received a Microwave Temp Log from DM-G. The log was back-dated for 12/2/24 and indicated yes to 'did the food reach 165 degrees'. The temperature was documented at 186 degrees and initialed by DM-G. The log also indicated how to safely reheat food in a microwave and read: Reheat food, then let sit for 2 minutes, remove the lid and stir with a clean utensil, wipe clean the probe of the food thermometer using single use food-grade wipes then insert food probe into food, so stem is covered, food is ready for consumption at 165 degrees F. On 12/4/25 at 12:57 PM, Surveyor interviewed DM-G who indicated DM-G had DM-G's backed turned to Surveyor on 12/2/24 when DM-G took the temperature of R18's soup. Surveyor indicated Surveyor observed DM-G hand the bowl of soup directly to a CNA without obtaining the temperature or stirring the bowl.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R3) of 4 sampled residents. On 9/11/24, R3 alleged staff pushed R3 to the floor. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s) .6. Providing complete and thorough documentation of the investigation. On 10/14/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including alcoholic cirrhosis of liver and personal history of other mental and behavioral disorders. R3's Minimum Data Set (MDS) assessment, dated 8/23/24, stated R3's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R3 had intact cognition. R3 was responsible for R3's healthcare decisions. R3's medical record indicated R3 was transferred to an emergency room (ER) on 9/11/24. R3 returned to the facility on [DATE], but refused to exit the vehicle and left/was discharged from the facility against medical advice (AMA). A progress note, dated 9/11/24, indicated R3 entered other residents' rooms and was assisted out of the rooms by staff. The note indicated R3 became increasingly aggressive with staff while looking for R3's spouse. R3 lost R3's balance and fell to the floor. The note indicated R3 continued to scream, did not allow anyone to touch R3, and wanted to be sent to the hospital. R3 alleged that R3 was pushed down. On 10/14/24, Surveyor reviewed a fall investigation for R3's fall. The investigation did not mention R3's allegation of physical abuse (being pushed). The investigation contained interviews with three staff and indicated witness statements were attached. Surveyor was not provided with the witness statements. On 10/14/24 at 12:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who, following a discussion of the above note in R3's medical record, verified an allegation of being pushed was an allegation of abuse. On 10/14/24 at 12:54 PM, Surveyor interviewed NHA-A with Director of Nursing (DON)-B present. NHA-A indicated the facility was unable to locate witness statements associated with R3's allegation of abuse on 9/11/24. DON-B indicated witness statements were written on 9/11/24; however, the witness statements were destroyed the next morning (9/12/24) after DON-B entered the information in the facility's electronic fall investigation document. DON-B indicated DON-B could not recall if DON-B was notified of R3's allegation of abuse. DON-B verified the nurse on duty did not mention R3's allegation of abuse on 9/11/24 when the nurse called DON-B about sending R3 to the hospital. NHA-A indicated if NHA-A had been notified of R3's allegation of abuse in a timely manner, NHA-A would have immediately initiated abuse investigation procedures, including a thorough investigation.

Based on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 2 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure thorough and timely caregiver background checks were completed for Certified Nursing Assistant (CNA)-C and Maintenance Staff (MS)-D. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation. On 10/14/24, Surveyor reviewed background check information for 8 facility and contracted staff, including CNA-C and MP-D. CNA-C's hire date was listed as 4/4/17. The facility did not provide proof that a Background Information Disclosure (BID) form, Department of Justice (DOJ) criminal background check letter, or Integrated Background Information System (IBIS) letter was obtained for CNA-C within the previous four years. MP-D's hire date was listed as 7/5/23. The facility provided a BID form and DOJ and IBIS letters for MP-D that were dated 2/23/24. The facility did not provide proof that a BID form, DOJ letter, or IBIS letter was obtained for MP-D prior to or on the date of MP-D's hire. On 10/14/24 at 12:21 PM, Surveyor interviewed Business Office Manager (BOM)-E who indicated BOM-E usually completes a caregiver background check before a new staff is brought into the facility. BOM-E indicated caregiver background checks should be completed every four years. Following a discussion of the above findings for CNA-C and MP-D, BOM-E indicated BOM-E would recheck their files. BOM-E indicated MP-D's documents, dated 2/23/24, may have been obtained if MP-D started to drive the facility's van. On 10/14/24 at 12:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A with BOM-E present. NHA-A indicated the facility was unable to find additional documents for CNA-C and MP-D. BOM-E indicated BOM-E's tracking sheet indicated all staff were up to date for caregiver background checks. On 10/14/24 at 1:47 PM, Surveyor reviewed an electronic spreadsheet used for caregiver background check tracking with BOM-E. BOM-E indicated the spreadsheet did not indicate when the most recent updates were entered. The spreadsheet indicated the most recent caregiver background check for CNA-C was completed on 4/13/21. BOM-E verified the facility had no proof the caregiver background check occurred because there were no documents in CNA-C's file. BOM-E verified MP-D's name was on the spreadsheet but there were no caregiver background check dates listed for MP-D.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) and local law enforcement in a timely manner for 1 resident (R) (R3) of 4 sampled residents. On 9/11/24, R3 alleged staff pushed R3 to the floor. The facility did not report the allegation of abuse to the SA or local law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a review date of 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. On 10/14/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including alcoholic cirrhosis of liver and personal history of other mental and behavioral disorders. R3's Minimum Data Set (MDS) assessment, dated 8/23/24, stated R3's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R3 had intact cognition. R3's was responsible for R3's healthcare decisions. R3's medical record indicated R3 was transferred to an emergency room (ER) on 9/11/24. R3 returned to the facility on [DATE] but refused to exit the vehicle and left/was discharged from the facility against medical advice (AMA). A progress note, dated 9/11/24, indicated R3 entered other residents' rooms and was assisted out of the rooms by staff. The note indicated R3 became increasingly aggressive with staff while looking for R3's spouse. R3 lost R3's balance and fell to the floor. The note indicated R3 continued to scream, did not allow anyone to touch R3, and wanted to be sent to the hospital. R3 alleged R3 was pushed down. On 10/14/24, Surveyor reviewed a fall investigation for R3's fall. The investigation did not mention R3's allegation of physical abuse (being pushed). On 10/14/24 at 12:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who, following a discussion of the above note in R3's medical record, verified R3's allegation of being pushed was an allegation of abuse. NHA-A could not recall when NHA-A was notified of R3's fall. NHA-A verified the facility did not report R3's allegation of abuse to the SA. On 10/14/24 at 12:54 PM, Surveyor interviewed NHA-A with Director of Nursing (DON)-B present. DON-B indicated DON-B could not recall if DON-B was notified of R3's allegation of abuse. DON-B verified the nurse on duty did not mention R3's allegation of abuse on 9/11/24 when the nurse called DON-B about sending R3 to the hospital. NHA-A indicated if NHA-A had been notified of R3's allegation of abuse in a timely manner, NHA-A would have reported the allegation of abuse to the SA.

Based on staff interview and record review, the facility did not ensure the environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 3 residents reviewed for falls. R1 fell in the facility on 1/26/24. The root cause of the fall was not identified and R1's plan of care was not updated to prevent future falls. Findings include: The facility's Accidents and Supervision policy, with a review date of 7/14/22, indicates: Evaluation and analysis of a fall involves examining the data to identify specific hazards and risks and developing targeted interventions to reduce the potential for accidents. Interventions will be implemented based on results of the fall evaluation and analysis of information about hazards and risks based on relevant standards. The facility will also ensure interventions are implemented correctly and evaluate the effectiveness of new interventions. On 4/9/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, type 2 diabetes, and arthritis. R1's most recent Minimum Data Set (MDS) assessment, dated 1/15/24, contained a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R1 had severely impaired cognition. An admission assessment, dated 1/12/24, indicated R1 was at risk for falls and included the following interventions: bed in low position and non-slip footwear. A fall assessment, dated 1/26/24, indicated R1 was found on the floor. The assessment indicated R1's bed was in a low position and R1 did not sustain any injuries. The assessment indicated floor mats were added as a fall intervention. An Interdisciplinary Team (IDT) progress note, dated 1/27/24, indicated the IDT reviewed R1's fall and added an intervention to keep R1's bed in the lowest position. The IDT did not identify a root cause for the fall. Surveyor noted R1's fall care plan did not contain an intervention for fall mats and did not contain any interventions after 1/12/24. On 4/9/24 at 2:13 PM, Surveyor interviewed [NAME] President of Success (VPS)-C who verified there were no interventions implemented after R1's fall. VPS-C verified the IDT should have implemented a different intervention since the low bed was already in place prior to the fall.

Based on staff interview and record review, the facility did not ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form was completed in its entirety for 2 Residents (R) (R20 and R37) of 3 residents who remained in the facility when their Medicare Part A benefits ended. R20's SNFABN did not have a preference selected under the Options section of the form. R37's SNFABN did not have a preference selected under the Options section of the form. Findings include: On 9/26/23 at 1:14 PM, Surveyor reviewed the required notices for sampled residents whose Medicare Part A services ended and whose preference was to remain in the facility. Surveyor noted the Options section of the SNFABN form provided to R20 and R37 was blank. On 9/27/23 at 9:55 AM, Surveyor interviewed Social Services Designee (SSD)-D who stated the previous social worker was responsible for reviewing the SNFABN form with residents, but SSD-D is now responsible for completing the forms. SSD-D stated the Resident Care Management Specialist (Licensed Practical Nurse (LPN)-C)) fills in the name, date, services, and cost sections of the form. LPN-C then provides the form to SSD-D to review with residents who select an option and sign the form. SSD-D stated SSD-D did not receive formal training, but reads the form to residents and has them sign the form. SSD-D denied additional knowledge about the form, including the Options section. On 9/27/23 at 10:28 AM, Surveyor interviewed LPN-C who confirmed LPN-C fills in the form and gives the form to SSD-D to review with residents and have them sign. LPN-C stated LPN-C took over the task after the previous social worker said they were not educated on how to fill out the form. LPN-C confirmed LPN-C fills in the name, service, and cost section of the form, but denied LPN-C completes the Options section. On 9/27/23 at 10:35 AM, Surveyor reviewed the facility's policy on Advanced Beneficiary Notice of Non-Coverage which indicates: If the beneficiary cannot or will not make a choice, the notice should be annotated. Surveyor noted no additional information or explanation was noted on the form, or in the residents' medical records. On 9/27/23 at 10:44 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who acknowledged an option was not selected on R20 and R37's SNFABN forms. NHA-A stated NHA-A's expectation is that staff ensure the form is completed in its entirety before the resident signs the form.

Based on staff interview and record review, the facility did not ensure an SCSA (Significant Change in Status Assessment) was completed for 1 Resident (R) (R19) of 13 sampled residents. The facility did not complete and submit an SCSA when R19 had a significant change on or about 8/15/23. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15 indicates: A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. On 9/26/23, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] with diagnoses to include alcohol-induced dementia (cognitive loss caused by excessive/chronic ingestion of alcohol resulting in damage to the frontal lobes of the brain causing disinhibition, loss of planning and executive functions, and a disregard for the consequences of behavior). R19's Minimum Data Set (MDS) assessment, dated 8/15/23, contained a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R19 had moderately impaired cognition. R19's Power of Attorney for Healthcare (POAHC) document, dated 6/7/18 and activated 4/29/22, indicated R19's POAHC agent was responsible for R19's healthcare decisions. R19's MDS assessment, dated 5/30/23, indicated R19 required supervision of one staff for bed mobility and could complete transfers and use the toilet independently with set-up from staff. R19's MDS assessment, dated 8/15/23, indicated R19 required extensive assistance of one staff for bed mobility, transfers and toilet use. R19's Care Area Assessment (CAA) for the 8/15/23 MDS indicated: CAA area triggered due to ADL (activities of daily living) assistance during look-back period since re-admission from the hospital .extensive assistance has been needed with several ADLs, see POC (plan of care) .(R19) recently readmitted to the facility after hospitalization for fall with scalp laceration and pneumonia. (R19) has required extensive assistance with several of (R19's) ADLs as per documentation. (R19) is refusing therapy services. A referral for hospice has also been made, but (R19) didn't qualify at this time. Due to increased number of falls and confusion, 1:1 has been put into place for (R19's) safety. On 9/27/23 at 11:52 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R19's goal of care was palliative and stated, (R19's) not able to walk anymore. (R19's) very weak and able to pivot transfer only. On 9/28/23 at 8:52 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated LPN-C was the facility's MDS Coordinator. LPN-C verified LPN-C completed R19's 8/15/23 MDS. When asked what qualified as a significant change, LPN-C indicated one of the reasons to do an SCSA was a change in two or more care areas. LPN-C verified LPN-C did not complete an SCSA for R19 on 8/15/23, but should have. LPN-C indicated R19 was due for an Annual MDS and a corporate staff opened R19's Annual MDS. LPN-C indicated the facility's care team discussed the potential hospice component, but LPN-C didn't change the MDS from Annual status to SCSA status. LPN-C indicated a corporate Registered Nurse (RN) signed R19's 8/15/23 MDS as complete and correct. LPN-C verified R19's 8/15/23 MDS should have been an SCSA based on a change in the three care areas listed above.

Based on staff interviews and record review, the facility did not consult with the resident's physician when there was a need to alter treatment significantly or with a significant change in the resident's physical status for 1 Resident (R) (R1) of 3 sampled residents. R1 had been evaluated at the hospital ER (emergency room ) due to a change in condition on the evening of [DATE] and returned to the facility in the early morning hours of [DATE]. R1 was diagnosed with [REDACTED]. R1 received potassium supplements, IV (intravenous) fluids and antibiotics at the hospital and was sent back to the facility with orders to continue potassium supplement and oral antibiotics. R1 was thought to have a UTI (urinary tract infection). On [DATE], R1 was having difficulty swallowing, continued with lethargy and low oral intake of food and fluids and on the evening of [DATE], was rousable by sternal rub and was [MEDICAL CONDITION]. The facility did not consult with the physician until the late morning of [DATE] regarding R1's continued decline when R1 was ordered to be sent back to the ER. Findings include: 1. R1 was admitted to the facility on [DATE] after sustaining a fall at home due to increased weakness. It was noted that during hospitalization , R1's BUN (Blood Urea Nitrogen) was 19 (normal is ,[DATE]) and Creatinine was .68 (normal is XXX,[DATE].02). Both blood tests are indicators of hydration and kidney function status. R1 had [DIAGNOSES REDACTED]. R1 was own decision maker upon admission to the facility. R1 had also been prescribed a regular diet with regular textured foods with a high calorie supplement twice daily. On [DATE], R1 was noted to have progressive weakness over the past week with bilateral leg [DIAGNOSES REDACTED]. Therapy services were initiated, [MEDICATION NAME] for muscle spasms was ordered, and a scan of the lower back per neurology was performed. On [DATE], R1 presented with signs and symptoms of a [MEDICAL CONDITION] respiratory infection and was prescribed [MEDICATION NAME] to aid in liquefying respiratory secretions and cough. A nursing entry dated [DATE] at 10:51 a.m. indicated, Doctor updated via fax that resident will not wear [MEDICAL CONDITION] (Continuous Position Airway Pressure) device and physician prefers resident wears but has the right to refuse. A nutritional evaluation completed on [DATE] noted R1 was nutritionally stable with an intake of ,[DATE]%. Fluid intake parameters were noted to be calculated at ,[DATE] ml (millimeters) per day. On [DATE], consideration was being given for guardianship status for R1 due to overall decline and decline in cognition status. On [DATE], a nursing entry in R1's medical record recorded at 9:35 p.m. indicated, Resident in bed all shift, refusing to eat and drink. Resident found to be lethargic, disorient, unable to state own name and unable to follow directions. Resident found to have rapid irregular apical pulse at 112. Blood pressure and oxygen saturation within normal limits, afebrile but cool and clammy. Respiratory rate 22. Physician updated and resident sent to ER. Review of the ER records indicated R1's pulse rate at 11:00 p.m. on [DATE] was 96. Blood work indicated a WBC count of 30,500 (normal 3XXX,[DATE]), had a critically low potassium level of 2.3 (normal 3XXX,[DATE].11), a BUN of 29 and a normal Creatinine level. A urinalysis indicated probable UTI. R1 was given 1 liter of IV fluids (prior to midnight) and antibiotics and oral potassium. It was noted that a scan of the brain and a chest x-ray were within normal limits. R1 was transported back to the facility on [DATE] at approximately 1:30 a.m. with orders to continue oral antibiotics and potassium supplements. A nursing entry signed by RN (Registered Nurse)-C dated [DATE] at 11:02 a.m. indicated, The resident's tachy pulse of 101. Resident alert but looks straight through you. Color is paste pale white. Took medications crushed with a lot of cues. Sips of water only. Resident would not eat any breakfast with several attempts. Will continue to monitor. A nursing entry signed by LPN (Licensed Practical Nurse)-D dated [DATE] at 10:56 p.m. indicated, Resident continues to be lethargic and disoriented during shift but rousable with sternal rub. When supper offered, resident was unable to stay alert enough to eat. Resident took approximately 300 ml and able to take med's crushed in applesauce. Remains afebrile, and [MEDICAL CONDITION] at 116. Pulse irregular. Resident remained in bed all shift. Will continue to monitor. R1's physician was not updated or consulted when R1 continued to decline. There was no indication that an RN assessed R1 during the evening shift on [DATE]. Review of the facility's records of R1's fluid intake for [DATE] indicated R1 drank approximately 640 ml of fluids for the day. A nursing entry dated [DATE] at 1:27 p.m. and documented by RN-C indicated, Resident currently having a difficulty in swallowing and coughing on liquids and crushed medications in applesauce. Downgraded to honey thick liquids. Lung sounds- scattered rhonci, questioning possible aspiration. Afebrile. Skin is cool paste pale and tenting. Resident is alert but will not respond to you verbally, looks straight past you. Called the on call physician and was instructed to fax. A nursing entry dated [DATE] at 2:55 p.m. indicated, Fax order (from on call physician) is to send (R1) to ER to reevaluate. On [DATE] at 9:40 a.m., the Surveyor interviewed DON (Director of Nursing)-E. DON-E stated, (R1) started with a UTI in early May. After that, (R1) became weaker and more dependent on staff. Had a neurology consult and a scan of the back was ordered. Therapy was ordered as well. I noticed (R1) had difficulty swallowing. I think it was on [DATE] but may have been on [DATE]. I was trying to feed (R1) breakfast and (R1) wasn't swallowing. I had the nurse downgrade the diet. The physician wasn't notified. Speech Therapy was notified. I was surprised that the hospital sent (R1) back the early morning hours of [DATE] after just 4 hours especially with the critical potassium level and high white count. On [DATE] at 11:05 a.m., the Surveyor interviewed RN-C. RN-C stated, I noted during morning pills on [DATE], (R1) was having difficulty swallowing water and was coughing. I called the doctor on call at around 9:30 a.m. and no one answered. I called again and got a hold of the clinic and left a message. I couldn't get a fax through to the fax number we had. I got a fax that my faxes had not gone through but I finally got them to go through at around 12:45 p.m. The doctor on call called back at around 2:42 p.m. to instruct me to send (R1) to the ER. The doctors that work for that group want a fax from us, not a call. We are always instructed to send a fax. I worked the day shift on [DATE]. (R1) does run pulse rates of ,[DATE] at times. I reported to the evening nurse to monitor pulse. The Surveyor showed RN-C the [DATE] nursing entry documented by LPN-D at 10:56 p.m. RN-C stated, I would have notified the doctor at that point. We knew (R1) was sick according to the labs done at the ER (on [DATE]-[DATE]). Those people we watch specifically closer and check on them more frequently. On [DATE], NHA (Nursing Home Administrator)-B sent the Surveyor a fax dated [DATE] which indicated that NHA-B had gotten in contact with LPN-D regarding R1. The time of the interview was not documented. The fax stated, Spoke to the nurse that took care of (R1) on [DATE] and [DATE]. On [DATE], (LPN-D) documented that (R1) was found to be lethargic and disoriented, and had a rapid irregular apical pulse of 112. (LPN-D) notified the physician and (R1) was sent to the hospital. The next night, (LPN-D) observed the resident after receiving report that the ER had sent (R1) back during the night. (LPN-D) did not notify the MD because there was not a change in condition from the night before when (LPN-D) did send (R1) to the ER and they sent (R1) back. On [DATE], (LPN-D) document that (R1) continues to be lethargic and disoriented .afebrile [MEDICAL CONDITION] at 116. Pulse irregular. On [DATE] at approximately 10:00 a.m., the Surveyor interviewed MD (Medical Doctor)-A via telephone. MD-A was R1's primary care physician. MD-A stated, (R1) was sent back to the facility (in the early morning hours of [DATE]) with a WBC of over 30,000. When I did see the ER report, I was going to have (R1) sent back to the hospital, but by then, (R1) had already been sent out (on [DATE]). It should have been a red flag. Continued lethargy, [MEDICAL CONDITION] arousable with sternal rub that the nurses absolutely should have been contacting the physician. That should have been a required call. (R1) had been alert previous to all this and was own decision maker. The nurses probably got a little clouded due to the fact that (R1) was so sick when sent out to the ER (on [DATE]) but the ER sent (R1) right back. (R1) had been declining in general before all this. Increased falls and declining cognition. The hospital thought (R1) may have had meningitis, but couldn't get fluid from the spinal tap. R1 expired on [DATE].

Based on observation, record review, resident and staff interviews, the facility did not provide adequate pain relief for 2 (R (Resident) 2 and R4) of 11 sampled residents; during a wound care observation, the Surveyor observed facial grimacing and groaning, as well as R2 verbalizing pain during the procedure. R2 was not offered pain relief before, during, or after the wound care observation. In addition, R2 verbalized pain to the left buttocks during multiple interactions with Surveyor. Example 1 (R2) is being cited at a scope/severity of G (actual harm). Staff did not report R4's complaints of itching and pain or behaviors of pinching vaginal area, despite the CNA (Certified Nursing Assistant) Care Card instructions to do so. Findings include: The facility policy titled: Pain Management Guideline dated 2/10/15 states: GUIDELINE: Functions of appropriate pain management include, but are not limited to: ~ Ensuring involvement of patient/resident in pain management ~ Recognizing and reporting pain as a 5th vital sign ~ Assessing pain and evaluating response to pain management interventions using a pain management scale based on patient/resident self-report or objective assessment for the cognitively impaired ~ Intervening to treat pain before the pain becomes severe ~ Anticipating pain during activities that may be uncomfortable (i.e. dressing changes, transfers, bathing) and pre-treating with pain medication ~ Using non-drug interventions to assist in pain management ~Using knowledge of dosages to maintain both resident safety and pain relief as routes and types of ordered drug(s) change ~ Documenting pain assessment and interventions prior to giving medication. Evaluation activities should be recorded in a concise manner per the plan of care. Nursing staff should utilize the electronic pain evaluation and nursing note link when it is available ~ Recognize the patients who have chronic pain will benefit most from an effective, scheduled pain medication regimen Assessment: Pain assessment tools: Numeric Rating Scale: The patient/resident identifies pain on a 0-10 scale, 0=no pain and 10= worst pain imaginable (very severe or horrible) Documentation: The licensed nurse updates the plan of care to reflect changes to interventions for ongoing pain management. ~ The interdisciplinary team and patient/resident evaluate the effectiveness of each patient's/resident's pain management plan at the time of the initial comprehensive assessment, quarterly, following a significant change, after a fall, and annually. Findings and/or recommendations are documented in the medical record, as indicated, and the plan of care is updated as needed. Examples: 1. R2's medical record included a face sheet dated 2/22/17 with documented [DIAGNOSES REDACTED]. R2's admission MDS (Minimum Data Set) assessment dated [DATE] documented R2 to be dependent on staff for bed mobility, transfers, dressing, toileting, and hygiene. R2's BIMS (Brief Interview of Mental Status) score of 11 out of 15, indicated the resident's cognition was moderately impaired. R2 remains independent in health care decision making. R2's current physician orders [REDACTED]. Additionally, R2's PRN (as needed) medications included: ~ Tylenol 650 mg every 4 hours as needed for mild pain or fever ~ [MEDICATION NAME]/APAP ([MEDICATION NAME])- [MEDICATION NAME] 5-325 mg every 4 hours as needed for pain. R2 developed 3 Pressure Injuries to the resident's left buttock, originally identified as a single abrasion, on 3/12/17. Wound notes dated: 3/12/17, 3/19/17, 3/27/17 included documentation R2 had no pain to the wounds. Wound notes dated 4/3/17 documented the most medial (closest to the center of the body) of the 3 wounds caused pain rated at 4. A pain management plan was in place. R2 expressed pain at 0 for the lateral left buttock wound and no pain management plan was in place. Review of R2's careplans revealed the following: ~ Pressure Ulcer careplan did not identify any current wounds, goals or interventions related to pain management for the wounds. ~ Altered skin integrity non pressure related to: abrasion on buttock from bedpan per wound clinic is a pressure area did not include interventions to monitor/assess R2 for pain related to the wounds. ~ Pain Management careplan, did not specifically address R2's buttock wounds, but included the following interventions: Administer pain medication as ordered, cold compress to affected area, evaluate and establish level of pain on numeric scale/evaluation tool, evaluate characteristics and frequency/pattern of pain, evaluate need for bowel management regimen, evaluate need for routinely scheduled medications rather than PRN (as needed) pain med (medication) administration, evaluate need to provide medications prior to treatment or therapy, evaluate what makes the patient's pain worse, implement the patient's preferred non-pharmacological pain relief strategies, observe for potential medication side effects, utilize pain monitoring tool to evaluate effectiveness of interventions, and warm compress to affected area. R2's Outpatient Wound Care Progress Note dated 3/30/17, documented, . Patient is being seen for follow up wound care of abdominal wound. (R2) now has a painful wound on (R2's) buttock .Left buttock and scrotum with Stage II pressure ulcers, the medial buttock wound is Unstageable with adherent eschar . On 4/11/17 at approximately 9:15 a.m., during the initial facility tour, R2 reported to Surveyor having pain to the buttocks related to a sore that developed in the facility. On 4/12/17 at 11:15 a.m., R2 verbalized discomfort to the resident's back and buttocks areas to Surveyor. On 4/12/17 at 2:50 p.m., the Surveyor observed RN (Registered Nurse)-B perform wound care to R2's 3 Pressure Injuries to the left buttock. RN-C assisted to reposition R2 during the wound care. During this observation, R2 displayed noticeable facial grimaces and groaned loud enough to be heard. R2 stated loudly, Can I have a new butt since this one hurts so bad. Prior to wound care, RN-B and RN-C did not assess R2's pain level or ask the resident if pain medication was needed. In addition, RN-B and RN-C did not assess R2's pain level following the wound care. On 4/12/17 at 3:10 p.m., the Surveyor interviewed RN-B regarding R2 voicing pain during the wound care observation. RN-B verified R2 indicated the wounds to the resident's buttocks were painful and indicated was unsure when R2 last received pain medication. RN-B stated, I'd have to look up when R2 had received a pain medication. RN-B commented R2 always reports pain, so you have to kind of look more at nonverbals and others to know if (R2) is in pain. RN-B verified pain medication had not been offered to R2 prior to, during, and/or after wound care. R2's 4/2017 MAR (Medication Administration Record) did not include documentation that the resident had received PRN pain medication, Tylenol or [MEDICATION NAME] on 4/12/17. Additionally, R2's Shift pain assessment documented 0 on 4/12/17. R2's progress note documented by RN-B on 4/12/17 at 6:33 p.m., regarding wound care completed and observed by Surveyor documented, Dressing change completed to the three wounds of left buttocks . No s/s (signs or symptoms) of pain during dressing change. On 4/13/17 at 7:55 a.m., R2 informed the Surveyor having back and buttocks pain related to the resident's sores. On 4/13/17 at 11:00 a.m., the Surveyor interviewed DON (Director of Nursing)-A regarding R2's complaints of uncontrolled pain. DON-A verified R2's pain should be assessed prior to and during dressing changes, and pain control measures should be implemented prior to painful procedure such as a dressing change. DON-A stated she does not specifically ask R2 if the resident is in pain during the weekly wound assessments, but rather documents pain as '0' unless R2 verbalizes pain while DON-A provides wound care. 2. Surveyor reviewed R4's medical record from 4/11/17 to 4/13/17. R4's MDS assessment, dated 2/24/17, indicated R4 had multiple [DIAGNOSES REDACTED]. R4's BIMS score was 0, indicating cognitive impairment. The resident's CNA care card dated 4/10/17, included the instruction: vaginal area gets yeasty, alert nurse if res (resident) is noted pinching vaginal area or shoving wads of toilet paper in vaginal area . On 4/11/17 at 12:50 p.m., the Surveyor observed R4 reaching in front of pants, grabbing at vaginal area yelling it hurts .it itches. On 4/11/17 at 12:52 p.m., the Surveyor observed CNA-J respond to assist R4 to the toilet. R4 urinated into toilet then stood as CNA-J cleansed R4's posterior perineal area. R4 continued to state It itches so bad in here and I can't scratch it, while grabbing at vaginal area. CNA-J stated to R4 Can you take your hands away so I can wash you there? R4 moved hands and CNA-J cleansed the area. On 4/11/17 at 1:18 p.m., the Surveyor interviewed CNA-J who confirmed the above observation. On 4/13/17 at 9:05 a.m., the Surveyor observed R4 state loudly and repeatedly with emotion: It itches. I can't scratch it. I have to go potty. On 4/13/17 at 9:08 a.m., the Surveyor observed CNA-K assist R4, who continued to complain of itching to the vaginal area, with toileting cares. R4 urinated a small amount in the toilet and indicated being done. R4 stood and stated multiple times It hurts .It itches while holding hands near perineal area as CNA-K cleansed R4's perineum, stating: We can't scratch that .can't even pat it. R4 suddenly and loudly stated I gotta pee again. CNA-K assisted the resident to sit as R4 urinated a few drops. R4 stood and CNA-K cleansed the resident's perineal area. Immediately after the above, Surveyor interviewed CNA-K, who confirmed the above observation and verified R4 often puts hands in vaginal area. On 4/13/17 at 1:50 p.m., the Surveyor interviewed CNA-K, who confirmed R4's complaints of itching and hurting while hands near vaginal area, and urinating small amounts with urgency. CNA-K confirmed the CNA care card required alerting nurse if R4 pinches vaginal area and stated: (R4) didn't pinch herself, I told her not to. CNA-K verified not reporting the symptoms to a nurse, even though the care card instructed staff to do so, stating this was usual behavior for R4. On 4/13/17 at 1:54 p.m., the Surveyor interviewed RN-B, who confirmed staff did not report signs or symptoms of vaginal/urinary irritation that shift. RN-B confirmed no reports of these symptoms had been documented since 4/11/17, and verified the symptoms were not usual and could indicate infection. RN-B confirmed R4 had not been assessed for additional treatment needs. On 4/13/17 at 1:56 p.m., the Surveyor interviewed DON-A, who confirmed staff should be notifying nurses of changes in resident, or signs of vaginal/urinary irritation.

Based on observations, record review, resident and staff interviews, the facility did not ensure 4 ( R (Resident) 2, R1, R6 and R10) of 6 sampled residents reviewed for pressure injuries and skin risk received the necessary treatment and services to promote healing and prevent new ulcers from developing. R2 was admitted to the facility without documented PI's (Pressure Injuries) and developed 3 PI's to the resident's left buttocks while at the facility. R2 experienced significant untreated pain related to the wounds. R2's medical record did not include wound documentation in accordance with current standards of practice, wound care was not completed to maintain infection control standards, R2's fabric Hoyer sling remained in place between the resident's buttocks and ROHO (pressure relieving) cushion, pressure relieving interventions were not being implemented in accordance with R2's plan of care, and R2's PI plan of care did not address air mattress settings/monitoring. Example 1 (R2) is being cited at a scope/severity of G (actual harm). R1 developed an unavoidable DTI (Deep Tissue Injury) to the resident's right heel. The facility did not perform routine wound monitoring in accordance with current standards of practice. R6 was assessed at high risk for developing pressure injuries. The Surveyor had observations of R6 sitting on a Hoyer lift sling while sitting in a Broda chair. In addition, staff did not apply barrier cream after an incontinent episode, per the resident's plan of care. R10 was consistently observed, for 4 hours, seated in recliner without a pressure redistribution cushion and no repositioning was completed. Findings include: The facility's undated 'Skin Integrity Guideline' Policy references NPUAP (National Pressure Ulcer Advisory Panel) as the primary source. The Quick Reference Guide entitled Pressure Ulcer Prevention published by the NPUAP in 2009 indicated high pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to. Ensure that the heels are free of the surface of the bed. Heel protection devices should elevate the heel, completely off loading them. The second edition published in 2014, entitled Prevention and treatment of [REDACTED]. ~ indicated the reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called 'floating heels.' Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows. ~ Pressure Ulcers should be comprehensively assessed initially on identification and at least weekly thereafter. An NPUAP White Paper (March 2015) entitled Do Lift Slings Significantly Change the Efficacy of Therapeutic Support Surfaces? examined the risks and benefits of leaving a sling under a resident/patient .The fabric or composition of the device is important, as some may have less impact than others on the therapeutic functions of the support surface. The assessment of the patient should be reviewed against the physical features of the sling to be utilized. Healthcare clinicians for each individual patient must critically review the impact, both the risk and the benefit, of leaving a sling beneath a patient. The NPUAP White Paper concluded, The decision regarding placement/removal of Safe Patient Handling and Mobility (SPHM) equipment between uses must balance the putative risk (decreased efficacy of a therapeutic support surface) and potential benefit (easier repositioning increasing frequency and/or efficacy) on pressure ulcer prevention . The NPUAP redefined the definition of a pressure injuries during the NPUAP 2016 Staging Consensus Conference that was held April 8-9, 2016 in Rosemont (Chicago), IL. The updated staging system includes the following definitions: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. 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 extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. 1. During the initial facility tour on 4/11/17 at approximately 9:15 a.m., R2 informed the Surveyor was experiencing buttock pain related to sores that were caused from being left too long on the bedpan. On 4/11/17 at 9:30 a.m., the Surveyor interviewed DON (Director of Nursing)-A as part of the initial tour. DON-A indicated R2 had a facility-acquired Stage 2 PI to the resident's right buttock related to being on the bed pan. DON-A indicated the wound was originally documented as shearing, but changed to a PI after the wound clinic classified the area as such. R2's medical record included a face sheet dated 2/22/17 with documented [DIAGNOSES REDACTED]. R2's medical record revealed the resident was admitted to the facility without any documented open areas to the resident's buttocks. R2's admission MDS (Minimum Data Set) assessment dated [DATE] documented R2 to be dependent on staff for bed mobility, transfers, dressing, toileting, and hygiene and was at risk for the development of PIs. R2's BIMS (Brief Interview of Mental Status) score of 11 out of 15, indicated the resident's cognition was moderately impaired and R2 remains independent in health care decision making. R2's most recent Braden Assessment (a tool for predicting skin breakdown risk) was conducted on admission and dated 2/18/17. The assessment indicated R2 was not at risk for skin breakdown. R2's PI careplan for Abrasion to buttock per wound clinic is a PI initiated on 3/13/17 documents the following interventions: ~ Complete Braden Scale per Living Center policy; conduct weekly skin inspection; go back and check on resident if he has been on bedpan for a while and ask if he can come off; monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings; provide pressure reducing wheelchair cushion; provide pressure reduction/relieving mattress; provide thorough skin care after incontinent episodes and apply barrier cream; ROHO cushion, air mattress; Skin assessment to be completed per Living Center policy; Treatments as ordered; turning and reposition schedule per assessment. ~ An additional care plan with a focus of: Pressure Ulcer actual or at risk documents an intervention of 'float heels'. R2's CNA (Certified Nursing Assistant) Kardex (a tool used to guide care) did not include a skin section documenting how CNA's are to care for R2's current PIs. Additionally, R2's CNA Kardex did not include the use of the ROHO cushion, the air mattress, and how the air mattress should be maintained. Under 'Precautions', the CNA Kardex stated watch time on bedpan, even if (R2's) call light is not on go and check if can be taken off . Wound Monitoring: R2's Wound Evaluation Flow Sheet dated 3/12/17, documented a right buttock abrasion 3.0 cm (centimeters) x (by) 1.4 cm with a depth of 0.1 cm. The note documented the area as reddened skin without an open area, and noted an area to residents right buttocks, is an abrasion like area and appears to be from sitting on a bed pan. Resident did report to writer that (resident) sits on the bed pan for long periods of time sometimes if needed. At this time would recommend zinc oxide and monitoring of the area. The next Wound Evaluation Flow Sheet dated 3/19/17, documented the wound as 8.0 cm x 0.3 cm without measurable depth. Under staging the wound is documented as Unstageable and described as 80% [MEDICATION NAME] tissue and 20% slough. The following narrative was documented, wound was an abrasion last week upon assessment from the bed pan, this week upon assessment noted that the bottom of the abrasion has opened up and now has slough present to about 20% of the area The next Wound Evaluation Flow Sheet dated 3/27/17, documented the wound as 5.1 cm x 2.5 cm x 0.1 cm with 20% slough. The wound margins were documented as undefined and macerated with maceration to the surrounding tissue. The next Wound Evaluation Flow sheet dated 4/3/17, documented the wound as a Stage 2 PI measured as 1.0 cm x 0.4 cm x 0.2 cm with 50% slough and 50% granulation tissue with the following note: Wound has decreased in size since wound clinic visit and eschar is now 50% slough in the wound bed. An additional Wound Evaluation Flow sheet that was dated 4/3/17, documented a blister to R2's left buttocks identified on 3/19/17 with measurements of 2.3 cm x 1.3 cm x 0.1 cm and documents, This is the outer left buttock wound, and describes the area as a 'blister that opened'. The wound bed is described as 100% [MEDICATION NAME] tissue. No follow up measurements/assessments are documented on this Wound Evaluation Flow sheet. An additional Wound Evaluation Flow sheet was dated 4/3/17, documented a wound to R2's left buttock as MASD (Moisture Associated Skin Damage) identified on 4/3/17 with measurements of 1.8 cm x 1.2 cm x 0.1 cm and describes the wound as 100% [MEDICATION NAME] tissue, MASD/denuded skin to left inner buttock/scrotal area. No follow up measurements and/or assessments were documented on this Wound Evaluation Flow sheet. R2's Outpatient Wound Care Progress Note dated 3/30/17, documented . Patient is being seen for follow up wound care of abdominal wound. (R2) now has a painful wound on his buttock . Left buttock and scrotum with Stage 2 pressure ulcers, the medial buttock wound is Unstageable with adherent eschar .Left buttock - 4.5 cm x 6.4 cm with eschar .Posterior scrotum (near left buttock) - 2 cm x 1 cm .Start aggressive off-loading Proper off-loading is imperative for his wounds to have a chance of healing. On 4/13/17 at 11:00 a.m., Surveyor interviewed DON-A regarding R2's left buttock wounds. DON-A indicated the former wound care nurse originally documented the wounds on 3/12/17, indicating a reddened abrasion related to the bed pan. DON-A indicated that area was incorrectly documented for several weeks as the 'right buttock', when in actuality the wound(s) were to R2's left buttock. Additionally, DON-A indicated the wound to R2's left buttock began as a reddened linear area, but has since become three separate well defined open areas. DON-A indicated the facility began referring to the open areas as PI on 3/30/17, after the wound clinic evaluated R2's open areas to the left buttock and referred to them as PIs. DON-A verified the most recent wound assessment dated [DATE], only referred 1 of the open areas as pressure, while the other two areas were referred to as a blister and MASD. DON-A indicated she is not wound care certified, and relies on the wound care clinic to make care decisions for the wounds. DON-A indicated she updates the wound clinic with any changes to the presentation of the wound. DON-A indicated per wound clinic findings, the left buttock wounds are all PIs and verified the wound assessment had not been completed for each of the wounds since 4/3/17, despite NPUAP standards and facility policy indicating they should be assessed at least weekly. DON-A commented the facility did not investigate the root cause of the PIs to R2's left buttocks to include the explanation of a bedpan as the cause, the facility did not complete an investigation of the bedpan being the cause and did not educate staff in an attempt to prevent future wounds to R2 and/or other facility residents. Additional documentation provided by the facility on 4/17/17 included an Outpatient Wound Care Progress Note for a visit R2 had on 4/14/17. The note documents, Left buttock with three full thickness ulcerations with a mix of slough and granular tissue debrided to increase granulation . Wounds are painful to palpation. Wound measurements are not documented on the note. Wound Care/ Pain: On 4/12/17 at 11:15 a.m., R2 verbalized discomfort to the resident's back and buttocks areas to the Surveyor. On 4/12/17 at 2:50 p.m., Surveyor observed RN-B perform wound care to the 3 PIs on R2's left buttock with RN-C assisting with repositioning the resident. Surveyor observed 3 distinctly defined PIs in a linear pattern consistent with the probable placement of a bedpan to R2's left buttock. The lateral most wound was covered in slough which inhibited the Surveyor's ability to visualize the wound bed. The middle wound appeared beefy red with minimal depth, and the medial wound began to bleed with the removal of the dressing, therefore, depth was apparent, but the wound bed was unable to be visualized by Surveyor. RN-B did not assess R2's pain prior to beginning the wound care. With gloved hands, RN-B removed the dressings on each of the open areas. RN-B then removed the gloves and applied new gloves without performing hand hygiene. Although RN-B used separate saline soaked 4 X 4 gauze, RN-B washed each wound while wearing the same gloves. After cleansing the wounds, RN-B removed soiled gloves and again applied clean gloves without performing hand hygiene. RN-B then used dry 4 x 4 gauze to dry each wound. While wearing the same gloves, RN-B applied barrier cream with the right hand to the lateral wound. RN-B removed the right hand's glove and applied a clean glove without performing hand hygiene. RN-B applied barrier cream to the middle and medial wounds with the same gloved hands. RN-B removed the soiled gloves and applied clean gloves without performing hand hygiene. RN-B then assisted with the placement of R2's brief and repositioned R2 in bed. RN-B removed the soiled gloves and performed hand washing in the sink. During the provision of wound care, R2 displayed noticeable facial grimaces and groaned loud enough to be heard. Additionally, R2 stated loudly, Can I have a new butt since this one hurts so bad. Prior to wound care, RN-B and RN-C did not assess R2's pain level or ask the resident if pain medication was needed. In addition, RN-B and RN-C did not assess R2's pain level following the wound care. During this observation, RN-B and RN-C informed the Surveyor R2 did not have PIs to the right buttock, and documentation as such was incorrect as the wounds have always been on the resident's left buttock. RN-B added sometimes documentation of the wound is documented as 'right buttock' because all three wounds are on R2's left buttock and they are difficult to distinguish. RN-B and RN-C agreed all 3 wounds to R2's left buttock were related to pressure and R2 often refuses to offload. RN-B and RN-C verified R2's refusals to offload did not always get documented in the resident's medical record. On 4/12/17 at 3:10 p.m., the Surveyor interviewed RN-B regarding R2 voicing pain during the wound care observation. RN-B verified R2 indicated the wounds to the resident's buttocks were painful and indicated was unsure when R2 last received pain medication. RN-B stated I'd have to look up when R2 had received a pain medication. RN-B commented R2 always reports pain, so you have to kind of look more at nonverbal's and others to know if (R2) is in pain. RN-B verified pain medication had not been offered to R2 prior to, during, and/or after wound care. R2's 4/2017 MAR (Medication Administration Record) did not include documentation that the resident had received PRN pain medication, Tylenol or [MEDICATION NAME] on 4/12/17. Additionally, R2's Shift pain assessment documented 0 on 4/12/17. R2's progress note documented by RN-B on 4/12/17 at 6:33 p.m., regarding wound care completed and observed by Surveyor documented, Dressing change completed to the three wounds of left buttocks . No s/s (signs or symptoms) of pain during dressing change. On 4/13/17 at 7:55 a.m., R2 informed the Surveyor having back and buttocks pain related to the resident's sores. On 4/13/17 at 11:00 a.m., the Surveyor interviewed DON (Director of Nursing)-A regarding R2's complaints of uncontrolled pain. DON-A verified R2's pain should be assessed prior to and during dressing changes, and pain control measures should be implemented prior to painful procedure such as a dressing change. DON-A stated she does not specifically ask R2 if the resident is in pain during the weekly wound assessments, but rather documents pain as '0' unless R2 verbalizes pain while DON-A provides wound care. Fabric Hoyer (full body lift) sling: On 4/12/17 at 8:30 a.m., the Surveyor observed R2 seated in a wheelchair in the resident's room. R2 was seated on the fabric Hoyer sling positioned between R2's buttocks and the ROHO cushion in the wheelchair. On 4/13/17 at 7:55 a.m., the Surveyor observed R2 seated in a wheelchair in the north dining room. R2 was seated on the fabric Hoyer sling positioned between R2's buttocks and the ROHO cushion in the wheelchair. On 4/13/17 at 11:00 a.m., the Surveyor interviewed DON-A regarding R2 sitting on the fabric Hoyer sling while sitting up in a wheelchair. DON-A indicated R2's Hoyer sling is always left between the resident's buttocks and the ROHO cushion. DON-A verified any type of material located on top of a ROHO cushion can reduce the cushions pressure relieving properties. DON-A indicated based on past experience, she feels removing the Hoyer sling from beneath a resident's buttocks poses more risk for the resident and staff members than the benefits. DON-A indicated a risk/benefits assessment had not been completed for R2 related to maintaining the Hoyer sling on top of the ROHO cushion. Additionally, DON-A indicated not looking into the possibility of obtaining a different sling for R2 such as a mesh sling that may allow more breathability for R2's skin and reduce the extra material on top of the ROHO cushion. Positioning Per Careplan: On 4/12/17 at 8:50 a.m., the Surveyor interviewed CNA (Certified Nursing Assistant)-D, who indicated R2 is usually good about laying down to offload pressure when prompted, however R2 sometimes requires encouragement to do so. Following the provision of wound care on 4/12/17 at 2:50 p.m., R2 allowed RN-B and RN-C to reposition the resident on his right side to offload the buttocks area without additional prompting or reproaching. On 4/13/17 from 8:37 a.m. to 10:05 a.m., the Surveyor maintained continuous observation of R2 in bed. R2 was positioned on his back, with his left heel in full contact with the mattress for the duration of the observation. On 4/13/17 at 10:15 a.m., the Surveyor interviewed CNA-D, who verified R2's left heel had not been free floated that morning, and added R2's left heel is never free floated. Additionally, CNA-D reiterated R2 sometimes requires extra encouragement for repositioning and refusals are reported to the nurse. R2's progress note dated 3/29/17, documented R2 also refuses to lay down at times or stay in bed longer than 15 minutes which is important for his wound healing. Will make up/down schedule for him as he likes to be early for meals . R2's medical record did not include additional documentation of R2's refusal of position changes. On 4/13/17 at 11:00 a.m., the Surveyor interviewed DON-A regarding R2's positioning. DON-A verified R2 has current PIs and is at risk for the development of additional PIs, therefore his left heel should be free floated whenever the resident is laying down to reduce pressure. Additionally, DON-A verified R2 should be positioned off of the resident's buttocks when he is in bed, but added that R2 often refuses repositioning. DON-A verified R2's medical record did not include documentation of R2 refusing to be repositioned. Air Mattress: R2's air mattress was observed to be set to alternating pressure every 15 minutes and 'Fowlers' setting during observations of each day of survey (4/11/17, 4/12/17, and 4/13/17). Review of R2's plan of care/ Kardex did not include recommended settings for the air mattress and did not include who would monitor the air mattress to ensure the correct settings were maintained. On 4/13/17 at 11:00 a.m., Surveyor interviewed DON-A regarding R2's air mattress. DON-A indicated therapy or maintenance would be responsible for adjusting R2's air mattress and verified R2's plan of care did not address appropriate settings for the resident's air mattress. DON-A stated was unsure what settings R2's air mattress should be set at. 2. On 4/11/17, Surveyor reviewed R1's medical record, which revealed R1 developed an unavoidable DTI to the resident's right heel on 2/26/17. Weekly wound monitoring was conducted from 2/26/17 until 3/27/17 by the facility. R1's medical record did not include documented wound assessments after 3/27/17. On 4/12/17 at 11:38 a.m., the Surveyor interviewed DON-A, who verified wound rounds are supposed to be done weekly and the most recent assessment of R1's right heel DTI had been completed on 3/27/17. DON-A stated a follow-up wound assessment would be conducted that day. On 4/13/17 at 11:00 a.m., DON-A provided the Surveyor with the recent wound assessment that had been completed on 4/12/17. The wound assessment indicated a minimal increase in the width of the wound. Documentation indicated a follow up wound assessment would be conducted and the physician would be notified for possible changes to treatment. 3. R6 was admitted to facility on 1/11/16 with [DIAGNOSES REDACTED]. R6's most recent MDS assessment dated [DATE], documents R6 needs extensive assist with bed mobility, transfers, ambulation, dressing, eating and hygiene. R6 requires a Hoyer lift for transfers and utilizes a Broda chair with staff assist. R6 is on hospice due to a recent decline in cognition and physical functioning deficit issues. R6's skin care plan dated 1/13/16 indicates to provide thorough skin care after incontinent episodes and apply barrier cream. R6's Braden scale for predicting pressure injury risk indicates R6 is at high risk for developing pressure injuries. On 4/11/17 at 11:50 a.m., the Surveyor observed R6 sitting in a Broda chair in the dining area. The resident was sitting on the Hoyer sling at this time. On 4/12 at 8:30 a.m., 9:30 a.m., 10:30 a.m. and 11:08 a.m., the Surveyor observed R6 sitting in a Broda chair. During these observations, R6 was sitting on the Hoyer sling. On 4/12/17 at 12:50 p.m., the Surveyor observed CNA-N and CNA-O provide incontinence cares for R6. When CNA-N and CNA-O completed the cares with R6 and were prepared to leave room, the Surveyor asked if the CNA's had completed cares with R6 and both CNA's indicated yes. The Surveyor then asked asked CNA-N if barrier cream had been applied to R6 and CNA-N indicated no and commented it should have been applied. On 4/13/17 at 11:15 a.m the Surveyor interviewed DON-A regarding R6. DON-A indicated R6's care plan did not address the use of R6's Hoyer sling in the Broda chair. DON-A indicated the use of the Hoyer sling was not assessed or made the reesident aware of the risks of sitting on a sling in the Broda chair. DON-A indicated it would be her expectation that the CNA's would be applying the barrier cream to R6's buttocks area after incontinence cares. 4. On 4/12/17, the Surveyor reviewed the medical record of R10. The resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. R10's most recent MDS assessment, dated 2/4/17, documented R10 was at risk for pressure injury development, was frequently incontinent of bladder, required extensive assist for transfers, bed mobility and ADL's (Activities of Daily). R10's Risk for pressure injury plan of care, with the revision date of 3/22/17, included interventions for pressure reducing wheelchair cushion, pressure reduction/relieving mattress, assist with repositioning with toileting schedule and PRN (as needed). On 4/13/17 from 8:30 a.m. to 12:30 p.m., the Surveyor consistently observed R10 seated in a recliner without a pressure redistribution device. Staff members did not reposition R10 during the four hour observation period. On 4/13/17 at 12:10 p.m., the Surveyor interviewed DON-A regarding R10. DON-A verified R10 should be repositioned every 2 to 3 hours. DON-A indicated due to R10's risk for development of pressure injury, limited bed mobility, frequent incontinent episodes and the amount of time the resident remained in the recliner, a pressure redistribution cushion should have been placed in the recliner. DON-A indicated R10's pressure injury plan of care would be updated to include pressure redistribution cushion to be used in recliner. DON-A verified the standard of practice used by facility is NPUAP (National Pressure Ulcer Advisory Panel).

Based on record review and staff interviews, the facility did ensure 1 (resident #1) of 6 sampled residents reviewed received adequate supervision and assistive devices to prevent accidents. The facility did not implement necessary interventions (the pull tab alarm) to prevent resident #1 from falling on 7/25/15. The plan of care was not updated to reflect resident #1's noncompliance on 7/26/15, resulting in a second fall. The care plan was not updated to reflect resident #1's noncompliance with alarms, which puts the resident at risk for having another fall related to noncompliance with alarms. Resident #1 was diagnosed with [REDACTED]. Findings Include: According to a nurse's note documented by RN (Registered Nurse)-A, dated 7/24/15, resident #1 was admitted to the facility on this date from the hospital. Resident #1 had been hospitalized due to a fall with a resultant subdural hematoma, renal failure requiring dialysis, and [DIAGNOSES REDACTED] with an underlying history of alcoholism. The resident was noted to be alert with some confusion. A pull tab alarm was placed on the resident while in bed and in the wheelchair, related to resident #1's impulsiveness and poor safety awareness. Resident #1's CNA (Certified Nursing Assistant) care card was updated at this time to include: bed to the floor, fall mat, and pull tab alarm. A nurse's note dated 7/24/15 at 10:46 p.m., documented resident #1 had a pull tabs alarm in bed and in wheelchair related to impulsiveness and poor safety awareness. A nurse's note dated 7/25/15 at 11:46 a.m., documented resident #1 was found on mat on floor .call light on. The 7/25/15 fall investigation form completed by LPN (Licensed Practical Nurse)-B indicated no fall equipment was in place at the time of the fall, including the use of alarms. A nurse's note dated 7/26/15 at 10:00 p.m., documented resident #1 was found sitting on floor leaning on right elbow on right side up against bed. A second fall investigation, dated 7/26/15, indicated resident #1 fell at 10:00 p.m., from the wheelchair, that the resident had transferred self from chair to bed. The form indicated the bed and chair alarm was present, not attached to the resident and the alarm was not sounding. In addition, the question relating to if the alarm turned on was not answered. A hand written entry on this fall investigation stated resident #1 removes alarms. A nurse's note dated 7/26/15 at 11:25 p.m., documented resident #1 complained of occasional pain to the right lower extremity. Resident #1's plan of care was not updated to reflect the resident's noncompliance with alarm use and/or any changes related to the resident's fall on 7/26/15. The resident's plan of care was not updated until 7/31/15, at which time a pressure pad alarm was added (however the plan of care did not indicate if the pressure pad alarm was to be used in the bed, the wheelchair or both). A late entry nurse's note dated 7/30/15 at 10:40 a.m., documented a call was received from 1 day surgery (resident had surgical procedure relating to dialysis) that resident #1 complained of broken leg from fall Was seen by physician same day and ordered x-ray right leg. X-ray showed fracture right lower leg. The radiology report dated 7/31/15, documented resident #1 had a right distal fibula fracture, minimal displacement. A review of additional nurse's notes from 7/24/15 through 7/29/15 documented resident #1 denied pain. Resident #1's CNA care card had not been updated and included the following interventions: bed to floor, fall mat, and pull tab alarm. The care card was dated 8/13/15, not original date of care card, but date of last review of care card. On 8/14/15 at 10:00 a.m., surveyor # interviewed CNA-C regarding resident #1 and fall intervention devices. CNA-C indicated she is working resident #1's unit today and stated she did not think the resident turned off alarms or was noncompliant with them. On 8/14/15 at 10:35 a.m., surveyor # interviewed CNA-D regarding resident #1. CNA-D stated resident #1 always turns the personal alarms off. On 8/14/15 at 10:37 a.m., surveyor # interviewed RN-E regarding resident #1. RN-E confirmed she develops electronic care plans for residents, along with other nursing staff. RN-E stated she was not aware of resident #1 removing alarms or noncompliance with fall interventions and confirmed that the plan of care was not updated to reflect resident #1's noncompliance with alarms. RN-E indicated the use of the pull tab alarm had been present on resident #1's care card since 7/24/15, and therefore was not a new intervention after the resident's fall on 7/25/15. On 8/14/15 at 11:05 a.m., surveyor # interviewed LPN-B regarding resident #1's fall on 7/25/15. LPN-B stated resident #1 did not have any personal alarms as part of the plan of care at that point, but a pull tab alarm was added after the fall on 7/25/15. LPN-B confirmed that resident #1's pull tab alarm was never added to the electronic falls plan of care when admitted . On 8/14/15 at 11:10 a.m., surveyor # interviewed RN-A who admitted resident #1 on 7/24/14. RN-A stated resident #1 was a fall risk on admission and she added a low bed, fall mat, and the use of a pull tab alarm at all times on 7/24/15. RN-A stated she added those interventions to the CNA care card on 7/24/15. RN-A also stated resident #1 would remove the alarms often and received more frequent checks due to the removal of personal alarms. On 8/14/15 at 11:15 a.m., surveyor # interviewed CNA-F who found resident #1 on the floor on 7/25/15. CNA-F confirmed she did not hear an alarm sounding when resident #1 was found on the floor and she was not aware if the resident was supposed to have a personal pull tab alarm at that time. On 8/14/15 at 11:30 a.m., surveyor # interviewed NHA (Nursing Home Administrator)-G regarding resident #1. NHA-G stated no education was provided to staff related to falls, as a result of resident #1's fracture of unknown origin and the investigation conducted by the facility which began on 7/31/14 was related to the injury of unknown origin rather than an in-depth fall investigation. NHA-G stated resident #1's care card was reviewed 8/13/15 and that date was not the development date of the care card. NHA-G stated there was no original development date noted on resident #1's CNA care card, as it was hand written. As part of the facility's investigation dated 7/31/15, staff were interviewed. The following questions were part of the fall investigation: ~ Has (Resident #1's) bed been in low position when you have seen (the resident) in bed? ~ Have the floor mats been in place when (resident #1) is in bed. Three of the staff interviewed stated no to those questions, indicating there were times that either the plan of care had not been followed or the resident was noncompliant and either elevated the bed or moved the floor mat. Resident #1's plan of care had not been updated after the fall and education was not provided to staff related to fall interventions, as a result of the facility's self report investigation.

Based on interview and record review, the facility did not ensure that 1 of 2 Residents reviewed (Resident #1) with pressure ulcers received the necessary treatment and services to promote healing of the pressure ulcer. * Resident #1 was admitted to the facility with a stage 1 pressure ulcer of the coccyx on 2/24/14. On 3/21/14 a measurement of the pressure ulcer was taken and it was noted to be a purple/blue deep tissue injury with a superficial opening. The physician was not notified with the deterioration of the pressure ulcer on 3/21/14. On 3/24/14, the Registered Nurse documented, Skin to coccyx/buttocks is seriously breaking down. RN-C did not call Resident's physician regarding her pressure ulcer deterioration on 3/24/14. On 3/24/14, Resident #1 was sent to the [MEDICAL TREATMENT] center, who in turn sent Resident #1 to the emergency room due to low blood pressure. The 3/24/14 emergency report stated, resident was sent from the [MEDICAL TREATMENT] center due to low blood pressure after about 3 hours of [MEDICAL TREATMENT]. 15cm by 20 cm black sacral decubiti ulcer. Possible [MEDICAL CONDITION]. The hospital history and physical dated 3/27/14 stated Resident was found to have a large gangrenous stage 4 sacral decubitus ulcer. There is also concern about the [MEDICAL TREATMENT] catheter is a possible source [MEDICAL CONDITION]. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was assessed as having fully intact long and short term memory and was able to make her own health care decisions. Resident #1 was also assessed to be incontinent of bowel and bladder. Resident #1's admission assessment dated [DATE] at 10:30 p.m. was completed by Registered Nurse (RN)-C. Under the section labeled skin conditions the buttock area is circled and labeled red. On 4/3/14 Surveyor # reviewed Resident #1's Pressure Ulcer evaluation flow sheet. The measurements were as follows for Resident #1's buttock area (area of pressure ulcer verified by Director of Nurses (DON) 4/3/14 as is not identified on sheet): 2/25/14: 12 centimeters (cm) long by 21 cm wide, no depth, unbalanchable area. Educated to be off back. Treatment [MEDICATION NAME]. 3/3/14: 7 cm long by 12 cm wide, no depth, red/pink abraised area. Educated on changing positions. Treatment [MEDICATION NAME]. 3/5/14: 6.4 cm long by 8.2 cm wide, no depth, scant serous drainage. Educated on changing positions states: I am comfortable on back. Treatment [MEDICATION NAME]. On 4/8/14 Surveyor # reviewed Resident #1's care plan for skin integrity dated 3/7/14 which read: resident will position off back in bed education and encouragement given. [MEDICAL TREATMENT] to use wheelchair cushion in chair related to buttock breakdown. The measurements on Resident #1's Pressure Ulcer evaluation flow sheet continue: 3/12/14: Right 5 cm long by 7 cm wide, no depth, left 4 cm long, no width or depth. Scant serous drainage. Red/ pink blanchable abraised. Encouraged and educated on position changes refuses. Treatment [MEDICATION NAME]. 3/18/14: Left 1.6 cm long by 1 cm wide, no depth. Right 4.4cm long by 0.4 cm wide, no depth. Scant serous drainage. Abraised. Educated on position changes. Fax out for wound clinic. Treatment [MEDICATION NAME]. 3/21/14: Left 1.6 cm long by 1.2 cm wide, 0.2 cm deep. Right 5.2 cm long by 1 cm wide, no depth. Scant serous drainage. Surrounding skin purple, red and blue. Deep tissue injury 11cm by 7 cm. Wound clinic referral. Treatment [MEDICATION NAME]. (This is a change in the pressure ulcer as there is now depth and a deep tissue injury is identified.) Surveyor # noted that this is the last documentation in Resident #1's record regarding her wound until 3/24/14; despite noted changes in the wound. On 4/3/14 Surveyor # reviewed Resident #1's nursing notes dated 3/24/14 at 12:00 a.m. written by RN-C (RN-C worked the P.M. shift 3/23/14). Which read: Skin to coccyx/buttocks is seriously breaking down. On 4/3/14 at 2:20 p.m. Surveyor # interviewed RN-C who stated he saw Resident #1's pressure ulcer on admission and the evening before she went to the hospital on [DATE]. RN-C stated on admission Resident #1's buttocks were just red but on 3/23/14 Resident #1's buttocks appeared bruised with pinpoint open areas that had serous drainage coming from them. No necrotic skin was present. RN-C stated he did not call Resident #1's physician regarding her pressure ulcer deterioration on 3/23/14. On 4/3/14 at 1:20 p.m. Surveyor # interviewed the DON-B who is also the wound nurse for the facility and is wound certified. DON-B stated she did not call Resident #1's physician with the deterioration of the pressure ulcer. DON-B stated that Resident #1 never went to the wound clinic as it takes a while to get in. Per interview with RN-F on 4/9/14 at 9:15 a.m., RN-F stated she tried to get the wound clinic appointment as soon as possible for Resident #1. RN-F stated that the wound clinic only accepts new patients on Fridays and did not have any openings on 3/21/14 (the order for Resident #1 to see the wound clinic was written on 3/18/14). RN-F stated that the wound clinic did not have an appointment for 2 weeks but were looking to see if they could get her in sooner. On 4/8/14 at 8:37 a.m. Surveyor # interviewed RN-D who saw Resident #1's pressure ulcer the weekend before she was sent to [MEDICAL TREATMENT] and to the hospital on [DATE]. RN-D stated Resident #1 had dark bruising to her buttocks with pinpoint open areas with weeping. No necrotic skin was present. RN-D stated Resident #1 refused to be repositioned or lie down after she was in her chair for the day. RN-D stated she educated Resident #1 that if she did not reposition that breakdown may occur. On 4/8/14 at 1:45 p.m. Surveyor # interviewed Certified Nursing Assistant (CNA)-H who saw Resident #1's buttocks a couple hours before her transport to [MEDICAL TREATMENT] on 3/24/14. CNA-H stated that Resident #1's buttocks were black/purple and not open. Looked like bruised skin. On 4/9/14 Surveyor # interviewed DON-B who stated Resident #1 was on a roho cushion (a high quality pressure reduction cushion) and a communication form was sent to [MEDICAL TREATMENT] about resident #1's pressure ulcer and that the cushion was needed in the [MEDICAL TREATMENT] chair. (No written evidence was found as the facility does not keep a copy of the communication form it sends to [MEDICAL TREATMENT].) DON-B stated that Resident #1 went to [MEDICAL TREATMENT] about 2 p.m. on Monday, Wednesday and Friday. On 4/9/14 at 12:15 p.m. Surveyor # interviewed [MEDICAL TREATMENT] employee-I who stated that Resident #1's nurse did not remember being informed of Resident #1's pressure ulcer but if she had a cushion in her wheelchair it would have been transferred to the [MEDICAL TREATMENT] chair. On 4/8/14 Surveyor # reviewed Resident #1's emergency room report dated 3/24/14 which read: Resident #1 was sent from the [MEDICAL TREATMENT] center due to low blood pressure after about 3 hours of [MEDICAL TREATMENT]. 15cm by 20 cm black sacral decubiti ulcer. Possible [MEDICAL CONDITION]. On 4/8/14 Surveyor # reviewed Resident #1's history and physical from the hospital dated 3/27/14 which read: Resident #1 was found to have a large gangrenous stage 4 sacral decubitus ulcer. There is also concern about the [MEDICAL TREATMENT] catheter is a possible source [MEDICAL CONDITION]. She did undergo surgical debridement; however her condition continued to deteriorate. Family elected to place her on comfort measures. Resident #1 was pronounced dead at 11:10p.m. on 3/26/14. Cause of death was attributed to septic shock. On 4/8/14 Surveyor # reviewed Resident #1's progress note from the hospital dated 3/25/14 which read: Infected sacral decubitus ulcer with possible gas gangrene (gas gangrene is defined as a type of rapidly progressing gangrene usually brought on as a result of injury.) On 4/9/14 Surveyor # reviewed Resident #1's death certificate dated 3/26/14 at 11:10 p.m. which read: Immediate cause of death septic shock due to infected sacral decubitus ulcer. The above findings were shared with the Administrator and Director of Nurses at the exit meeting on 4/9/14 at 2:00 p.m. Additional information was requested if available. None was provided.

Based on record review and staff interview the facility did not consult with a physician when 1 of 5 sampled residents (Resident #1) experienced a change in condition. * Resident #1 was admitted to the facility with a stage 1 pressure ulcer of the coccyx on 2/24/14. On 3/21/14 a measurement of the pressure ulcer was taken and it was noted to be a purple/blue deep tissue injury with a superficial opening. The physician was not notified with the deterioration of the pressure ulcer on 3/21/14. On 3/24/14, the Registered Nurse documented Skin to coccyx/buttocks is seriously breaking down. RN-C did not call Resident's physician regarding her pressure ulcer deterioration on 3/23/14. The pressure ulcer continued to deteriorate and Resident #1 was subsequently hospitalized with an infected stage 4 pressure ulcer. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was assessed as having fully intact long and short term memory and was able to make her own health care decisions. Resident #1 was also assessed to be incontinent of bowel and bladder. Resident #1's admission assessment dated [DATE] at 10:30 p.m. was completed by Registered Nurse (RN)-C. Under the section labeled skin conditions the buttock area is circled and labeled red. On 4/3/14 Surveyor # reviewed Resident #1's Pressure Ulcer evaluation flow sheet. The measurements were as follows for Resident #1's buttock area (area of pressure ulcer verified by Director of Nurses (DON) 4/3/14 as is not identified on sheet): 2/25/14: 12 centimeters (cm) long by 21 cm wide, no depth, unbalanchable area. Educated to be off back. Treatment [MEDICATION NAME]. 3/3/14: 7 cm long by 12 cm wide, no depth, red/pink abraised area. Educated on changing positions. Treatment [MEDICATION NAME]. 3/5/14: 6.4 cm long by 8.2 cm wide, no depth, scant serous drainage. Educated on changing positions states: I am comfortable on back. Treatment [MEDICATION NAME]. On 4/8/14 Surveyor # reviewed Resident #1's care plan for skin integrity dated 3/7/14 which read: resident will position off back in bed education and encouragement given. [MEDICAL TREATMENT] to use wheelchair cushion in chair related to buttock breakdown. Measurements on Resident #1's Pressure Ulcer evaluation flow sheet continue: 3/12/14: Right 5 cm long by 7 cm wide, no depth, left 4 cm long, no width or depth. Scant serous drainage. Red/ pink blanchable abraised. Encouraged and educated on position changes refuses. Treatment [MEDICATION NAME]. 3/18/14: Left 1.6 cm long by 1 cm wide, no depth. Right 4.4cm long by 0.4 cm wide, no depth. Scant serous drainage. Abraised. Educated on position changes. Fax out for wound clinic. Treatment [MEDICATION NAME]. 3/21/14: Left 1.6 cm long by 1.2 cm wide, 0.2 cm deep. Right 5.2 cm long by 1 cm wide, no depth. Scant serous drainage. Surrounding skin purple, red and blue. Deep tissue injury 11cm by 7 cm. Wound clinic referral. Treatment [MEDICATION NAME]. (This is a change in the pressure ulcer as there is now depth and a deep tissue injury is identified.) Surveyor # noted that despite observed changes by facility staff in Resident #1's wounds this was the last documentation of any information related to Resident #1's pressure ulcer until 3/24/14. There is no indication that the physician was notified from 3/21/14-3/23/14 regarding Resident #1's pressure ulcer. On 4/3/14 Surveyor # reviewed Resident #1's nursing notes dated 3/24/14 at 12:00 a.m. written by RN-C (RN-C worked the P.M. shift 3/23/14). Which read: Skin to coccyx/buttocks is seriously breaking down. On 4/3/14 at 2:20 p.m. Surveyor # interviewed RN-C who stated he saw Resident #1's pressure ulcer on admission and the evening before she went to the hospital on [DATE]. RN-C stated on admission Resident #1's buttocks were just red but on 3/23/14 Resident #1's buttocks appeared bruised with pinpoint open areas that had serous drainage coming from them. No necrotic skin was present. RN-C stated he did not call Resident #1's physician regarding her pressure ulcer deterioration on 3/23/14. On 4/3/14 at 1:20 p.m. Surveyor # interviewed the DON-B who is also the wound nurse for the facility and is wound certified. DON-B stated she did not call Resident #1's physician with the deterioration of the pressure ulcer. DON-B stated that Resident #1 never went to the wound clinic as it takes a while to get in. Per interview with RN-F on 4/9/14 at 9:15 a.m., RN-F tried to get the wound clinic appointment as soon as possible for Resident #1. RN-F stated that the wound clinic only accepts new patients on Fridays and did not have any openings on 3/21/14 (the order for Resident #1 to see the wound clinic was written on 3/18/14). RN-F stated that the wound clinic did not have an appointment for 2 weeks but were looking to see if they could get her in sooner. On 4/8/14 at 8:37 a.m. Surveyor # interviewed RN-D who saw Resident #1's pressure ulcer the weekend before she was sent to [MEDICAL TREATMENT] and then to hospital on [DATE]. RN-D stated Resident #1 had dark bruising to her buttocks with pinpoint open areas with weeping. No necrotic skin was present. RN-D stated Resident #1 refused to be repositioned or lie down after she was in her chair for the day. RN-D stated she educated Resident #1 that if she did not reposition that breakdown may occur. On 4/8/14 at 1:45 p.m. Surveyor # interviewed Certified Nursing Assistant (CNA)-H who saw Resident #1's buttocks a couple hours before her transport to [MEDICAL TREATMENT] on 3/24/14. CNA-H stated that Resident #1's buttocks were black/purple and not open. Looked like bruised skin. On 4/8/14 at 2:00 p.m. Surveyor # interviewed Medical Director-E who stated that the facility should have called Resident #1's physician with the deterioration of the pressure ulcer on 3/21/14. Medical Director-E stated she would not have ordered cultures with the description of the pressure ulcer from the measurements and would have kept the same treatment of [REDACTED]. On 4/9/14 at 9:38 a.m. Surveyor # interviewed Physician-G who was Resident #1's primary physician. Physician-G stated the facility should have called him with the deterioration of the pressure ulcer on 3/21/14 but with the pressure ulcer assessment documentation information he would have ordered them to keep the [MEDICATION NAME] in place to protect the area and see him on Monday (3/24/14) either at [MEDICAL TREATMENT] or his office. On 4/8/14 Surveyor # reviewed Resident #1's emergency room report dated 3/24/14 which read: Resident #1 was sent from the [MEDICAL TREATMENT] center due to low blood pressure after about 3 hours of [MEDICAL TREATMENT]. 15cm by 20 cm black sacral decubiti ulcer. Possible [MEDICAL CONDITION]. On 4/8/14 Surveyor # reviewed Resident #1's history and physical from the hospital dated 3/27/14 which read: Resident #1 was found to have a large gangrenous stage 4 sacral decubitus ulcer. There is also concern about the [MEDICAL TREATMENT] catheter is a possible source [MEDICAL CONDITION]. She did undergo surgical debridement; however her condition continued to deteriorate. Family elected to place her on comfort measures. Resident #1 was pronounced dead at 11:10p.m. on 3/26/14. Cause of death was attributed to septic shock. On 4/8/14 Surveyor # reviewed Resident #1's progress note from the hospital dated 3/25/14 which read: Infected sacral decubitus ulcer with possible gas gangrene (gas gangrene is defined as a type of rapidly progressing gangrene usually brought on as a result of injury.) On 4/9/14 Surveyor # reviewed Resident #1's death certificate dated 3/26/14 at 11:10 p.m. which read: Immediate cause of death septic shock due to infected sacral decubitus ulcer. The above findings were shared with the Administrator and Director of Nurses at the exit meeting on 4/9/14 at 2:00 p.m. Additional information was requested if available. None was provided.

Based on observations, interviews, and record reviews, the facility did not ensure all staff provided care and services to prevent pressure ulcer development in 1 of 4 residents reviewed with pressure ulcers. Resident #2 is at high risk for the development of pressure ulcers. On four occasions during the survey, Resident #2 was not positioned so his heels were floating in bed in the appropriate manner to prevent the development of additional skin breakdown. During one observation the right heel was noted to be mushy and soft, indicating internal damage to the heel tissue. This is evidenced by: The facility policy and procedure for skin integrity was received on 12/6/13. This policy had a revision date of 2013. According to this policy, staff are to "... Initiate positioining schedule to meet individual resident needs and minimize concentrated pressure to skin..." Resident #2 has medical [DIAGNOSES REDACTED]. Resident #2 had his left foot amputated on 9/18/13 related to a gangrenous, non-healing wound. The most recent Minimum Data Set assessment dated [DATE], indicated Resident #2 requires extensive assistance of staff for bed mobility. On 11/24/13, a positive culture for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus was identified in the incision of the left stump. On 12/3/13, Resident #2 presented with a newly opened area on his left sacrum and right dorsal (top) foot. On 12/3/13 at 9:22 a.m., Surveyor # interviewed Resident #2's spouse, FM-F (family member). FM-F stated Resident #2 is "highly susceptible to breakdown because of his bad heart and Diabetes. He needs to be watched carefully for breakdown and needs to be off his bottom." FM-F stated Resident #2 recently developed a new sore on his buttocks that the staff need to watch. She further stated it's really hard because Resident #2 is up in the chair from 6:30 in the morning until after supper. Two continuous observations were conducted with Resident #2. With each observation, he was up in the wheelchair from 6:30 a.m. until after lunch. During this time frame, he did work with therapy in which standing and repositioning occurred. The facility completed a Daily Care Card for Resident #2 which was last updated on 12/4/13. The Care Card indicates staff are to position Resident #2 off of his sacrum and elevate his heel. The following dates and times indicate this was not consistently provided for Resident #2: ~ 12/4/13 at 1:13 p.m.: Resident #2 was in his bed laying on his left side. There was a bed pillow positioned between his knees but the right heel and left stump were laying directly against the bed mattress. ~ 12/4/13 at 4:30 p.m.: Resident #2 was in bed positioned on his back (against the sacrum). The resident's right and left leg were resting on a bed pillow positioned under the resident's knees, however, the right heel was resting on the surface of the mattress. ~ 12/5/13 at 1:10 p.m.: Resident #2 was positioned in bed on his back (against the sacrum). There was a bed pillow positioned between his knees and both the left stump and the right heel were resting on the mattress surface. On 12/5/13 at 1:15 p.m., Surveyor # asked RN-J (Registered Nurse) about the correct positioning of Resident #2's foot. RN-J stated that Resident #2 should have his heel floated to prevent pressure. The Surveyor asked RN-J to accompany her to the resident and showed her the positioning of Resident #2's foot on the mattress and asked if this was correct. RN-J stated it was not correct as "his heels should be up so we can fit our hand underneath, they should be floating." She then repositioned Resident #2's pillow so that the right heel was floating off the pillow and the left stump was resting on top of the pillow. On 12/5/13 at 3:05 p.m., Surveyor # observed RN-H conduct the treatments to Resident #2's sacrum, left stump incision, and right top of foot. Resident #2 was in bed on his back (against the sacrum). His right heel was positioned against the mattress surface. 1. The sacrum wound measured approximately 0.5 cm (centimeters) in length by 0.3 cm width. It was a Stage II wound with the outer region a dark pink to red tissue surrounding the open area. 2. The right foot had a scabbed area on the top of the foot (Dorsal area) that measured approximately 1.0 cm length by 0.4 cm width. The right heel was dark red, mushy and soft. RN-H stated, "Last night it was not like this. It was blanching last night when I put the dressing on. It is clearly mushy now. I have told the aides that he has to have the feet up." RN-H stated she was going to search out a proper heel device for use in bed to allow Resident #2's heel to float. She also stated she was going to get a foot cradle to keep the linens off the tops of his toes. 3. The left stump was dry with a clearly defined suture line. There were no open areas. On 12/5/13 at 3:45 p.m., Surveyor # asked the Director of Nursing (DON) regarding the positioning of Resident #2 when in bed. The DON stated heels should be floating, not touching the mattress. On 12/6/13, Resident #2 had a Heelz-up device and a foot cradle positioned on his bed, however this was after Resident #2 had a decline.