Every finding on record at Skyline Heights Nursing and Rehabilitation

Based on interview and record review, the facility staff failed to prevent, identify, assess, measure, document, and implement necessary interventions for the prevention of avoidable pressure ulcers that developed shortly after a resident's admission, for 1 (#1) of 18 sampled residents. The resident had one Stage lll on his heel and one Stage lll on the gluteal area, which were both avoidable. The deficient practice placed the resident at risk of having a deterioration of the pressure ulcer. Findings include: Review of resident #1's medical record showed she was admitted on [DATE], with a diagnosis of diabetes, heart disease, hypothyroidism, and kidney disease (not all inclusive).Review of resident #1's EHR showed the following related to pressure ulcers/care: - The facility nursing progress notes dated 5/4/26 at 3:38 p.m. showed resident #1 was admitted to the facility following surgical repair of a fractured hip. - On the admission skin assessment, dated 5/4/26, resident #1 had multiple bruised areas (front of her right shoulder, right front axilla, right breast, right temporal area, abdomen, right outer forearm, right dorsum of her right hand, left outer forearm, left antecubital space, right antecubital space, left dorsum of left hand), one surgical wound (right trochanter). The assessment showed resident #1 had no pressure ulcers present upon admission. Review of resident #1's baseline care plan dated 5/5/26 showed the resident was at risk for skin impairment related to a diagnosis of Diabetes. The goal for resident #1's skin was to be free of redness, blisters, and discoloration through the next review date. The care plan centered around resident #1's legs and feet, but not other areas of the body at risk, and included the following interventions:-Ensure blankets are not tight against toes.-Moisturizing lotion to bilateral lower extremities to include the feet.-Notify Provider as needed.-Offer off-loading of heels when in bed.-Proper fitting shoes.-Routine nail care.-Routine Weekly Skin assessments. Review of resident #1's admission Minimum Data Set assessment, with an assessment reference date of 5/10/26, showed resident #1 was not at risk of developing pressure ulcers/injuries. The assessment showed resident #1 did not have any pressure ulcers upon admission.Review of facility nursing progress note dated 5/11/26 at 10:20 p.m. showed, Patient was seen by wound care nurse related to buttock. The documentation did not describe the identified skin problem on the resident's buttocks. Resident #1's nursing note did not identify or reflect information on the stage (severity determination) or the measurements of the resident's skin concern area. Review of the wound nurse's progress note written on 5/12/26 at 1:01 a.m. showed the facility wound nurse documented there was a situation/concern for resident #1's right and left gluteal fold, and the skin region needed further assessment. The wound nurse's progress note requested wound care recommendations for the resident's gluteal region, but the gluteal region concerns for #1 were not described in the note.Review of progress notes dated 5/12/26 at 6:53 p.m. showed, Skin Issue: #10: Skin issue has not been evaluated. Location: Left heel. Laterality/Orientation: Left. Issue type: Pressure ulcer/injury. Wound was present on admission. The note did not show if the wound was avoidable or unavoidable. The pressure ulcer was not evaluated for stage or size. This note contradicts the admission note written on 5/4/26, which showed resident #1 had no pressure ulcers on admission, and it was documented eight days after the resident's admission, and it was the first documentation of the left heel pressure ulcer. The documentation did not show the stage, size, or description of the heel wound. Review of the resident #1's physician assistant's provider notes, dated 5/18/26, showed the concern for resident #1 was a urinary tract infection and low blood glucose readings. The note did not show the nurses made the provider aware of resident #1's heel pressure ulcer. Resident #1's heel pressure ulcer was not noted in the physician assistant's provider notes. A review of the dietitian's assessment, dated 5/18/26, showed the resident was started on Boost, a nutritional supplement. Review of resident #1's May 2026 treatment records showed a physician's order dated 5/19/26 directing staff to monitor the Stage III pressure injury to the resident's left heel and monitor for signs and symptoms of infection or deterioration and document the findings. The staff was to notify the provider if complications were noted. If the wound was covered by a dressing, and the dressing was not ordered to be changed at that time, the nurses were to note the condition of the dressing and any global indicators of infection every shift. There was no treatment ordered for the pressure ulcer for resident #1's left heel. The physician ordered diabetic skin care to resident #1's lower extremities. Review of resident #1's physician order on the treatment records included: moisturizing lotions, off-loading heels, soft boots, an air mattress, routine nail care, proper fitting shoes, and ensure blankets are not tucked in too tight. The staff was directed to choose which intervention was implemented and document when it was used. Review of resident #1's nurse progress notes dated 5/21/26 at 3:15 a.m. showed only three skin issues, which included a surgical wound on the right front trochanter, bruising on the right front axilla, and the abdomen. The resident's heel Stage lll pressure ulcer and the sacrococcygeal (gluteal fold) pressure ulcer had not been documented as resolved; however, they were not documented as ongoing wounds.Review of resident #1's nurse's notes dated 6/14/26 at 5:17 a.m. showed resident #1 had a skin issue described as, Skin issue has not been evaluated. Location: Left Gluteus. Additional location information: dry, dark brown, peri wound was hyperpigmented, Issue type: Other skin issue. Other skin issue description left upper gluteus Wound acquired in-house. Undermining: No. Tunneling: No. [sic] The progress note did not show what type of wound was acquired on resident #1's gluteus, if the wound was avoidable, and there were no notes for the measurements or severity determination of the wound. The right side of the resident's gluteus was not documented on. Review of resident #1's June 2026 medication and treatment record showed the left gluteal region wound and peri wound (area around the gluteal region) was to be cleansed with wound cleaner; Skin prep was then to be applied to the peri wound. Then an island dressing/Opti foam was to be applied to the affected area every shift. It was noted resident #1 was to be followed by a [Name] wound care team two times a day for wound care. There were no physician orders for treatment of resident #1's gluteal region on the June treatment record. It was unclear if the wound was on the left side or right side, or if it had grown into one wound on the gluteus.Review of Resident #1's nursing note, dated 6/14/26, completed by the wound nurse, reflected the physician assistant was contacted by phone, and it was reported resident #1 had a Stage lll pressure sore on gluteal region. The left/right side was not mentioned, and the Staging of the wound was identified by the nurse. Review of resident #1's physician assistant's notes, for a telephone encounter, dated 6/14/26, showed an Unstageable wound to the left gluteus. Although the nurse who contacted the physician assistant on 6/14/26 reported a Stage lll wound, the provider noted it was Unstageable but did not visualize the wound personally at that time. There were no measurements of the wound. There was documentation to show there was some erythema and reportedly mild warmth to the wound that was without drainage. The center of the wound was dark, possibly eschar. Resident #1 started on an antibiotic for seven days. The physician assistant asked for the wound care clinic to be notified as the wound needed to be debrided (medically removing dead, damaged, or infected tissue to promote healing and reduce the risk of infection). A treatment was started on 6/14/26 for the gluteal wound. Review of resident #1's PA notes showed that on 6/18/26, a pressure ulcer that was Unstageable wound on the gluteus with eschar covering it was identified as being 4 cm x 4 cm in size. The physician assistant noted the wound clinic should be consulted. Review of resident #1's physician progress notes dated 6/23/26 showed the resident had a full-thickness Stage III pressure ulcer to the left sacrococcygeal (gluteal) area. The physician note showed documentation of the description of the pressure ulcer, which was measuring 2.4 cm by 2.4 cm and a depth of 0.1 cm. The wound was draining a moderate amount of serosanguineous drainage. The physician ordered the staff to change the dressing two to three times a week with Mepilex (foam wound dressing).Review of resident #1's June 2026 treatment administration record for the left gluteal region pressure ulcer showed: - Cleanse wound and peri wound with wound cleaner.- Apply skin prep on peri wound.- Place an island dressing/Opti foam to affected area every shift. (MD order was for two to three times a week)- Resident will be followed by [Clinic Name] for wound care two times a day for wound care. Review of a resident #1's physician's progress note, written 6/30/26, showed the resident went to the physician's office for a medical follow-up. The physician's note described the left sacrococcygeal (gluteal) area as a Stage III pressure ulcer which measured 2.7 cm by 2.4 cm by 0.1 cm in depth. The wound was draining a moderate amount of serosanguineous drainage. The wound was debrided of subcutaneous tissue, fibrin, necrotic debris, and slough by the physician. Resident #1's pressure ulcer had deteriorated from 6/23/26 and increased in size. Nothing was noted about the right side of the resident's gluteal region. Review of resident #1's medical record showed the resident was not seen at the wound clinic on 6/16/26 as ordered by the physician. Resident #1 was seen at the wound clinic on two occasions, 6/23/26 and 6/30/26. The wound clinic documentation was the only staging and measurement of the gluteal/sacrococcygeal wound that developed in-house on 5/21/26.During an interview on 7/14/26 at 12:43 p.m., NF3 stated resident #1 developed a sacral Stage III bedsore. NF3 said she visited resident #1 and stayed with the resident for many hours. NF3 said resident #1 was not turned while she was visiting but was allowed to lie on her back. NF3 stated resident #1 told her the staff do not turn her off her backside very often, and the adult incontinence products were only changed twice a day. NF3 said resident #1 was recently hospitalized . NF3 said resident #1 was coming back to the facility, but she hoped resident #1 got better care this time. NF3 said she was worried the pressure ulcer would get worse and resident #1's condition would deteriorate.During an interview on 7/14/26 at 1:50 p.m., NF4 stated the wound on resident #1's sacrum developed at the nursing home. NF4 said the sacrum wound started with redness and progressed to an Unstageable wound. NF4 stated another provider saw the wound on 6/18/26 and identified an Unstageable wound and referred resident #1 to the wound clinic. The statements about the Unstageable wound were not correlating to the events that occurred, with the nurse reporting the wound was a Stage lll wound, not an Unstageable wound. During an interview on 7/16/26 at 10:22 p.m., with staff member O and staff member B, staff member O said she was assisting the certified nurse assistant and had a visual of resident #1's buttock area. Staff member O did not know the date but stated the date and a wound assessment would be in the nurse's notes. Staff member O stated the wounds were to be assessed and measured on a weekly schedule. Staff member O said a clinic nurse practitioner came to the facility to complete wound rounds, which included assessing and measuring the wound. Staff member O said the interdisciplinary team was responsible for updating the care plans Monday through Friday with changes in the resident's condition.Review of resident #1's current care plan effective through the date of her hospitalization on 6/30/26, showed the facility failed to update the care plan to include the pressure ulcer to resident #1's sacrococcygeal (gluteal) area, which started on 5/21/26, and the Stage III pressure ulcer on her left heel which was present on 5/12/26. The care plan was unchanged from the baseline admission care plan. On 7/14/26 at 4:05 p.m., the surveyor requested all the weekly skin and wound assessments for resident #1. The request was to include the wound description, stages, and measurements for resident #1's pressure ulcers on her left heel and her gluteal area. By the end of the survey on 7/17/26, no documentation was received for the left heel pressure wound. Two sets of wound measurements for the sacrococcygeal wound were received. The wound measurements were taken at a physician's appointment on 6/23/26 and 6/30/26. A review of the facility's Policy and Procedure titled Wound Treatment Management, which was undated, showed:1. Wound treatments will be provided in accordance with the physician's orders, including the cleansing method, type of dressing and frequency of dressings.2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders.Based on the policy, the review of resident #1's medical record reflected the policy was not followed, as resident #1's Stage III pressure ulcer did not have treatment orders, and the wound had been present for two months. There were no progress notes showing the nurses requested treatment for the wound. A review of the facility's Policy and Procedure titled Pressure Injury Prevention and Management, undated, and not followed by licensed staff per record reviews, showed:. 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate. Review of resident #1's medical record and the Recertification survey plan of correction dated 4/3/26 showed the facility failed to carry out or sustain corrections identified in the plan of correction. Facility staff did not identify the wounds and immediately implement measures to prevent a deterioration of a skin concern or wound. Wound documentation was either not done or inconsistent for the wound location, description and details, size, and severity. Staff did not follow the facility policies and procedures, and/or ensure the resident attended all wound care appointments, which further contributed to the overall failure. The resident's care plan was not inclusive of necessary interventions to prevent the development and/or care of pressure ulcers on the resident's heel and/or gluteal area. deterioration of the wound(s).

Based on interview and record review, the facility failed to ensure the resident's medication regimen was thoroughly assessed and free from unnecessary medications that may cause sedation, for 1 (#1) of 9 sampled residents. Resident #1 was on hospice and had multiple medications for pain or agitation/behavior contributing to sedation. This was not addressed by the facility. The resident was sent to the hospital for further evaluation. Findings include:During an interview on 4/22/26 at 12:00 p.m., NF1 stated that when she arrived at the facility on 1/17/26, the resident was unconscious with minimal response to painful stimuli. NF1 stated resident #1 appeared to be sedated. The family decided to send the resident to the hospital for further evaluation. NF1 stated the resident had not returned to the facility. NF1 stated the resident passed away at the hospital. NF1 stated the resident was not conscious from admission to the hospital to the resident's passing away. NF1 stated the emergency room provider said the resident had an overdose of medications. NF1 stated the resident's level of consciousness had deteriorated so much and quickly that the family was shocked to see his condition when they arrived at the facility. During an interview on 4/23/26 at 10:14 a.m., staff members A and B were interviewed together. Staff member B stated the resident was referred to hospice services on 1/9/26, and was admitted to hospice on 1/13/26 for metastatic cancer. Staff member B stated the resident had orders for pain medication from the hospice provider, but was also seen by the in-house provider to discuss medications. Staff members A and B stated the resident had been under one-to-one (staff oversight) at the hospital before being admitted to the facility. Staff member B stated the resident's cognition and actions were impulsive with intermittent aggressiveness towards staff. Staff member B stated the facility had to initiate one-to-one supervision. Staff member B stated the one-to-one was successful in keeping the resident busy so he would not perseverate about wanting to get up and ambulate. Staff member B stated that even with the one-to-one supervision, he had been able to act quickly. The interventions implemented soon became unsuccessful, and the provider was notified and questioned if pain was one of the contributors to the aggressive behavior. The facility staff had several conversations with the family, and they had chosen to implement hospice services. When the resident displayed aggressive behaviors, the family was notified. At the time of implementation of hospice services, the resident continued one-to-one supervision. Hospice staff discontinued some of the resident's medications and added morphine and lorazepam. Staff member B stated the family had not been prepared for a decline in condition related to intake of food and fluids and the progression of the resident's disease process. Staff members A and B stated the resident was receiving pain medications. Staff members A and B stated the family was concerned about the dosage of medications the resident was taking. When the family arrived at the facility on 1/17/26, they had requested that the resident be sent to the hospital. Staff member B stated the facility had a discussion with the family regarding hospice services. Staff member B stated the facility had contacted the hospice nurse to update her on the resident's status and the family's wishes to send the resident out to the hospital. Staff members A and B stated there were no concerns with the resident's medications. Review of resident #1's Medication Administration Record, dated for the period of 1/5/26 through 1/17/26, showed the resident was taking the following medications: -12 doses of Prednisone 10 mg (a steroid). This medication was ordered on 1/7/26 for one time daily for upper respiratory infection.-26 doses of quetiapine 125 mg (an antipsychotic). This medication was ordered on 1/6/26 for delirium and psychosis every eight hours.-Seven doses of hydrocodone 5/325 mg (opioid pain reliever). This medication was ordered on 1/14/26 three times daily for pain.-Eight doses of lorazepam 1 mg (antianxiety). This medication was ordered on 1/14/26 every four hours as needed for agitation.-Three doses of Morphine 0.5 ml (narcotic pain reliever). This medication was ordered on 1/14/26 for every four hours as needed for pain.-A one-time dose of olanzapine 5 mg at bedtime, scheduled (an antipsychotic) on 1/16/26 for agitation and anxiety.-On the day before the resident's transfer to the hospital, the resident was administered 5 mg of olanzapine, 10 mg of prednisone, 5/325 mg of hydrocodone, two doses of Ativan, 1 mg each, and 0.5 ml of morphine. On the day the resident was transferred to the hospital, he was given 1 mg of Ativan, 0.5 ml of morphine, and 10 mg of prednisone. Review of resident #1's progress notes from the resident's admission to discharge, 1/5/26 through 1/17/26, showed combative and unsafe behavior. The resident had multiple medications for psychosis, pain, anxiety, and a steroid for an upper respiratory infection.The facility failed to review resident #1's medications as a contributing factor for sedation. The facility failed to assess resident #1's medications for duplicate therapy and adverse consequences. The resident only had a minimal response to painful stimuli when sent out to the hospital. Review of resident #1's Medication Administration Record, dated 1/1/26 through 1/17/26, showed the resident rated pain for three days, on a 1 to 10 scale, with 10 being the worst, as: 1/15/26 - 5/10, 1/16/26 - 3/10, and 1/17/26 - 7/10. Review of resident #1's ER visit documentation, dated 1/17/26, showed the resident was brought to the hospital for a decrease in level of consciousness. Review of resident #1's hospital emergency room progress note showed the resident was brought into the emergency room for an altered mental status. The resident was hypoxic prior to arrival and was receiving supplemental oxygen. Per report from the family, the resident had been more sedated at the facility lately. The resident did become more alert in the emergency room.Review of resident #1's hospital History and Physical, dated 1/17/26, showed the resident was reportedly ambulatory when he arrived at the facility. However, the resident became weaker with multiple falls at the facility. His speech became nonsensical and incoherent. The family was notified of his decline. The resident was placed on hospice care and prescribed hydrocodone and morphine to address pain. The family was concerned about how fast the resident had declined and wanted the resident to be seen at the hospital. Under the Assessment/Plan section of the History and Physical, it showed the resident's dementia and chronic encephalopathy may be exacerbated by disease progression and use of opioid use, possible steroid-induced psychosis, and electrolyte imbalance.

Based on interview and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field when the dietitian was not scheduled and working at the facility full-time (35 hours). The staff in the dietary department were not following sanitary practices or storing food properly, and this increased the ongoing risk of cross-contamination for anyone receiving food or products from the kitchen, and for deficient practices to continue. Findings include:During an interview on 3/9/26 at 11:52 a.m., staff member J stated she was not certified as a Dietary Manager. Staff member J said she was currently enrolled to complete a Certified Dietary Manager program, but she had a year to complete the course. Review of facility document titled, State Food Safety, received on 3/10/26, showed staff member J had a State Food Safety Food Manager Certification with an issuance date of 5/23/22.During an interview on 03/12/2026 at 11:35 a.m., staff member O said she provided oversight to the dietary department when she was in the facility once a week. The day she is in the facility, she monitored lunch service and did some education for the dietary staff. Refer to F812 - Food Storage/Safety/Sanitization, for concerns related to the dietary department and oversight.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen; failed to ensure food located in the coolers was labeled and dated; and failed to ensure cooler temperatures were maintained in the food storage safe zone. This deficient practice increased the risk for the development of foodborne illnesses and unsanitary conditions for all residents who received food from the kitchen. Findings include:During the initial tour of the kitchen, on 3/9/26 at 11:52 a.m., the following observations and interviews were made:-The thermometer inside the reach-in refrigerator near the deep fryer showed a temperature of 50 degrees.-A plastic drinking cup of a creamy brown liquid and a plastic drinking cup containing pink liquid were stored in the walk-in cooler. Staff member J said it looked like the staff's drinks and should not be there.-A 5-gallon bucket of sauerkraut was not covered.-A plastic bag of breadsticks located in the freezer was not closed or dated when opened.-A plastic bag of green beans stored in the freezer was not closed or dated when opened.-The deep fryer oil had a film of brown residue floating on the surface. The fryer basket hanging over the deep fryer oil contained cooked chicken strips and French fries, showing the fryer was being used with the residue in the oil. -The burners on the right-hand side of the stove were soiled with dried white batter. The batter was on the burner grate and on the cooktop surface.Review of the temperature log on the reach-in cooler, near the deep fryer, with a date of 3/9/26 on the p.m. shift, showed:-3/2/26, p.m. shift; 42 degrees,-3/8/26, a.m. shift; 50 degrees,-3/9/26, p.m. shift; 45 degrees.The form did not show what had been done to correct the temperatures that exceeded the accepted parameters.During observations and interviews on 3/10/26 at 8:50 a.m., staff member M said the reach in cooler near the deep fryer temperature was too warm yesterday. Staff member M said the cord to the cooler was replaced, and now the temperature was staying within the proper temperatures. The thermometer in the cooler showed 40 degrees. Staff member M said staff were educated the day before about notifying the manager if the cooler temperature was too warm (out of an acceptable range).The following was observed:-Under the cooler by the fryer, the floor was soiled with debris causing it to look unclean, black, and greasy.-The deep fryer oil, on the left, was covered with brown floating debris. The oil was very dark brown, and the brown floating debris looked the same as on 3/9/26. -The right-hand stove grates were soiled with dried white batter. The batter was on the burner grate and on the cooktop surface. This was the same dried batter from 3/9/26.-The backsplash behind the burners had splatters of dried red food spots. Staff member J said kitchen staff did a weekly deep clean.-Inside the oven on the right, there was food debris and black food particles. -The handle of the Zephaire convection oven was sticky to touch.-Two gallons of milk in the reach-in cooler were opened but not dated for when they were opened. - One quart of Silk milk was open and not dated. - Numerous larger containers of juices, which were pink, yellow, light brown, dark brown, red, and orange in color, were not labeled or dated with the contents.During an interview on 3/10/26 at 8:52 a.m., staff member J said an in-service was conducted on 3/9/26 regarding the cooler temperature and what to do if the temperature was out of range. During an observation and interview on 3/10/26 at 8:59 a.m., staff member N was observed hand washing some dishes and loading dirty dishes into trays. Staff member N used a cloth that was sitting on the dirty dish of the dish area to pull the tray out of the dishwasher after the dishes were finished washing. Staff member N then pushed the new tray of dirty dishes into the dishwasher. The dishwasher was then cycled to wash the tray of dishes. Staff member N was observed scrubbing a large restaurant pan. After the tray of dishes was washed, staff member N pulled them out of the dishwasher with his soiled hands. Staff member N then put the restaurant baking pan into the dishwasher. After the pan had been washed, he used the same soiled towel that was sitting on the dirty dish table, grabbed the baking pan, and removed it from the dishwasher. At no time during this observation did staff member N wash his hands before touching the clean trays and clean dishes. Staff member N, when interviewed, stated he did not touch the clean dishes with his dirty hands. Staff member N said he did not touch the dishes, just the tray.Review of a facility policy titled Monitoring of Cooler/Freezer Temperature, dated 6/23/25, showed:1. Logs will be checked and logged twice per day by designated personnel 3. All refrigerator storage must be maintained at or below 41 degrees, unless otherwise specified by law 5. If the temperatures are found to be out of range, the supervisor will be notified immediately for corrective action.

Based on observation, interview, and record review, the the nurses failed to ensure enhanced barrier precautions were followed when performing wound care for 1 (#24) of 27 sampled residents and failed to ensure weekly documentation related to the monitoring and prevention of legionellosis was completed as part of the facility's water management plan. This deficient practice increased the risk for exposure to infectious diseases, including drug resistant organisms and legionellosis. Findings include:1. During an observation on 3/9/26 at 1:37 p.m., NF2 was observed providing wound treatments to resident #24's sacral pressure ulcer and bilateral heel pressure ulcers. NF2 was observed wearing a protective gown and gloves. NF2 used her gloved right hand to reposition the chair she was seated on, and without changing gloves, was observed debriding resident #24's right heel wound. The failure to change the soiled glove to a clean glove, increased the risk of cross contamination. During an observation on 3/9/26 at 1:46 p.m., staff member E was providing care to resident #24's right heel and sacral wound. Staff member E was standing at resident #24's bedside, and opening dressing packages, which were then placed on the bed. Staff member E was not wearing a protective isolation gown. Staff member E applied the wound dressing to resident #24's sacral wound and did not put on an isolation gown. During an interview on 3/11/26 at 7:22 a.m., staff member B said she would expect the wound nurse to wear a gown when changing dressings on a resident with a wound. Staff member B said that if a nurse was just standing and watching, then a gown wouldn't be necessary. Staff member B said if the nurse was providing the care and applying the dressing, she should have a gown on. During an interview on 3/12/26 at 7:30 a.m., staff member E said assisted NF2 with resident #24's wound care. Staff member E said after NF2 left the room, she applied the dressings to resident #24's heels and sacral area. Staff member E said she had a gown on during wound care. Review of the facility policy and procedure, titled Enhanced Barrier Precautions, with a revision date of 4/11/25, showed: . 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: -Wound (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wound, and chronic venous stasis ulcers) and/or indwelling medical devices. 3. Implementation of Enhanced Barrier Precautions: -PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: -.wound care: any skin opening requiring a dressing. 2. During an interview on 3/12/26 at 8:45 a.m., staff member L stated he was new to his position and was unaware of the facility's water management program processes. Staff member L stated he was in the process of receiving training from staff member T remotely. During an interview on 3/12/26 at 8:50 a.m., staff member T stated he had been orienting staff member L on the facility's maintenance processes. Staff member T stated the facility was using the Direct Supply TELS system for monitoring and implementation of the facility's water management program. Staff member T stated he had discovered the previous Maintenance Director was not documenting water management, legionella prevention, monitoring, and testing. Staff member T stated the facility's Maintenance Director should perform weekly monitoring of the TELS system to ensure Legionella prevention. Review of a facility document titled F-880 Infection Control Legionella Plan and Monitoring, undated, showed the following: On December 1st, 2025, during internal document review, the previous Maintenance Director was not documenting Water Management and Legionella Prevention Monitoring and testing. This practice is not in compliance with 42 CFR 483.30, CMS Guidelines, or ASHRAE standards. This practice of not documenting had the possibility to affect the entire population of the facility. The current Maintenance Director was educated by a corporate life safety resource, and the computerized maintenance management system, Direct Supply TELS, is now in place to log and document these inspections in accordance with the requirements . [sic] Review of a facility document titled, Water Management Program, dated 10/17/23, showed the following data for the period of 3/1/25 through 3/1/26: Testing and monitoring of Water Management Plan for Legionella . Main Building . All these inspections, tests and measurements need to be documented and recorded . Review of the weekly testing and monitoring log showed the following dates were marked No action recorded: -4/12/25 through 6/7/25 -7/5/25 through 8/9/25 -9/27/25 -10/11/25 through 11/15/25 Review of the weekly monitoring log for the period of 3/1/25 through 3/1/26 showed 22 of 52 required weekly water management monitoring activities lacked documentation of completion for the facility's monitoring system. The facility's failure to consistently monitor and document the water management program increased the risk for Legionella growth and potential exposure to Legionella and legionellosis.

Based on interview and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards related to wound care, and failed to follow physicians' orders for the wound care for the resident's numerous wounds, for 1 (#2) of 27 sampled residents. This deficient practice placed the resident at risk for a deterioration in wounds or infections, and the concerns continued over several months. Findings include: During an observation and interview on 3/10/26 at 9:15 a.m., resident #2 was seated in his chair, using both limited verbal communication and his communication board to talk with the surveyor. Resident #2 told the surveyor that the staff did not always change the dressing on the wounds on his feet.During an interview on 3/10/26 at 10:09 a.m., NF6 said resident #2 told her the nurses don't consistently change the dressings on his feet and toes.During an interview on 3/11/26 at 10:55 a.m., NF3 said resident #2 had a complicated wound with an external fixation device. NF3 said the wound clinic sent the facility orders and directions for wound care, but the nursing staff did not follow them. NF3 said to circumvent the problem with the orders not being followed, resident #2 was brought to the wound clinic weekly. NF3 said it was tough to relay the importance of wound management (to the facility) due to turnover and the number of staff. NF3 said the wound nurse and the DON (Director of Nursing) were responsible for the wound treatment of the Tibial corticotomy. NF3 said the treatment consisted of cleansing the wounds, the application of dressings to the toes, and the management of the Tibial corticotomy. NF3 said, Overall, the communication between the facility and the clinic could be better, rather than the facility just not doing the treatment.Review of resident #2's December 2025 treatment logs showed:Treatment #1 - Starting 12/19/25, the staff will distract (pull out) the piece of bone the fixator is connected to 0.5 mm per day, and the order showed to pull out the large knob in the direction of the arrow and plus sign one quarter turn, two times per day, to equal 0.5 mm at 8:00 a.m. and 8:00 p.m. The treatment was to be done only by the wound nurse or the DON. The treatment record documentation showed the treatments were not completed as ordered.Treatment #2 - Right second toe diabetic ulcer: the order showed to cleanse the area and allow it to dry. Apply Betadine over the wound. Toes will be wrapped with a dressing for a surgical wound to foot. The treatment was not completed as ordered per the documentation.Treatment #3 - Hematoma to the top of the left fourth toe. The order showed to cleanse with wound cleanser and allow it to dry completely. Apply skin prep daily. The treatment was not completed as ordered per the documentation.Treatment #4 - Right foot, first toe amputation site. The order showed to ensure the area is cleansed and allowed to dry. Apply Betadine to the wound bed. Cover with ABD pad and wrap with kerlix to form a football dressing. Ensure there is enough padding for extra protection. The treatment was not completed as ordered per the documentation.Treatment #5 - Right foot hallux amputation site. The order was to cleanse and allow to dry. Apply Betadine-soaked gauze, cover with ABD pad, and wrap with kerlix. The treatment was not completed as ordered per the documentation.Treatment #6 - Wound care suspected deep tissue injury to the right foot, on the third, fourth, and fifth toes. The orders were to ensure the areas were cleansed and allowed to dry. Apply skin prep to the top of toes and between toes. The treatment was not documented as completed as ordered.Treatment #7 - Right leg pin care. The order was to cleanse the pins with wound wash and cover the pins with wound wash. Then cover pins with Xerofoam. Paint incision with Betadine once daily, then cover with Kerlix and Ace. The fixator required quarter-turn adjustments twice a day, every Tuesday, Thursday, and Saturday. The treatments were not completed as ordered per the documentation.Review of resident #2's January 2026 treatment logs showed:Treatment #1 - Starting 12/19/25, the staff were to distract (pull out) the piece of bone the fixator was connected to 0.5 mm per day. Then pull out the large knob in the direction of the arrow and plus sign one quarter turn, two times per day, to equal 0.5 mm at 8:00 a.m. and 8:00 p.m. The treatment was only to be done by the wound nurse or the DON. The treatments were not completed as ordered per the documentation.Treatment #2 - Right second toe. The order was to cleanse the area and allow it to dry. Apply Betadine over the wound. Toes were to be wrapped with wound dressing for the surgical wound to foot. The treatment was not completed as ordered per the documentation.Treatment #3 - Hematoma to the top of the left fourth toe. The orders were to cleanse with wound cleanser and allow it to dry completely. Apply skin prep daily. The treatments were not completed as ordered per the documentation.Treatment #4 - Right foot, first toe amputation site. The order was to ensure the area was cleansed and allowed to dry. Apply Betadine to the wound bed. Cover with ABD pad and wrap with kerlix to form a football dressing, and ensure there is enough padding for extra protection. The treatment was not completed as ordered per the documentation.Treatment #5 - Right foot hallux amputation site. The order was to cleanse the site and allow it to dry. Apply Betadine-soaked gauze and cover with ABD pad, then wrap with kerlix. The treatment was not completed as ordered per the documentation.Treatment #6 - Wound care suspected deep tissue injury to the right foot, on the third, fourth, and fifth toes. The orders were to ensure the areas were cleansed and allowed to dry. Apply skin prep to the top of toes and between toes. The treatment was not completed as ordered per the documentation.Treatment #7 - Right leg pin care. The order was to cleanse pins with wound wash and cover pins with wound wash, then cover pins with Xerofoam. Paint incision with Betadine once daily, cover with Kerlix and Ace. The fixator required a quarter-turn adjustment twice a day, every Tuesday, Thursday, and Saturday. The treatment was not completed as ordered per the documentation.Review of resident #2's February 2026 treatment logs showed:Treatment #5 - Right foot hallux amputation site. The order was to ensure the area was cleansed and allowed to dry. Apply Betadine-soaked gauze. Cover with ABD pad and wrap with kerlix to form a football dressing. Secure with coban and ensure there was enough padding for extra protection. The treatment was not completed as ordered per the documentation.Treatment #6 - Wound care suspected deep tissue injury to the right foot, third, fourth, and fifth toes. The orders were to ensure the area is cleansed and allowed to dry. Apply skin prep to the top of toes and between toes. The treatments were not completed as ordered per the documentation.Treatment #7 - Right amputation site. The orders were to cleanse the area with normal saline and peri-wound with soap and water. For the peri-wound skin, apply antifungal ointment. Wound filler silver alginate rope. The secondary dressing was an ABD pad, kerlix, and ace wrap. The treatment showed to offload using the football dressing and only wrap to the ankle. This was two times a week for one week. The treatment was not completed as ordered per the documentation.During an interview on 3/12/26 at 7:30 a.m., staff members B and E were present. Staff member E said she initiated the medical provider's (wound) orders, and the order would then be populated on the resident's treatment administration record. Staff member B said the treatment would be signed off on the treatment administration record sheet when completed. Staff member B said having the treatment administration record checked off showed the treatment was completed. Staff member E said it might have been her mishap when the treatment administration record was not signed off (for resident #2).

Based on observation, interview, and record review, the facility failed to ensure medication carts remained locked when a staff member was not in attendance; and failed to ensure monitoring was completed as needed for the unit refrigerator temperatures that stored medications. This failure put the security of resident medications located in an unlocked and unattended medication cart at risk of theft or misuse, and placed residents who had refrigerated medications at risk for experiencing negative effects from improperly stored medications. Findings include: During an interview on 3/11/26 at 9:49 a.m., staff member Q stated it was her first time being assigned to work on the Rim View hallway. Staff member Q stated she was going slowly because she had not been shown the resident's preferences for medication pass previously.During an observation on 3/11/26 at 10:02 a.m., staff member Q was preparing medications to administer to a resident in his room. Staff member Q entered the resident's room and closed the door. Staff member Q left the medication cart unattended and unlocked in the hallway across from the resident's door. Staff member Q opened the resident's door after about two minutes to begin the medication administration with the surveyor present.During an interview on 3/11/26 at 11:13 a.m., staff member R stated a medication cart needed to be locked when a staff member left the medication cart unattended. Staff member R stated if a medication cart was in a hallway, staff should lock the cart before leaving it.Review of a facility policy titled, Medication Storage, dated 5/9/25, showed: . 1. General Guidelines:a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts.). c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.During an interview on 3/12/26 at 11:05 am, staff member A stated she could not provide records of the Rim View unit medication refrigerator logs. The logs would show the daily temperature checks and signatures showing staff checked the temperatures. Staff member A stated the refrigerator temperature logs were stored in a staff member's office and must have been moved when construction began in the facility, so she would check for the logs in storage.Review of a facility policy titled, 'Storage of Medication Requiring Refrigeration, dated 5/9/25, showed: . It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. 1. The facility must provide safe and effective storage of all drugs and biologicals in a locked storage area under proper temperature controls with limited access by authorized personnel consistent with state or federal requirements and professional standards of practice. 4. Refrigerators used for the storage of medications and biologicals:. d. Temperature should be maintained between 36-46 degrees F.e. Temperature should be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of person performing the check clearly written. h. Historical temperature logs should be kept in a central location.A request to the facility was made on 3/12/26 for medication room refrigerator temperature logs for October 2025 through present. The facility did not provide logs of medication refrigerator temperatures for the Rim View unit by the end of the survey.

Based on interview and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days, unless the rationale for continuing the medication was documented by a medical provider, for 1 (#5) of 27 sampled residents. Findings include:During an interview on 3/12/26 at 12:02 p.m., staff member B stated that the as-needed psychotropic medication for resident #5 should have been discontinued after 14 days. Staff member B stated the medical provider would have to assess resident #5's need for continued use of a psychotropic medication, if they chose to continue the medication after the 14-day period, and then enter a new order. Staff member B could not explain why the as-needed psychotropic medication was not reviewed for continued use after day 14.Review of resident #5's physician order, dated 10/1/25, showed an order for trazodone HCL 100 mg oral tablet, give 50 mg by mouth, as needed for insomnia at bedtime. The as-needed order failed to include the 14-day duration for the psychotropic medication.Review of resident #5's medication regimen review, dated 11/1/25, showed the pharmacist notified the attending physician about the as-needed trazodone order. The form showed, . has an order for Trazodone 50 mg, taking 1 tablet at bedtime as needed along with a scheduled 50 mg tablet with no stop date indicated. The form showed the physician agreed with the recommendation and signed the form on 11/21/25.Review of the facility's policy titled, Use of Psychotropic Medication(s), dated 6/2025, showed, . a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or the prescriber for the rationale for the extended time period and indicate a specific duration.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised to accurately reflect individual resident-centered care needs for 2 (#s 2 and 5), and identify a resident's preference for 1 (#5) of 27 sampled residents. Findings include:1. Review of resident #2's electronic health record showed resident #2's diagnoses included Diabetes Mellitus, End Stage Renal Disease on hemodialysis, Atrial Fibrillation, Congestive Heart Failure, Cerebral Vascular Accident, and amputation of hallux (bony bump at the base of the great toe) and second toe with dehiscence and necrosis of the bone. Review of resident #2's physician order, dated 2/13/26, directed the staff to monitor the dialysis port on the right side of resident #2's chest for signs and symptoms of infection and document. Review of resident #2's care plan, dated 8/16/23, showed the staff was to check access site daily fistula/graft/catheter - signs of infection. Monitor thrill and bruit daily and document findings; report abnormal findings to physician. The care plan was not updated to identify the change in dialysis access site from a fistula to an IV port. Resident #2's care plan did not include the name, location, or phone number of the dialysis clinic where he was treated. Resident #2's care plan did not include the dialysis treatment days, how he would be transported to dialysis, or the times when he would be picked up for and returned to the facility after dialysis. During an interview on 3/11/26 at 3:00 p.m., staff member B said the staff would not listen for a bruit and thrill as resident #2 had a central port. Staff member B said resident #2 had a fistula in the past, but it was not being used now. Staff member B said she helped update care plans while the facility's care plan process was being revised. During an interview on 3/12/26 at 11:35 a.m., staff member O said resident #2's only dietary restriction was a diabetic controlled carbohydrate diet. Staff member O said the facility updated the care plans. Review of resident #2's care plan showed he was on a no-added salt diet, with double protein portions and Nepro dietary supplement daily. A review of resident #2's physician's order dated 12/15/25 showed the resident was ordered to receive a controlled carbohydrate diet. The care plan was not updated to reflect the change in diet. 2. During an observation and interview on 3/9/26 at 3:55 p.m., resident #5 was in her room, seated in an electric wheelchair with a seatbelt secured around her waist. Resident #5 stated she used the seatbelt on her wheelchair to prevent her from slipping out of her chair. Resident #5 stated the wheelchair seatbelt made her feel safe. During an interview on 3/11/26 at 2:05 p.m., staff member AA stated it was up to the nurses to complete and update a resident's care plan. Staff member AA stated that if a resident utilized a seatbelt while in a wheelchair, the information would be in the resident's care plan. Review of resident #5's care plan, dated 1/23/26, failed to show interventions related to resident #5's use of a seatbelt while she is in her electric wheelchair. Review of resident #5's power mobility indoor driving assessment, dated 8/14/25, showed resident #5's electric wheelchair seatbelt was used by the resident. Review of resident #5's occupational therapy note, dated 4/7/25, showed that resident #5 utilized the wheelchair seatbelt feature.

Based on interview and record review, the facility failed to publicly post the total number and the actual hours worked for each required nursing staff category. This deficient practice limited resident and public access to required nurse staffing information. Findings include:During an interview on 3/10/26 at 3:10 p.m., staff member G stated the daily staff posting was not always completed with the actual staffing numbers and hours worked by required staff. Staff member G stated she had posted the number and hours for required staff based off the facility's staff schedule, but she did not always update the posting to reflect any changes. Staff member G stated she was not aware the actual number and hours worked by required staff needed to be posted.Review of the facility's daily staff posting information, dated 1/1/26 through 1/31/26, failed to show on 25 of 31 days the actual number and hours for required staff who worked each shift.

Based on interview and record review, the facility failed to submit the findings of a Facility Reported Incident to the State Survey Agency prior to the five-day deadline for 1 (#5) of 8 sampled residents. Findings include:Review of a Facility Reported Incident submitted to the State Survey Agency on 11/29/25, involving resident #5, which showed: a facility resident had suffered an unwitnessed fall with injury. The findings of this incident should have been submitted to the State Survey Agency no later than 12/5/25. The findings were submitted to the State Survey Agency on 12/7/25, which was two days late. During an interview on 12/30/25 at 12:27 p.m., staff member A stated, I was out of state when the incident (with resident #5) happened. I had staff member C filling in for me, and she was the one who submitted the findings to the State Survey Agency. She alerted me that it was late.During an interview on 12/30/25 at 1:49 p.m., staff member C stated she did realize the findings were submitted late for the event for resident #5. Staff member C said she missed it and submitted it as soon as she realized it needed to be submitted.During an interview on 12/31/25 at 8:09 a.m., staff member A stated no education had been provided for staff member C on reporting requirements related to the event for resident #5. Review of a facility document titled, Abuse, Neglect and Exploitation with an implementation date of 6/23/25, showed: .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to update a resident's comprehensive care plan with new interventions for incontinence care for 2 (#s 4 and 7) of 8 sampled residents. Findings include:During an interview on 12/30/25 at 9:11 a.m., resident #4 stated, The staff told me I cannot wear a liner and a brief anymore (for incontinent episodes). They make us use reusable liners, and they are very small. They don't last as long, and I have more accidents. I have talked to the staff about how much I don't like them. I want to go back to the disposable big liners I had before. Resident #4 stated, I used to participate in care planning, but I don't anymore.During an interview on 12/30/25 at 12:27 p.m., staff member A said the care plans should reflect all the incontinence products tried for the resident or any changes related to incontinence care. During an interview on 12/30/25 at 1:56 p.m., resident #7 stated, I am having too many accidents (with incontinence), and the little reusable pads just aren't working for me.Review of resident #4's comprehensive care plan, with a revision date of 4/14/25, showed: .Focus: ADL's with bowel and bladder.Goal: Interventions with brief with insert.Interventions: I have reviewed and signed a risk vs. benefit form addressing the pros and cons with materials close to body that may cause increased infection and UTI. Date initiated: 12/27/23. [sic]Resident #4's comprehensive care plan failed to show the updated interventions for incontinence products, education provided to the resident on the risks vs benefits of the new products, and the facility's change in the incontinence product which the resident felt was not working. Review of resident #7's comprehensive care plan with a revision date of 10/2/25 showed: .Focus: ADL's with bowel and bladder,Goal: Interventions with brief insert,Interventions: I have reviewed and signed a risk vs. benefit form addressing the pros and cons with materials close to body that may cause increased infection and UTI. Date Initiated: 12/27/2023.Resident #7's comprehensive care plan failed to show the updated interventions for incontinence products, education provided to the resident on the risks vs benefits of the new products, and the facility's change in the incontinence product, which the resident felt was not working.

Based on observation, interview, and record review, the facility failed to inform and educate residents when there was a change in incontinence treatment/products, for 2 (#s 4 and 7) of 8 sampled residents. The lack of facility communication and explanation caused resident #4 and #7 to be upset and frustrated. Findings include:During an observation and interview on 12/30/25 at 9:11 a.m., resident #4 stated, The staff told me I cannot wear a liner and a brief anymore because 'The State' told them they couldn't allow it. I just think the facility doesn't want to spend money. They are making us use these reusable liners, and they are very small. I have talked to the staff about how much I don't like them, and they just say I have to use them. I want to go back to the big liners I had before. I could buy them myself, but I don't think I should have to. I am frustrated because I have had more accidents. The facility hasn't explained to me why they changed; they just did it. Resident #4 pointed at her dresser and stated, Look, the reusable ones are up there. The reusable liners were black in color, small, thin, and lightweight. Resident #4 appeared sad and frustrated during this conversation.During an interview on 12/30/25 at 12:06 p.m., staff member B stated some residents want to wear a brief and a liner, so they don't need to be changed as often throughout the day. Staff member B stated, We are trying different things with them (residents), such as toileting schedules and reusable liners that wick away moisture. We educated residents during the resident council about skin breakdown and moisture. During an interview on 12/30/25 at 12:27 p.m., staff member A stated, Double briefing is never good, and residents need air flow down there (perineal area) to prevent skin breakdown. We have tried several different types of incontinence products, and the reusable (products) seem to wick away more moisture. We ordered different sizes and tried them on three different residents. I went over the purpose and education that I presented to staff at the resident council meeting. I will get those minutes for you.During an interview on 12/30/25 at 1:56 p.m., resident #7 stated, I am having too many accidents, and the little reusable pads just aren't working for me. I like the big ones. Resident #7 stated, What would happen if I had a moment and bought the big disposable ones myself.During an interview on 12/31/25 at 8:09 a.m., staff member A stated, I could not find any documentation of us educating residents on the benefits of the reusable incontinence liners.Review of resident #4's comprehensive care plan with a revision date of 4/14/25 showed: .Focus: ADL's with bowel and bladder.Goal: Interventions with brief with insert.Interventions: I have reviewed and signed a risk vs. benefit form addressing the pros and cons with materials close to body that may cause increased infection and UTI. Date initiated: 12/27/23. [sic]Review of resident #4's physician order, dated 12/4/2023, showed: Active: Patient may use inconsistence inserts per patient preferences. Notify provider of any skin breakdown. [sic]A request was made on 12/31/25 at 7:56 a.m. for documentation confirming education provided to residents about the new liners and skin breakdown. The facility did not provide documentation of education provided to residents about new incontinence products by the end of the survey period.

Based on interview and record review, the facility failed to document the wound identified by the physician, to properly assess during skin checks, treat, and monitor a facility acquired diabetic ulcer for a resident with a history of diabetes, neuropathy, and sores on the feet, for 1 (#1) of 13 sampled residents. The deficient practice contributed to the deterioration of the wound, which resulted in the resident's right great toe being amputated. Findings include: On 11/4/25 at 11:45 a.m., the Administrator, Chief Nursing Officer, and Corporate Resource Nurse, were notified that an Immediate Jeopardy existed in the area of F684, Quality of Care, related to the failure to identify, monitor, and treat a diabetic ulcer for a resident with a history of neuropathy, diabetes, and sores on the feet. The failure resulted in the resident's hospitalization and amputation of the right great toe. This affected one resident (resident #1) of those sampled. The Severity and Scope identified for the Immediate Jeopardy were determined to be at the level of J. The facility provided an acceptable plan to remove the immediacy, and the plan was accepted by the State Survey Agency. Upon removal of the immediacy, the severity and scope were lowered to a G. The facility carried out the plan to remove the immediacy, which was verified onsite by surveyors, on 11/5/25 at 10:43 a.m.Review of resident #1's physician note, dated 6/27/25, showed: . He (Resident #1) also complained about some foot wounds as noted below. We discussed having him seen by wound care and he was amendable. The bilateral feet as imaged below with distal right great toe wound and the appearance of blisters of the distal left toes. The physician's Assessment/Plan showed: ? Ulcerative callus of the dorsal right great toe # left distal toe wounds .-would benefit from seeing wound care with his vasculopathy status, high risk-wound care referral placed today . [sic]a. Risk and History of Wounds: Review of a facility document titled Nurse/Provider Communication Form, dated 1/23/24, showed the resident presented with an open friction area to the right great toe and a scabbed area to the right middle toe.Review of a document titled, Wound Tracker Form, dated 6/29/24, showed Resident #1 was seen by wound care that day, and notes showed the resident had wounds on the Right distal 4th and 5th toe, both due to being cut while clipping his nails. The resident had a documented history of toe wounds. Review of resident #1's skin and wound evaluation documentation, dated 6/29/24, showed, . A. Describe . 22a. Other, specify, toe nails clipped to close . 23. Acquired: In-house Acquired 24. How long has the wound been present? . 1. New . G. Orders 1. Goal of Care: Healable .I. Progress .Notifications: No response .b. Diagnoses:Review of resident #1's diagnoses listing showed the following: - Type II Diabetes Mellitus without Complications, with a date of 5/28/25, and a created date of 5/29/25, which was on re-admission. - Polyneuropathy, Unspecified, with a date of 5/28/25, and a created date of 5/29/25, which was on readmission. - Pressure Ulcer of Other Site, Unstageable, with a date of 9/25/25, and a created date of 10/21/25, which was added during the resident's stay. - Type II Diabetes Mellitus with Foot Ulcer, with a date of 9/25/25, and a created date of 10/21/25, which was added during the resident's stay. - Non-pressure Chronic Ulcer of other Part of Right Foot with Fat Layer Exposed, with a date of 9/25/25, and a created date of 10/21/25, which was added during the resident's stay. The facility failed to identify the diabetic foot ulcer on resident #1's right great toe, identified by the physician in June of 2025, until September 2025. The facility staff did not add the right great toe wound to the diagnoses listing until 10/21/25.c. Care Plan: Review of resident #1's care plan showed, .Focus: [Resident #1] has physical functioning deficit related to: CVA, Repeated Falls, Other Lack of CoordinationInterventions: .-Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse, date Initiated: 8/16/23Focus: Risk for alteration in skin integrity r/t DM2, ESRD, CVA, incontinence, weakness, date Initiated: 6/4/25Goal: Skin will not show signs of skin breakdown through the next review dateInterventions: - Rx'd TX to R great toe diabetic ulcer (see orders) date Initiated: 10/21/25, Revision on: 10/22/25Notify physician as needed, date initiated: 6/4/25. Weekly skin assessment per facility protocol, date initiated: 6/4/25. Based on the review of resident #1's care plan, the facility did not identify the diabetic foot ulcer, the associated diagnoses, or pertinent interventions for the right toe ulcer until 10/21/25, and information was added to the care plan on 10/22/25. Although the resident had a long history of toe wounds, the care plan was shown to be ineffective, as shown by the delay in care, treatment, and documentation to address the right great toe wound. During an interview on 10/29/25 at 1:02 p.m., staff member C said that when a skin issue was identified, the nurses would write a progress note, which would alert administrative staff by use of the 24-hour report, and it was then reviewed by the IDT. Staff member C stated care plans were reviewed weekly to ensure interventions were being done. If there were progress notes related to skin issues, the DON and or ADON would discuss the skin issues with the staff. Staff member C said all residents' wounds were monitored, they had through measurements, and weekly wound assessments. Staff member C stated that the effectiveness of the wound care treatments is evaluated by the healing of the wound. Staff would communicate with the provider if the wound was not healing. Staff member C stated she would expect a toe wound to be care planned. Staff member C stated she was aware of resident #1's toe wound but was not aware of its history.During an interview on 11/5/25 at 10:42 a.m., staff member G stated that when a skin issue was identified, she would report it to the nurse. Staff member G stated that any type of bruise, skin tear, blister, or wound would be reported to the nurse. Skin assessment sheets would be completed to include the description and location of the wound.During an interview on 11/5/25 at 12:09 p.m., staff member E stated she rounded with the wound care provider at the facility. Staff member E stated the nursing staff would know there was a skin issue with a resident because it would be identified in the physician's orders and treatment would be on the TARs. Staff member E said that when a resident went out for wound care, the process would be to contact the provider to get the progress notes and update the physician's order. Staff member E stated resident #1 was not seen by the wound care provider because resident #1 was out of the facility on the days the wound care provider came to the facility.During an interview on 11/5/25 at 1:02 p.m., staff member H stated when a skin issue was identified, the nurse would complete wound measurements, and the provider would be notified.During an interview on 11/10/25 at 1:30 p.m., staff member I, stated he identified concerns with resident #1's right great toe in June 2025. Staff member, I stated it was his expectation of facility staff to identify and provide ongoing monitoring for diabetic residents with a history of toe wounds, and to provide preventative measures, such as floating the resident's heels, weekly skin checks, and diabetic foot care. Staff member I stated he communicated this to the facility as the standard of care.d. Assessments and Treatment of Right Great Toe:Review of resident #1's primary care progress note, dated 8/1/25, showed, . Has sore to top of right great toe, area has minimal drainage, nonodorous .Assessment/Plan# ? ulcerative callus of the dorsal right great toe# left distal toe wounds, improved .- Will order Mupirocin ointment to be placed to both ares BID x 7 days. Has been using Triple abx. ointment w/out any resolve.-Monitor and report any worsening . [sic]Review of resident #1's weekly head-to-toe skin checks, performed by the facility's licensed nursing staff, showed the following for the right great toe wound and assessments:- 7/2/25, No skin issues - Although the resident had an identified right great toe wound in June of 2025.- 7/9/25, No skin issues- 7/16/25, No skin issues- 7/23/25, No skin issues- 7/30/25, No skin issues- 8/6/25, Skin issues noted .Right toe(s) - R great toe skin alteration- 8/17/25, Skin issues noted, right great toe wound- 8/24/25, Skin issues noted, . Right toe(s) - scabbed area medial R great toe. Antibiotic ointment as per (physician) order. - 8/27/25, Skin issues noted . Antibiotic ointment applied as per order - The right great toe was not addressed- 9/9/25, Skin issues noted . sore to right great toe- 9/16/25, Skin issues noted - the right great toe was not addressed- 9/23/25, Skin issues noted, Right great toe, old wound still healing- 10/1/25, Skin issues noted, Right toe(s) - small wound on the right great toe, scab formed, edema around the wound.- 10/8/25, Skin issues noted, Right great progressing well. Healing-10/15/25, Skin issues noted, Right great toe sore healing well.-10/18/25, Skin issues noted, Right toe(s) - toe wound in state of healing.Review of resident #1's medication administration record for July and August 2025 showed no Mupirocin External Ointment 2% doses were administered as ordered by the physician. Review of resident #1's History and Physical, obtained from the wound care clinic, dated 7/8/25, showed the facility sent the resident to the wound clinic without relaying concerns or providing documentation and or details on the resident's skin concerns, including the ulcer on the right great toe. Documentation completed by the wound clinic showed the following: Chief Complaint.Sent from [Facility Name] for wounds. Unsure where any wounds are. No documentation from [Facility Name] on wound Known diabetic. Known vasculopathy.The patient states his chief complaint is 'wound care'.Unfortunately, no documentation from [Facility Name] about why patient is here and patient cannot explain this himself.Did not have any pressure, diabetic, venous, or arterial ulcer that I could appreciate.Sent back to [Facility Name] with return precautions given.-RTC: PRN. No documented ulcers that we could appreciate. Would appreciate documentation from [Facility Name] if patient does have wounds. Educated [Facility Name] should do routine wound checks and Braden scores . [sic] Review of resident #1's geriatric service note, dated 7/10/25, showed, .The bilateral feet as imaged below with distal right great toe wound and the appearance of blisters of the distal left toes.Assessment/Plan# ? ulcerative callus of the dorsal right great toe# left distal toe wounds.-Continue to monitor . [sic]Review of resident #1's primary care progress note, dated 8/29/25, showed, . He (Resident #1) continues to have a wound to his right great toe, and we discuss having him seen wound care at [Facility Name]. He is agreeable to this. I do ask staff to ensure he is on their list . Integumentary: Warm, dry. Has sore to top of right great toe, area has minimal drainage, nonodorous. Has 1 cm round scabbed area to top of right great toe. [sic]Review of resident #1's medication and treatment administration records for June, July, and August 2025 showed:June 2025: Mupirocin External Ointment 2%, Apply to toes topically as needed for sores on toes. There were no doses administered in June. July 2025: Mupirocin External Ointment 2%, Apply to toes topically as needed for sores on toes. There were no doses administered in July. August 2025: Mupirocin External Ointment 2%, Apply to Right great toe topically two times a day for Toe Sore for 7 days, start date 8/1/25. This was documented as being completed.-Mupirocin External Ointment 2%, Apply to toes topically as needed (prn) for sores on toes. There were no PRN doses administered in August 2025.Review of resident #1's EHR showed SBAR progress note, dated 9/1/25, which included: Situation: patient co (complains of) redness and pain in right foot. Black spot noted on great toe, redness on all toes. Background/Date: Diabetic in a wheelchairBackground: no response Assessment: no responseAssessment (RN)/Appearance(LPN): black spot on great toe. redness on all toes on right foot. Recommendation: pt would like the provider to assess feet. Response: no responseReview and notify (New interventions/recommendations) (Time and person(s) notified): no response Review and Notification: no response Response: Name of family member notified and time of notification: no response Response: Name of MD notified and time of notification.: no response [sic]Review of resident #1's primary care progress note, dated 9/4/25, showed, . [Resident #1] tells me today he is worried about his foot. He reports it started turning red a few days ago and feels warm. He has also not had any drainage from his great toe ulceration which he has had for a while. Has sore to top of right great toe, area has minimal drainage, nonodorous. Has 1 cm round scabbed area to top of right great toe. New area of redness noted to all five toes to right foot, Worse on exam compared to prior exam. Concern for Cellulitis with worsening redness to right foot compared to 8/29/25 visit. Discussed abx. and will start Doxycycline 100 mg BID x 10 days. Will be seen by Wound Care at [Facility Name] next week. [sic]Review of resident #1's primary care progress note, dated 9/13/25, showed the physician discussed wound care with the resident and it was decided it would be better to have the resident go to the wound care clinic downtown because he was at dialysis when the wound care rounds were done at the facility, so he missed them. The physician documented, . his wound to his right great toe remains. He was to see wound care earlier this week on Monday, however missed her as he was at dialysis. The physician documented he would notify the facility to set up the appointments at the wound care clinic. Review of resident #1's wound care progress note, dated 9/25/25, showed, . The patient states his chief complaint is 'wound care.' History of Present Illness, The DFU (diabetic foot ulcer) is located on the r (right) great toe . status is worsening. This problem is not self-limited. The ulcer is limb-threatening. It is currently a [NAME] 1 ulceration. It has had a significant impact on functional capacity and/or quality of life. [sic]Review of resident #1's wound care patient instructions, dated 9/25/25, showed, . Orders, Pressure Ulcer - R great toe . Pressure ulcer of other site, Unstageable Onset 8/25/2025 - First Noted: 9/25/25 . The plan for the pressure ulcer is to cleanse the area with normal saline . Primary Dressing: 1. Therahoney, Secondary Dressing: 1. PolyMem, This treatment will be done 3 times per week for 1 week. [sic]Review of resident #1's medication administration record for October 2025 showed the physician's order for wound care on the right great toe, which was to apply Thera honey and polymed, was not started until 10/4/25, nine days after the physician's order was given. Review of resident #1's wound care progress note, dated 10/9/25, showed, . The DFU is located on the r great toe. The problem's status is worsening . Pain at the DFU is a 6 on a scale of 0 to 10. The pain is continuous.Review of resident #1's wound care progress note, dated 10/16/25, showed, . History of Present Illness . Pain at the DFU is a 9 on a scale of 0 to 10. The pain is continuous. The pain was documented as more severe than the prior wound care progress notes and assessments. Review of resident #1's primary care progress note, dated 10/17/25, showed, . Area to right great toes has increased in size since last assessed, with redness on his entire foot.Review of resident #1's weekly skin and nutrition IDT review, dated 10/23/25, showed resident #1 had a vascular/stasis ulcer, had skin break down on the right great toe, it was necrotic, and the resident was on an antibiotic for an infection in the toe. The overall wound status was declining/worsening.Review of resident #1's wound care progress note, dated 10/23/25, showed, . The DFU is located on the r great toe. The problem's status is worsening. This problem is not self-limited. The ulcer is limb threatening. It is currently a [NAME] 4 ulceration. It has had a significant impact on functional capacity and/or quality of life. Pain at the DFU is a 10 on a scale of 0 to 10. The pain is intermittent. Provider Comments .#Necrotizing fasciitis-Has acutely decompensated. Although was having culture directed antibiotic therapy, with TCOM showing essentially nonexistent oxygenation of the foot I do worry about antibiotic penetration.-Called ED. Patient will be transported by staff. [sic]Review of resident #1's notice of Transfer/Discharge for the facility, dated 10/23/25, showed the resident was admitted to the hospital from a wound care appointment. Review of resident #1's infection surveillance form, with a lock date of 10/27/25,showed, . 7. FOLLOW UP . 4. Comments: Resident hospitalized for wound infection IV ABX in place resident had necrotizing fasciitis with amputation of R Great toe continues to be hospitalized at this time . [sic]Review of the facility's policy titled Wound Treatment Management, Reviewed/Revised 5/15/2025, showed: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Treatment selection will consider wound etiology, condition, resident preferences, and risk factors.Policy Explanation and Compliance Guidelines: . 2. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.5. Treatment decision will be based on: a. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage.b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including shape, depth, and presence of a tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed.c. Location of the woundd. Goals and preferences of the resident/representative.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for the needed modifications include: a. Lack of progression toward healing.b. Changes in the characteristics of the wound . c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

Based on interview and record review, the facility failed to ensure a resident's comprehensive care plan contained information related to the diagnosis, care, and monitoring of a diabetic ulcer on a resident with a history of diabetes and neuropathy for 1 (#1) of 13 sampled residents. Findings include:Review of a facility document titled Nurse/Provider Communication Form, dated 1/23/24, showed the resident presented with an open friction area to the right great toe and a scabbed area to the right middle toe.Review of a document titled, Wound Tracker Form, dated 6/29/24, showed Resident #1 was seen by wound care that day, and notes showed the resident had wounds on the Right distal 4th and 5th toe, both due to being cut while clipping his nails. The resident had a documented history of toe wounds.Review of resident #1's diagnoses list showed:-Type II Diabetes Mellitus without complications, with a date of 5/28/25, and a created date of 5/29/25 (identified on readmission),-Polyneuropathy, unspecified, with a date of 5/28/25, and a created date of 5/29/25 (identified on readmission),-Type 2 Diabetes Mellitus with Foot Ulcer, with a date of 9/25/25, and a created date of 10/21/25 (identified during stay),-Non-Pressure Chronic Ulcer, of Other Part of Right Foot, With Fat Layer Exposed, with a date of 9/25/25, and a created date of 10/21/25 (identified during stay).Resident #1's diagnosis list showed the facility did not identify the diabetic ulcer on resident #1's toe until September 2025. The facility did not add it to the resident's diagnoses list until 10/21/25. Review of resident #1's care plan, with a revision date of 10/22/25, showed:-Focus: Risk for alteration in skin integrity r/t DM2, ESRD, CVA incontinence, weakness, date initiated: 6/4/25.-Goal: Skin will not show signs of skin breakdown through the next review date, date initiated: 6/4/25.-Interventions: Rx'd Tx to R great toe diabetic ulcer (see orders), date initiated: 10/21/25.-Assess need for ADL assistance in bed mobility and transfers, provide assistance as needed, date initiated: 6/4/25.-Notify physician as needed, date initiated: 6/4/25.-Weekly skin assessment per facility protocol, date initiated: 6/4/25.The comprehensive care plan did not show the residents history of sores on the feet, even though the resident had identified skin/foot problems back in 2024, and the plan did not contain information on the resident's current condition until 6/4/25. The comprehensive care plan also failed to provide preventative interventions for resident #1's diabetic foot ulcer or issues with the feet. During an interview on 10/29/25 at 10:32 a.m., staff member F stated if she noticed a change with a resident or if there was a new skin issue, she would notify the nurse, and the nurse would add the concern to the care plan. Staff member F also stated the nurses would let staff know of any changes added to the care plan, which would occur during shift change report.During an interview on 10/29/25 at 1:05 p.m., staff member C stated the charge nurses are responsible for care planning for any newly identified resident issues or changes in the resident's condition. Staff member C stated she would expect nurses to include preventative measures in the care plan when an issue was identified with a resident. Staff member C stated care plans are what directs resident care and should reflect the resident's needs.During an interview on 11/5/25 at 10:25 a.m., staff member E stated she would add any changes in the resident to the resident's care plan, including interventions such as pressure-relieving mattresses, offloading boots for feet, and any other special needs. Staff member E stated that any preventative measures for a resident should be care planned.During an interview on 11/5/25 at 1:42 p.m., staff member D stated she would let the nurse know if a new skin issue was identified, and the nurse would care plan for the skin concern. Staff member D stated staff will read the resident care plans and would notify the nurse if there was something missing on the care plan. Resident #1's care plan failed to show his history of issues with the feet and failed to provide preventative interventions to guide staff in his cares.

Based on interview and record review, the facility failed to ensure staff had the competencies and skills to identify, assess, document, and monitor a diabetic ulcer for 1 (#1) of 13 sampled residents. This increased the residents' risk of infection and resulted in hospitalization and amputation of the resident's great toe. Findings include: Review of a physicians visit note, dated 6/27/25, showed resident #1 had a diabetic ulcer on the right great toe.Review of resident #1's weekly head to toe skin checks performed by the facility staff showed the following:- 7/2/25, No skin issues- 7/9/25, No skin issues- 7/16/25, No skin issues- 7/23/25, No skin issues- 7/30/25, No skin issues- 8/6/25, Skin issues noted, Left lower leg - scab, Right toe(s) - R great toe skin alterationThe licensed nursing staff did not properly assess and document the resident's skin concerns when skin checks were completed and failed to identify the wound documented by the physician on 6/27/25.The medication administration record for July and August 2025 did not show evidence that staff administered the physicians' order for Mupirocin External Ointment 2%.During an interview on 10/29/25 at 1:05 p.m., staff member C stated, We (management) go through all physician orders during our morning meetings. The nurses are responsible for care planning and are supposed to write a progress note based on the skin assessment every time a skin assessment is performed. Staff member C stated, I go around every morning and do a huddle with the nurses, and then nurses do a daily huddle with CNAs . Staff member C stated wounds should be looked at weekly by a physician during physician rounds, and a note should be documented. Staff member C stated the nurses should do a weekly skin assessment in PCC and evaluate the wound by measuring the healing of the wound, and if it is not healing, they should inform the provider. During an interview on 11/5/25 at 10:25 a.m., staff member E stated, I do skin checks weekly. Sometimes skin issues might get missed on the skin checks, it just depends on how thorough the skin check is done . If I do identify a skin issue during the assessment, I would document it in the TAR or right on the UDA. PCC auto populates residents who are due for a skin check each day. It is always good when the skin check can be done during a bath day . I feel they are more thorough then. If they aren't scheduled for bath days, then we try to do them while staff are doing cares. [sic]During an interview on 11/5/25 at 12:28 p.m., staff member E stated, .If a resident had ongoing skin issues it should be on the TAR, in progress notes, and in the care plan. Staff member E stated, I have not had formal wound care training, but I have learned a lot by assisting the wound care clinic that comes to the facility. The only specialized training I have received was for wound vacs. Staff member E stated, I am very confident in my ability to fill out skin assessments, I would say I'm a 10/10. Staff member E stated, She would look at feet, toes, and heels for anyone with diabetes . Staff member E stated, A nick on the toe can go a long way on someone with diabetes.Record review of resident #1's skin check documentation and progress notes showed licensed nursing staff did not identify resident #1's diabetic foot ulcer during weekly skin checks for the month of July, and the licensed nursing staff failed to follow-up with the physician after the identification of a diabetic toe ulcer on 6/27/25.During an interview on 11/10/25 at 1:30 p.m., staff member I stated he was the physician who identified concerns with resident #1's right great toe in June 2025. Staff member I stated it was his expectation of facility staff to identify and provide ongoing monitoring for diabetic residents with a history of toe wounds, and to provide preventative measures such as floating the heels, weekly skin checks, and diabetic foot care. Staff member I stated he communicated this to the facility as the standard of care.Review of the residents' medical record showed resident #1 went to a wound care appointment on 10/23/25 and was sent by the wound care facility to the hospital for IV antibiotic treatment and amputation of the right great toe. This was a result of the facility failing to provide necessary services for the early identification of the wound and ongoing treatment, to maintain communication with the physician, and to provide preventative interventions.Refer to F684 - Quality of Care - for more detail related to the resident's foot wound and care concerns.

Based on interviews and record review, the facility neglected to ensure newly admitted residents were provided antibiotic and pain medications in a timely manner, to ensure the treatment of infections and pain was provided as necessary, for 3 (#s 73, 81 and 109) of 4 recently admitted residents. Resident #73 did not receive medications during his stay and resident #73 discharged home against medical advice. Resident #81 did not receive two doses of IV antibiotics which necessitated his re-admission to the hospital. Resident #109 was returned to the emergency room for further treatment. The neglect of care directly pertained to the facility pharmacy delivery program, oversight, and management of the system, and the medication system was not corrected in a timely manner to ensure negative resident outcomes, and neglect, were prevented. Findings include: 1. Review of resident #73's nursing progress notes showed he was admitted to the facility on [DATE] at 2:03 p.m., with a diagnoses of left lower lobe pneumonia and sepsis (infection). The note showed the medications were entered into the electronic medical record system and verified by two nurses. Review resident #37's pharmacist note, dated on 3/5/25 at 8:32 p.m., showed there was no irregularities noted. Review of resident #73's March 2025, medication administration records showed, No Order data found for MEDICATION ADMINISTRATION RECORD, No medications had been administered to resident #73 during his stay in the facility. Review of #73's social service note, dated 3/6/25 at 12:28 p.m., showed this was a late entry note, which included: [#73] and the family wanted him to leave the facility. The social services progress note showed resident #73 expressed that he wasn't being helped. This was the only note about what happened. There was no nurses not indicating there was any issue. I tried to call the resident and he didn't return my call. Resident #73 said the reason for him leaving was because medications were not being received. Resident #73 stated he suffers pain in his neck and back. Resident #73 has chronic pain and is under a pain contract. Review of resident #73's admission orders, as written and sent from the [Hospital Name] listed all his regular maintenance medications and showed the resident was to have received lovenox to prevent blood clots and the following medications for pain: - Tylenol 650 mg every 6 hours, - Gabapentin 400 mg three times a day, - Ibuprofen 400 mg as needed three times a day, - Tizanidine 2 mg every eight hours as needed, - Oxycodone 5 mg every six hours as needed. Review of resident #73's facility order summary report showed the only two physician orders documented was for the head of resident #73's bed to be up to prevent shortness of breath, and for a pain to be assessed per a pain scale, three times a day. No documented results were observed for these orders. During an interview on 3/24/25 at 9:40 a.m., NF1 said from the time resident #73 arrived at the facility until the next morning, resident #73 did not receive any medications. NF1 stated, resident #73 was on routine pain medications, and the providers would try to get resident #73 the medications he needed so a proper discharge could be provided. NF1 said the resident left against medical advice due to the lack of care. During an interview on 3/27/25 at 1:47 p.m., staff member D said there were no entries made to resident #73's medication administration record. Staff member D said without anything on the EMAR (electronic medication administration record) medications wouldn't have been given. 2. Review of resident #81's nursing progress notes showed resident #81 was admitted on [DATE] at 3:50 p.m. In addition to resident #81's routine maintenance medication, resident #81 was to be given Cefazolin 2000 by intravenous route every eight hours. Review of the [Hospital Name] after visit summary showed resident #81 had been hospitalized and treated for right septic shoulder and methicillin resistant staphylococcus aureus bacteremia. The after-visit summary contained the medication orders resident #81 was to receive. This summary showed resident #81 would be managed with IV (intravenous) antibiotics with an anticipated end of therapy date of 3/1/25. Review of resident #81's medication administration record for February 2025 showed, no doses of the cefazolin antibiotic was administered. The time frame on resident #81's medication administration record showed the resident missed two doses of antibiotics before he was discharged back to the hospital on 2/7/25 at 12:21 p.m., which was just under 24-hours from admission. During an interview on 3/24/25 at 9:40 a.m., NF1 said resident #81 was sent back to the hospital because he needed his IV antibiotics. NF1 said resident #81 was being treated for a septic (infection) shoulder and he needed IV antibiotics to treat the condition. During an interview on 3/25/25 at 8:00 a.m., NF2 said that resident had not been seen at the facility until 2/7/25. NF2 said resident #81 had not received any of his IV antibiotics because the staff had not found them. NF2 said the IV antibiotics hadn't been mixed and both nurses were LPN's and not able to mix the medications. NF2 said it did not look like he was going to get a dose of antibiotics any time soon, so he was sent back to the hospital. NF2 said the facility tells the providers they have pharmacy issues figured out, but these things keep happening. 3. Review of resident 109's nursing note, dated 3/19/25, showed the resident was admitted at 6:00 p.m. with a diagnoses of cellulitis with an abscess of the left foot, abscess of left thigh, and narcotic dependence. Review of resident #109's progress note, written by staff member A, dated 3/20/25, showed resident #109 was distressed about her pain. The note showed, It was when there was a lull in the conversation that she began focusing on her pain again. Review of resident #109's medication administration order showed resident #109 was to be given Vancomycin HCL 1750 mg intravenously two times a day until 4/6/2025. Review of resident #109's medication administration record showed resident #109 was not given any doses of the IV Vancomycin which was ordered. According to the medication administration record, she should have received one vancomycin dose during the time between the admission and when she was discharged at 9:30 a.m., to the emergency room. Review of resident #109's notice of transfer/discharge form dated 3/20/25 showed, resident #109 was transferred to the emergency on 3/20/25 at 9:30 a.m. The form showed resident #109 was transferred to the hospital for her health and safety because resident #109 pulled her picc line out. Review of #109's nursing progress notes, dated 3/20/25, failed to show when resident #109 pulled out her picc line, was transferred to the emergency room, or her mode of transportation to the ER. Review of #109's nursing progress note, dated 3/20/25 at 6:18 p.m., showed resident #109 returned from [Hospital Name] emergency department. The note showed new physician orders were received for oral antibiotics for resident #109. Review of resident #109's medication administration record showed resident #109 was given Hydrocodone on 3/21/25 at 9:48 a.m., STAT for possible opioid withdrawal symptoms. Review of resident #109's nursing progress notes, dated 3/24/25 at 8:54 a.m., showed resident #109 was to receive Linezolid 600 mg for cellulitis (infection). The nursing note showed the facility was out of stock for the medication and no Linezolid was available in the Nexsys (automated dispensing unit) machine. Resident #109's infection was to be treated with Linezolid through 4/10/15 at 6:00 p.m. During an interview on 3/25/25 at 8:00 a.m., NF2 said medications were not entered timely on resident #109's medication administration record, and she missed doses of antibiotics. Resident #109 pulled her picc line out sometime after admission. NF2 said resident #109 was a chronic user of hydrocodone. While in the hospital resident #109 received dilaudid and oxycodone. NF2 said the pharmacy did not give the staff a Nexsys code, allowing the nurse to pull a medication out of the backup system, and resident #109 ended up back in the emergency room for pain management and to have her picc line replaced. NF2 said she saw resident #109 on 3/21/25, and resident #109 was going through opioid withdrawal as she was sweating, thrashing, restless, and anxious. During an interview with staff member A and D on 3/25/25 at 11:00 a.m., staff member D said the facility started using a system for communication with the pharmacy to help improve communication and tracking. This is still early in its use but seems to be working so far. Staff member D said when the medications get ordered, and the pharmacy is aware of the physician orders by 2:00 p.m., the pharmacy ships the medications overnight, and the medications will be available the next day. If the medications aren't ordered prior to 2:00 p.m., the medications will not be delivered until two days later. Staff member A said there are medications that can be sent via a local satellite pharmacy. Staff member B said there are two local pharmacies which are used the most, but the facility will go anywhere needed to get the medications. During an interview on 3/25/25 at 11:09 a.m., staff member B said resident #109 was getting dilaudid and strong pain medications when she was in the hospital. She only had an order for hydrocodone when she admitted . She was having pain and pulled her picc (peripherally inserted central catheter) IV out. Staff member B said she tried to get resident #109 pain medications, but the correct prescription had not been sent to the pharmacy. Staff member B said she called the provider, and the prescription was sent to the pharmacy. The pharmacy sent a code which would allow the nurse to remove a dose of medication from the Nexsys system. The nurse did not enter the code in time, and the machine locked, preventing the removal of the narcotic. The nurse called the pharmacy for another code, but the pharmacy refused to give her another code. The resident did not get her pain medication. Staff member B said on the morning of 3/20/25, she contacted the provider, and a prescription was sent to a local pharmacy. Staff member B said she delivered Hydrocodone to the facility for resident #109, but she had been sent to the hospital. Staff member B also said resident #109 pulled her picc line out around 8:00 a.m. During an interview with resident #109 on 3/26/25 at 2:00 p.m., resident #109 said she did not get pain medication when she first came to the facility. Resident #109 stated, I thought I was going to die. Resident #109 stated her anxiety has gotten worse and now she is scared and afraid to be in pain. Resident #109 said she gets her pain medication on a schedule, except for one night nurse, and that nurse makes her wait for the pain medication. Review of #109's nursing progress note dated 3/24/25 at 8:54 a.m., showed resident 109 did not receive the am dose of linezolid 600 mg that was ordered twice a day for cellulitis. The nurses note showed there was no medication available in the nexsys (backup stock supply). Linezolid was ordered to start 3/20/25 to continue through 4/10/25. No doses were available to ensure antibiotics were given to resident #109, every twelve hours, as ordered by the physician. During an interview on 3/27/25 at 8:37 a.m., NF3 said he attended the QAPI meetings every month. NF3 said pharmacy issues were discussed, but the pharmacy issues revolved around the gradual dose reductions as recommended by the pharmacy. NF3 said the current pharmacy is located out of state, but the facility is trying to bridge issues with the help of local pharmacies. NF1 said he does not recall being informed of issues with getting particular medications. NF3 said he was not aware of any specific residents not getting antibiotics or pain medications. During an interview on 3/27/25 at 2:42 p.m., staff member E said the operating company just changed over pharmacies and medications are delivered to the facility from Idaho. The facility just initiated a system with the pharmacy to help with communication, and this will also allow for better tracking of medications. Staff member E said she was aware of some of the pharmacy issues, but not all of them, as she managed operations. Staff member E said she would expect the medical director would be made aware of issues with the pharmacy as the medical director is fairly involved in the facility.

Based on interviews and record review, the facility failed to ensure necessary medications were available for use when residents were admitted , or prior to the first dose being administered, for newly admitted residents, which resulted in the residents not receiving the medications (pain and antibiotics) at all, or not timely, and this caused negative outcomes due to the significant medication errors, for 3 (#s 73, 81, and 109) of 4 sampled residents for medication errors. Resident #73 received no medications from admission to discharge; resident #81 did not receive IV antibiotics and needed to be sent back to the hospital for treatment; and #109 did not receive pain or antibiotic medications, as needed. Findings include: 1. Review of resident #73's nursing progress notes showed he was admitted to the facility on [DATE] at 2:03 p.m., with a diagnoses of left lower lobe pneumonia and sepsis. The note showed the medications were being entered into the electronic medical record system for #73. Review of resident #73's March 2025, medication administration records showed no medications had been placed on the medication administration record, and resident #73 did not receive any medication while he was a resident at the facility. Review of resident #73's admission physician orders, as written and sent from the [Hospital Name] listed all his regular maintenance medications and showed the resident should have received the following medications and the number of medication errors for each: - Tylenol 650 mg every 6 hours - missed three doses, - Duloxetine 20 mg - missed one dose, - Enoxaparin 40 mg - missed one dose, - Gabapentin 400 mg - missed two and possibly three doses, - Lidocaine 4% patch - did not have patch removed, - Pantoprazole 20 mg - missed two doses, - Tamsulosin 0.4 mg one dose missed, - Ibuprofen 400 mg - as needed three times a day for pain, - Tizanidine 2 mg every eight hours as needed for pain - potential for two doses missed, - Oxycodone 5 mg every six hours as needed for pain - potentially one or two doses missed. Review of facility order summary dated 3/5/25 showed resident #73 had an opioid dependence, osteoarthritis left hip, cervicalgia, low back pain, and muscle spasms. Resident #73 has chronic pain and is under a pain contract. During an interview on 3/24/25 at 9:40 a.m., NF1 said from the time resident #73 arrived at the facility, until the next morning, resident #73 did not receive any medications. NF1 stated resident #73 was on routine pain medications and would be having significant pain. NF1 requested the staff to encourage the resident to wait at the facility so prescriptions could be managed, and resident #73 could get medications and a proper discharge could be completed. NF1 said the resident left against medical advice. During an interview on 3/27/25 at 1:47 p.m., staff member D said there were no entries made to resident #73's medication administration record. Staff member D said without anything on the EMAR (electronic medication administration record) medications wouldn't have been given. Staff member said resident #73 discharged against medical advice because he had not been given medication. 2. Review of resident #81's nursing progress notes showed resident #81 was admitted on [DATE] at 3:50 p.m. In addition to resident #81's routine maintenance medication, resident #81 was to be given cefazolin, an antibiotic, 2000 mg (milligrams) by intravenous route, every eight hours. Review of the [Hospital Name] after visit summary showed resident #81 had been hospitalized and treated for a right septic shoulder and methicillin resistant staphylococcus aureus bacteremia. The after-visit summary contained the medication orders resident #81 was to receive at the facility, once transferred. This summary showed resident #81 would be managed with IV (intravenous) antibiotics and would need to stay on IV antibiotic therapy until 3/1/25. Review of resident #81's medication administration record for February 2025 showed, no doses of the cefazolin antibiotic was administered. The time frame on resident #81's medication administration record showed the resident missed two doses of antibiotics before he was discharged back to the hospital on 2/7/25 at 12:21 p.m. During an interview on 3/24/25 at 9:40 a.m., NF1 said resident #81 was sent back to the hospital because he needed his IV antibiotics. NF1 said resident #81 was being treated for a septic shoulder and he needed IV antibiotics to treat the condition. During an interview on 3/25/25 at 8:00 a.m., NF2 said that resident had not been seen at the facility until 2/7/25. NF2 said resident #81 had not received any of his IV antibiotics because the staff had not found them. NF2 said it did not look like the resident was not going to get a dose of antibiotics any time soon, so the resident was sent back to the hospital. 3. Review of resident 109's nurses note, dated 3/19/25, showed the resident was admitted at 6:00 p.m., with a diagnoses of cellulitis (infection) abscess of the left foot, abscess of left thigh, and narcotic dependence. Review of resident #109's medication administration record showed, resident #109 was not given any doses of the IV Vancomycin ordered. According to the medication administration record, she should have received one vancomycin dose during the time between the admission and discharge to the emergency room. Review of nursing progress note, dated 3/20/25 at 6:18 p.m., showed resident #109 returned from [Hospital Name] emergency department. The note showed resident #109 did not have a picc line replaced and new orders were received for oral antibiotics for resident #109. Review of resident #109's medication administration record showed resident #109 was given Hydrocodone on 3/21/25 at 9:48 a.m., STAT for possible opioid withdrawal symptoms. Review of resident #109's nursing progress notes, dated 3/24/25 at 8:54 a.m., showed resident #109 was to receive Linezolid 600 mg for cellulitis. The nurses note showed the facility was out of stock and no Linezolid was available in the Nexsys machine. Resident #109's infection was to be treated with Linezolid through 4/10/15 at 6:00 p.m. During an interview on 3/25/25 at 8:00 a.m., NF2 said medications were not entered timely on resident #109's medication administration record and she missed doses of antibiotics. NF2 said the pharmacy did not give the staff a code allowing the nurse to pull a medication out of the backup system, and resident #109 ended up back in the emergency room for pain management, and to have her picc line replaced. NF2 said she saw resident #109 on 3/21/25 and resident #109 was going through opioid withdrawal as she was sweating, thrashing, restless and anxious. During an interview on 3/25/25 at 11:09 a.m., staff member B said resident #109 only had an order for hydrocodone when she admitted to the facility. She was having pain and pulled her picc (peripherally inserted central catheter) IV out. Staff member B said she tried to get resident #109 pain medications, but the correct prescription had not been sent to the pharmacy. Attempts to obtain the medication were unsuccessful, and the resident did not get her pain medication. During an interview with resident #109 on 3/26/25 at 2:00 p.m., resident #109 said she did not get pain medication when she first came to the facility. Resident #109 stated, I thought I was going to die. Resident #109 stated her anxiety has gotten worse and now she is scared now and afraid to be in pain. Review of nursing progress note dated 3/24/25 at 8:54 a.m., showed resident 109 did not receive the a.m. dose of linezolid 600 mg that was ordered, twice a day, for cellulitis. The nursing note showed there was no medication available in the Nexsys (backup stock supply). Linezolid was ordered to start 3/20/25 to continue through 4/10/25. No doses were available to ensure antibiotics were given to resident #109 every twelve hours as ordered by the physician.

Based on interview, and record review, the facility failed to provide physician-ordered medications at the prescribed dose and frequency, for 3 (#s 73, 81, and 109); and failed to ensure the availability of prescribed medications resulting in re-hospitalization for one 1 (#81) resident, resulted in 1 (#73) resident discharging against medical advice, and 1 (#109) resident experienced opioid withdrawal, of 4 sampled residents for medication concerns. Findings include: a. Review of resident #73's nursing progress notes, dated 3/5/25, showed resident #73 was admitted to the facility following a hospitalization. The nurse's notes showed the physician orders were being entered into the resident's electronic health record. Review of #73's pharmacist note, written at 8:32 p.m. on 3/5/25, showed there were no irregularities with the medications. The pharmacy note failed to show there were no medication orders in the resident electronic medical record. Review of #73's social services note, written on 3/6/25 showed no medications were given to resident #73 following his admission. The resident discharged against medical advice because the facility failed to administer medications. During an interview on 3/27/25 at 12:49 p.m., staff member B said there were no medications to give resident #73. Staff member B said there have been times when the medications for the facility have been stuck at other locations. b. Review of resident #81's nursing progress notes showed resident #81 was admitted on [DATE] at 3:50 p.m. In addition to resident #81's routine maintenance medication(s), resident #81 was to be given cefazolin (antibiotic) 2000 mg by intravenous route, every eight hours. Review of the [Hospital Name] after visit summary showed resident #81 had been hospitalized and treated for a right septic shoulder and methicillin resistant staphylococcus aureus bacteremia. The after-visit summary contained the medication orders resident #81 was to receive. This summary showed resident #81 would be managed with IV (intravenous) antibiotics with an anticipated end of therapy date of 3/1/25. Review of resident #81's medication administration record, for February 2025 showed, no doses of the cefazolin antibiotics were administered. The time frame on resident #81's medication administration record showed the resident missed two doses of antibiotics, before he was discharged back to the hospital, on 2/7/25 at 12:21 p.m. During an interview on 3/24/25 at 9:40 a.m., NF1 said resident #81 was sent back to the hospital because he needed his IV antibiotics. NF1 said resident #81 was being treated for a septic shoulder, and he needed IV antibiotics to treat the condition. NF1 said issues with pharmacy are an ongoing problem at the facility and it has not been taken care of. During an interview on 3/25/25 at 8:00 a.m., NF2 said that resident #81 had not been seen at the facility until 2/7/25. NF2 said resident #81 had not received any of his IV antibiotics because the staff was unable to locate them. NF2 said the IV antibiotics hadn't been mixed, and both nurses were LPN's, and were not able to mix the medications. NF2 said it did not look like he was going to get a dose of antibiotics any time soon, so the resident was sent back to the hospital. NF2 said the facility tells the providers they have pharmacy issues figured out, but these things keep happening. c. Review of resident #109's medication administration record showed resident #109 was not given any doses of the IV Vancomycin (antibiotic), ordered by the physician. According to the medication administration record, she should have received one vancomycin dose during the time between the resident's admission, and discharge, to the emergency room. Review of #109's nursing progress notes, dated 3/20/25, failed to show when resident #109 pulled out her picc line, that she was transferred to the emergency room, or what her mode of transportation was for going to the ER. Review of resident #109's medication administration record showed resident #109 was given Hydrocodone on 3/21/25 at 9:48 a.m., STAT for possible opioid withdrawal symptoms. During an interview on 3/27/25 at 11:49 a.m. staff member B said resident #109 could have been given hydrocodone at approximately 10:00 p.m. Staff member B said resident #109 did not have any hydrocodone to be administered. Staff member B said the discharging hospital did not send the actual prescription to the pharmacy for resident #109. Staff member B said she tried working with the pharmacy, from 10:00 p.m. until 8:30 a.m., the next morning, which was when resident #109 was finally able to get one dose of hydrocodone. Staff member B said by that time resident #109 was so anxious and in so much pain, she pulled her picc, for the IV antibiotics, out. Staff member B said she was able to finally get the narcotic for resident #109 from a satellite pharmacy. During an interview on 3/27/25 at 11:49 a.m. staff member B said she had not been trained on the Nexsys system. Staff member B said she had to figure it out by herself. Staff member B said the pharmacy does not send medication when a resident is admitted . Staff member B said the nurse enters the medication orders into the electronic health record, and if the orders are in before 2:00 p.m., the residents medications will be delivered the next morning. Staff member B said there have been malfunctions with the Nexsys system, and the system may have to be over-ridden if the medication is not a narcotic. Staff member B said when a narcotic is needed, the pharmacy will give the nurses a code to enter to allow the removal of the narcotic. Staff member B said there is a time limit on the code and if not used timely, the system will lock and the code will not work. Staff member B said there have been issues with the pharmacy. When the pharmacy is called, there is not always an answer, and the pharmacy may not return the nurse's call. Staff member B said if there is a storm and roads are bad, the medications may be held up and not arrive timely. Staff member B said the Nexsys does not contain all the inhalers ordered by the physicians. During an interview on 3/27/25 at 1:47 p.m., staff member D said the facility started using a system to improve the communication between nursing and the pharmacy. Staff member D said the pharmacy said the nursing staff need to use the Nexsys before calling a satellite pharmacy for medications. Staff member D said there are several pharmacies in [NAME] who contract with the facility. Staff member D said there were issues with the pharmacy, but processes were broken in the building as well. Staff member D said the IV antibiotic was found in a food refrigerator for resident #80. Staff member D said the only nurses in the building were LPNs and the medication was not identified as needing to be administered via IV push, diluted, or given IM. Staff member D said the pharmacy is being worked on as the location of the pharmacy recently changed to Idaho. During an interview on 3/27/25 at 3:04 p.m., NF4 said the pharmacy received the physician orders faxed to them. The orders are typed into the pharmacy software. The medications are filled and shipped at 4:00 p.m., for overnight delivery. If the medication orders are not received before 3:00 p.m., the medications will be sent for delivery the second day. NF4 said the weather conditions are outside of their control and medications may not be delivered timely. NF4 said the pharmacy let the facility know the box sent Monday, which should have arrived on Tuesday, did not arrive until Wednesday.

Based on observation, interview, and record review, the facility failed to provide palatable food; cooks were not following the facility menu; and the dietary department failed to provide foods specified on the resident's meal tickets, for 5 (#s 1, 37, 46, 69 and 92) of 24 sampled residents. These deficient practices had the potential to affect the quality of life and nutritional status of the residents. Findings include: During a lunch observation and interview on 3/25/25 at 1:00 p.m. residents #37 received a serving of mashed potatoes with brown gravy, macaroni salad, and chicken salad. Resident #37's friend was assisting him with his meal. When asked if the food tasted good, he shook his head no, and grabbed his friend's hand. Resident #37 did not receive a vegetable on his plate. During a lunch observation and interview on 3/25/25 at 1:02 p.m., resident #69 was observed to have mashed potatoes with brown gravy, macaroni salad, and a meat salad. Resident #69 states she doesn't like tuna salad. Staff sitting nearby had to tell resident #69 what the meat salad was. Resident #69 did not receive a vegetable. Resident #69 said the food did not taste good. During a lunch observation on 3/25/25 at 1:06 p.m., resident #46 and #92 received mashed potatoes with brown gravy, meat salad, and macaroni salad. These residents did not receive a vegetable. During an observation on 3/26/25 at 12:50 p.m., resident #1 was served baked ziti and carrots. The pasta in the main entre appeared overcooked, the tomato meat sauce looked pale mushy and overcooked. Resident #1's meal ticked showed resident #1 did not like carrots and did not like pasta. Resident #1 said she wasn't going to eat the carrots but had eaten some of the pasta. Review of the diet extension menu for 3/25/25 showed the Grove Menu to be served was a chicken salad sandwich, macaroni salad, grapes, and a vegetable medley. The menu did not show mashed potatoes and gravy as a substitute for any of the therapeutic diets or alteration in texture. During an interview on 3/25/25 at 1:30 p.m. staff member J said a new cook was being trained. She said the cook came from a hospital setting and was just learning about the menus. Staff member J said the mashed potatoes should not have been substituted for the vegetables. Staff member J said she should have been monitoring the meal she served, and the potatoes should not have been served, but a different vegetable should have been given.

Based on observation, interview, and record review, the facility failed to ensure wound dressings were changed as ordered by the physician, and failed to ensure sufficient wound documentation was completed, for 2 (#11 and #13) of 40 sampled residents. Findings include: 1. During an interview with resident #11 and her roommate, on 1/28/25 at 8:53 a.m., resident #11's roommate stated her (#11's) foot dressing had not been changed in a long time. Resident #11 nodded in agreement to her roommate's statement. Resident #11's left foot dressing had coban and kerlix wrapped tightly around her foot. The coban wrap was located about 1/4 of an inch in from the kerlix on the knee side. The coban wrap stopped about three inches from the tip of the great toe. Resident #11's heel was sitting on a pillow and not located in a Prevalon Boot. During an interview and observation on 1/29/25 at 8:01 p.m., resident #11 stated she felt that her foot condition had gotten worse since being at the facility. Resident #11 stated, I know it hurts a lot worse. Resident #11 also stated she had pain in her buttock area. Resident #11's left foot dressing had coban and kerlix wrapped tightly around her foot. The coban wrap was located about 1/4 of an inch in from the kerlix on the knee side. The coban wrap stopped about three inches from the tip of the great toe. Resident #11's heel was sitting on a pillow and not located in a Prevalon Boot. Review of resident #11's EHR showed three physician orders concerning wounds. Two orders showed a dressing change three times a week on: Directions: every day shift every Tue, Thur . Resident #11's physician wound orders showed: Offload using . Prevalon Boot . During an interview on 1/30/25 at 9:32 a.m., staff member L stated resident #11's foot wound started as a left toe amputation incision. Staff member L stated they were unsure about the exact timeline of resident #11's wounds, but stated they thought resident #11's foot condition was worsening. Staff member L stated resident #11 received care on the skilled (care) hall, then was transferred to the 200 hall. Staff member L stated resident #11 was then transferred to the 100 hall at the beginning of the year, and an infection had started. Review of resident #11's EHR showed a Weekly Head to Toe Skin Check, dated 11/28/24: Surgical incision where they amputated toe. Review of resident #11's EHR showed a Nutritional Assessment, dated 12/10/24: surgical incision - amputation left toe . Review of resident #11's EHR showed a Weekly Head to Toe Skin Check, dated 1/2/25: metatarsal area, left lateral foot, pressure ulcer left heel. Review of resident #11's EHR showed a Weekly Head to Toe Skin Check, dated 1/11/25: Left toe: surgical incision . comments: pressure ulcer left heel Review of resident #11's EHR showed a Skin and Wound Evaluation, dated 1/15/25: Location: Left Dorsum: 3rd Digit (Toe), Distal, Tip. The wound was described as having 100% eschar, wound measurements were provided, and it was documented that there was no evidence of an infection, Debridement: None. Review of resident #11's EHR showed a Skin and Wound Evaluation, dated 1/15/25: Type: Pressure; Stage: Deep Tissue Injury ., Location: Left Heel, Distal, Acquired: .Present on Admission, Progress: New . The resident developed a new deep tissue pressure injury. During an interview on 1/30/25 at 10:09 a.m., staff member L stated the dressing on resident #11's foot looked a bit tight and stated it did not appear the dressing had been changed on Tuesday as the physician had ordered. Staff member L stated it was rare to wrap any dressing in the exact same configuration. Staff member L stated they did not understand what was meant by the dorsum of the foot which was mentioned in the Skin and Wound Evaluations. Staff member L stated they would have assumed dorsum meant the top of the foot like dorsal. 14005 2. Review of resident #13's hospice note, dated 12/31/24, showed resident #13 had a Stage III pressure ulcer on her right medial buttock, which was acquired on 12/30/24. Resident #13's pressure ulcer measured 2 cm length by 2 cm width by 0.2 cm deep. The pressure ulcer had a moderate amount of drainage noted, but no tunneling, slough, or eschar. The wound was described as beefy red with white macerated skin to peri wound. Review of resident #13's hospice order, dated 12/31/24, showed a right medial buttock pressure ulcer. The orders showed nursing staff were to cleanse the right buttock wound with cleanser of choice, pat dry, and Apply barrier cream or skin prep of choice to macerated peri wound. Apply collagen sheet to wound bed, fold to fit if necessary, cover with bordered dressing. Change the dressing every day. Caregivers to change the dressing on days hospice nurse does not visit. The order was noted by facility staff on 1/3/25, with a note that showed, per hospice RN, facility nurse to change dressing prn or when hospice nurse is unable. The hospice nurse visits the resident twice a week. Review of resident #13's Weekly Head to Toe Skin Check, dated 12/31/24, showed a small open area on her buttock. The area was not measured or described in the assessment. Review of resident #13's Weekly Head to Toe Skin Check, dated 1/7/25, showed no skin issues. Review of resident #13's Weekly Head to Toe Skin Check, dated 1/14/25, showed resident #13 was being monitored and treated for Stage III pressure ulcer to coccyx. The resident was currently under Hospice Care with dressing changes, and PRN changes to be done by staff when not visited by Hospice, and the skin check showed, Dressing this day is clean, dry and intact. [sic] Review of resident #13's Weekly Head to Toe Skin Check, dated 1/22/25, showed only redness to bony prominences. The Stage III pressure ulcer was not addressed on this assessment. Review of resident #13's current care plan showed staff were to coordinate care with hospice. The physician ordered for resident #13 to have daily dressing changes to the Stage III pressure ulcer. The hospice nurse was scheduled two times a week to perform wound care. The facility nurse would be responsible for changing the dressing the other five days. Review of a Weekly Head to Toe Skin Check, completed by a staff nurse on /17/25, showed the wound was a Stage II, however the wound bed was unable to be visualized. The wound measured 1 cm in circumference. The progress note showed hospice performed the treatment and applied the dressing to resident #13's coccyx. Review of resident #13's January 2025 treatment record sheets showed there were no nurse signatures from 1/1/25 through 1/25/25. There was no documentation to show the wound treatments and dressing changes had been done during this 25-day period. During an observation on 1/27/25 at 1:46 p.m., resident #13 was sitting in her recliner chair, asleep. There was no gel cushion in resident #13's recliner for pressure relief. During an interview on 1/27/25 at 3:29 p.m., NF1 said resident #13 had slept in a recliner for fifteen or twenty years. NF1 said resident #13 recently developed a sore on her buttock. During an observation on 1/28/25 at 8:40 a.m., resident #13 was sitting in her recliner chair. There was no gel cushion in the recliner for pressure relief on her buttock. During an interview on 1/29/25 at 8:59 a.m., staff member D said the facility only changes resident #13's buttock wound dressing, as needed, if the dressing comes off. Staff member D said Hospice changes the dressings and measures the wound. Staff member D said the dressing was not scheduled to be changed every day. Staff member D was not sure when Hospice was coming next. During an interview on 1/29/25 at 9:14 a.m., staff member B stated resident #13 definitely needed a gel cushion on her chair. Staff member B went to resident #13's room and returned to the interview. Staff member B said the gel cushion was not on her chair. Review of resident #13's current care plan, showed the resident was to have a gel cushion placed in the recliner on 3/29/23. On 1/18/25, the care plan showed bed linens should be wrinkle free and a specialty air mattress was to be used. Resident #13 did not sleep in a bed, she slept in a recliner, so the interventions would not be beneficial for pressure relief for her wound.

Based on interview and record review, the facility failed to address an indwelling urinary catheter on admission, by not obtaining a valid indication for the catheter use, and failed to provide and document ongoing daily care and monitoring for the catheter, which resulted in a urinary tract infection, for 1 (#134) of 46 sampled residents. Findings include: During an interview on 1/17/24 at 11:03 a.m., resident #134 stated the facility did catheter care maybe three times during her stay (11/22/23 through 12/16/23). Resident #134 stated she developed a urinary tract infection on 11/27/23, which necessitated the administration of oral antibiotic medication. Resident #134 stated she complained about catheter care several times before the staff began to consistently perform catheter care. Review of resident #134's nursing admission assessment, dated 11/22/23, showed the resident had an indwelling urinary catheter. Review of resident #134's provider orders, dated between 11/22/23 and 12/16/23, failed to show a valid physician's order and indication of use for the resident's indwelling urinary catheter. Review of resident #134's provider order, dated 11/28/23, showed an order for cephalexin 500 mg, four times a day, for a urinary tract infection. Review of resident #134's provider order, dated 12/4/23, showed an order for urinary catheter care and, . for prevention infection pt (patient) is aware this is not being done . [sic] Review of resident #134's MAR and TAR, dated November and December of 2023, failed to show catheter care was done until 12/4/23. During an interview on 1/18/24 at 10:30 a.m., staff member H stated resident #134 should have been receiving routine perineal care twice daily and developed a urinary tract infection which necessitated treatment with an antibiotic medication, as a result of the facility's failure to provide appropriate care.

Based on interview and record review, the facility failed to prevent falls with significant injuries requiring residents to go to the emergency department, for 3 (#s 47, 229, and 279), of 5 sampled residents; and, #47 had a significant skin tear; #279 had multiple falls and injury to her head; #229 broke open a knee incision and had surgery to clean and repair the incision, and resident #47 was transferring himself to the bathroom independently, due to a lack of staff assistance at the time of the fall. The facility also failed to prevent a fall with fracture to a resident's patella, for 1 (#55), and failed to protect a resident from significant burns, for 1 (#24), of 8 sampled residents. Findings include: 1. Review of a facility reported incident, dated 1/22/23, showed, [Resident #47] had an unwitnessed fall in the main dining room which caused a significant skin tear to his left hand. Due to the significant skin tear, resident was sent to the ER for evaluation and treatment . Review of resident #47's MDS, dated [DATE], with an ARD of 1/4/23, section V0200, showed, resident #47's fall care area was triggered. Review of resident #47's comprehensive care plan showed the resident had a fall on 1/22/23, and fall interventions were added to the care plan. The care plan did not include fall interventions, prior to the fall, on 1/22/23. During an interview on 2/1/23 at 3:03 p.m., staff member I was looking at resident #47's comprehensive care plan. There were only two areas of concern listed on the comprehensive care plan. Staff member I stated, I don't know what happened here. There should be way more stuff on this care plan. His initial assessment looks like it wasn't completed, so neither was the care plan. Staff member I stated, there was a care plan from a previous admission that included falls as a concern, but the new admission care plan did not have falls included until the fall on 1/22/23. 2. During an interview on 1/31/23 at 9:02 a.m., resident #229 stated he fell in his bathroom, and he broke open the surgical incision, which was from his total knee surgery. He stated he got out of bed around 4:00 a.m., to go to the bathroom, and forgot his walker. He made it to the bathroom, but when he got up from the toilet, he fell on to his knee with the incision, and it broke open. He stated he was able to get to his recliner, but then he thought he must have passed out because he woke up with the CNA and the nurse there, and he was covered in blood. He stated he was sent to the hospital, and the wound (opened incision) had to have another surgery to clean it out, a wound vacuum was placed, and then it had to be sutured closed again. During an interview on 2/1/23 at 1:54 p.m., resident #229 stated, There has been four times I have pissed my pants waiting for them to come help. Resident #229 stated, the night he fell in the bathroom and reopened his surgical incision, he couldn't wait any longer, so he went to the bathroom on his own. 3. Review of resident #279's EMR, showed the resident was admitted to the facility on [DATE]. Resident #279 had a risk for falls, and the facility was advised by NF3 the resident required close supervision to keep her from falling. Resident #279 fell five times (7/7/22, 7/9/22, 7/12/22, 7/17/22, and 7/22/22) between her admission on 7/6/22 and her discharge to home from the facility on 8/10/22. Resident #279 was sent to the emergency department for two of the falls, for injuries to her head, and a hematoma on her hip. During an interview on 2/1/23 at 12:14 p.m., NF3 stated, She (resident #279) was not being closely monitored. I told them up front that you have to watch her all the time. They did not have enough staff to really watch her the way they needed to. We brought her home. They did finally manage to move her to a room next to the nurse's station and that helped some. She fell more at the facility than she did at home. She also hurt herself more there than at home. They (the facility) did not have the staffing to keep a close enough eye on her. I think she fell seven times there and went to the hospital twice! During an interview on 2/1/23 at 12:18 p.m., NF4 stated, They knew she (resident #279) was confused. She had several falls there, and we have all these bills from her having to go to the ER. They also didn't get all the staples out of her head. After she was home, she kept complaining of pain, and when EMS came to my house, they found two more staples. I can guarantee you no one in my family will ever go there again. She hasn't fallen once since she has been home. After several weeks, they moved her closer to the desk after she fell so many times. I know they were having horrible staffing problems. Review of resident #279's comprehensive care plan, dated 7/6/22, showed resident #279 was at risk for falls, and the resident required frequent rounding. During an interview on 2/2/23 at 8:39 a.m., staff member E stated, Management is who follows up on the falls. We can make suggestions, but management is usually who changes the care plans. We are the ones that fill out the fall report, and we can put suggestions on there, but then management does their thing and makes the changes. During an interview on 2/2/23 at 8:53 a.m., staff member Q stated, We don't have time to look at care plans, you have to understand the staffing around here. Hopefully, we get changes in care information from report, but some nurses are good at giving report, and others are not. I usually just ask the resident how they transfer or what kinds of things we do for them. Like I said, I don't know most of the residents on this hall, so it is easier to just ask them. If a resident has a fall, PCC will put up an alert task for extra charting for three days. The alert does not tell you if there is anything to be done differently to prevent falls. It just means we have more to chart. 33796 4. Review of resident #24's Facility Reported Incident, sent to the State Survey Agency, dated 8/13/22, showed the resident was given a hot cup of coffee during the lunch meal, and it spilled onto his lap. The liquid burn resulted in blisters to both of his inner thighs. The on-call physician was notified. Review of resident #24's facility investigation, not dated, showed Initially the burns were not painful, just slight discomfort noted. However, they became painful as the days passed, and on 8/20/22 the resident went to the ER. (for the burns) The intervention initiated was for the resident to have hot liquids with a lid. The staff were unable to determine where the coffee came from. The nurse who delivered the coffee to the resident said it came from the unit coffee pot. The CNA working the floor stated the coffee in the pot was cold, and the nurse must have put the coffee in the microwave. The nurse stated she did not put the coffee in the microwave. During an interview on 2/1/23 at 1:47 p.m., staff member B stated she had not been aware of the seriousness of the resident's burns, and did not know why education was not provided to staff regarding serving hot liquids. During an interview on 2/1/23 at 1:55 p.m., resident #24 stated the thing that bothered him about the burns was going out for a weekly treatment to the wound clinic. The burns have not healed. He stated the coffee cup fell off of his bedside table onto his lap. Review of resident #24's EMR showed he had continued to require wound care for the inner thigh burns for the last five months. 5. Review of resident #55's Facility Reported Incident, sent to the State Survey Agency, dated 5/31/22, showed the resident had a fall while transferring out of bed using a transfer pole. The fall resulted in a fractured patella. Review of the facility Fall Scene Investigation Report, dated 5/24/22, showed the root cause of the fall with the transfer pole was the bed was too high. The investigation did not show follow-up on why the bed was too high, and interventions to prevent further falls. A safety pole transfer evaluation was requested for resident #55, on 2/1/23 and 2/2/23. The facility did not provide the evaluation. During an interview on 2/1/23 at 1:14 p.m., resident #55 stated he did not remember the fall, but still used the transfer pole.

Based on observation, interview, and record review, the facility failed to provide an adequate number of staff to provide timely responses to requests for care for 14 (#s 3, 15, 20, 21, 26, 27, 29, 36, 37, 56, 229, 230, 235, and 429) of 15 sampled residents, which included several residents dependent on nursing staff for care. This failure caused a decrease in bathing for resident #21, resident #229 and #26 to have episodes of incontinence, resident #230 to have a decrease in bathing and to receive her pain medications late, resident #235 to have a decrease in bathing and had the potential to negatively affect care for all residents of the facility. It was identified some residents were waiting over an hour to receive assistance from staff. Findings include: During an interview on 1/31/23 at 9:05 a.m., resident #29 stated he was irritated and had filed a complaint for the previous evening when a CNA had taken him to the bathroom, and then they did not want anything to do with him for the rest of the shift. Resident #29 stated when he did use his call light no one came to answer it. During an observation and interview, on 1/31/23 at 9:22 a.m., resident #37 was in her room, sitting upright in a chair, wearing a clothing protector. The resident was waiting for her breakfast. The resident stated she had been waiting quite a while for her breakfast to arrive, and the facility did not seem to have enough caregivers to get things done in a timely fashion. Her breakfast was delivered at 9:35 a.m. During an interview on 1/31/23 at 1:51 p.m., resident #36 stated many residents were complaining about very long call light times, of greater than 30 minutes, before being answered; or, or calls being answered and then not having staff return to provide care, requiring another call. The previous night she had her call light go unanswered for over 30 minutes, and when she went out into the hallway to see if a nurse was available, she noticed several other residents in her hall had their call lights on as well, including a resident that was quite dependent on nursing staff for help. During an interview on 2/1/23 at 1:25 p.m., staff member W stated many of the residents complained about how long it took the staff to answer call lights. She said there were frequently instances when the nursing staff were caring for a fully dependent resident requiring one or two staff for assistance that took a significant amount of time; and as such, were unable to leave to answer other resident calls. She stated the facility recently had several resident care staff quit very quickly after their first shift, due to an inability to deal with the overwhelming amount of resident care, and work required during the shift. During an interview on 2/1/23 at 2:46 p.m., staff member M stated there were not enough staff to adequately provide care, and sometimes basic tasks such as turning bedbound residents or various assessments were often not completed timely or held due to staff not having enough time to accomplish all the work required. She stated, when staff complained to management about feeling there was not enough staff to be able to properly care for residents, or when there was a sick call (employee out ill), the facility would tell them to just figure it out. When a supervisor sat down at the nursing station, where the interview could be heard, staff member M stated she did not want to say anymore, and stated, I don't get in trouble. During an interview on 2/2/23 at 8:54 a.m., staff member A stated the facility expectation was a call light should not go unanswered for more than 15 minutes. Staff member A stated the amount of staff was determined by a corporate matrix, and it appeared the facility staffing was within the parameters of the matrix. Staff member A stated the facility was aware of the long call light wait times, but felt like the issue was staff not using their time wisely and needing more education. Staff member C stated there were several residents who required two staff members to assist with cares, and it was not reasonable for staff to leave to answer call lights, while assisting those residents. Staff member C stated everyone in the facility would answer call lights, even the maintenance employees, but they could not provide anything beyond answering the call light if the resident required nursing care. Review of the facility's form CMS-672, dated 1/31/23, showed: - 67 residents required assistance of one or two staff for dressing; and, 22 residents were fully dependent; - 74 residents required assistance of one or two staff for toilet use; and, 15 residents were fully dependent; and, - 69 residents in were in a chair most/all the time; and nine residents were bedfast Review of sampled facility call light wait times, for seven 24-hour time periods, from 1/6/23 to 1/30/23, showed: - Resident #229 - six wait times greater than 15 minutes, with the longest wait time of 49 minutes; - Resident #230 - 28 wait times greater than 15 minutes, with a longest wait of 70 minutes; - Resident #235 - six wait times greater than 15 minutes, with a longest wait of 78 minutes; - Resident #20 - 16 wait times greater than 15 minutes, with a longest wait of 85 minutes; - Resident #56 - seven wait times greater than 15 minutes, with a longest wait of 52 minutes; - Resident #429 - 12 wait times greater than 15 minutes, with a longest wait of 88 minutes; - Resident #29 - 14 wait times greater than 15 minutes, with a longest wait of 38 minutes; - Resident #3 - nine wait times greater than 15 minutes, with a longest wait of 69 minutes; and, - Resident #27- two wait times greater than 15 minutes, with a longest wait time of 44 minutes. Of the 23 longest wait times identified through the sampled days from 1/6/23 to 1/30/23, 20 (87%) occurred between 6:00 a.m. and 6:30 p.m., which were the day shift hours for the facility. 33796 Review of a Facility Reported Incident, sent to the State Survey Agency, dated 11/6/22, showed resident #26 stated she felt like she was choking on a piece of ham, and turned her call light on. The light was not answered for 40 minutes. Five residents were interviewed as part of the facility investigation, and two residents said the call lights had a long wait time to be answered. During an interview on 1/31/23 at 11:50 a.m., resident #26 stated staffing and call lights were still a concern. She stated six call lights were on the night before with no staff to answer them. This could not be verified through staff interviews or review of the schedule. Resident #26 also stated some staff nurses would not answer call lights. During an interview on 2/1/23 at 11:10 a.m., resident #15 stated she wrote a grievance regarding staff coming to her room when the call light was on, the light would be turned off, and the staff would not return. She stated she could not walk, and she was dependent on staff for her toileting needs. She stated the long call light times have caused her to be incontinent of bowel and bladder. 44770 During an interview on 1/31/23 at 9:24 a.m., resident #21 stated he would like to have more showers, but the facility did not have enough staff to get the showers done. Review of resident #21's comprehensive care plan, dated 4/5/18, showed resident #21 preferred three showers per week. Review of resident #21's bath record, from 1/1/23 to 1/31/23, showed resident #21 received eight showers out of 27 opportunities, and there were no refusals documented. During an interview on 2/1/23 at 1:54 p.m., resident #229 stated, There has been four times I pissed my pants waiting for them to help. NF5 said resident #229 has never had a problem with incontinence. She stated he just can't wait that long all the time. She stated he waited for a long time when he used his call light; and sometimes, they came in and told him there were other people ahead of him, and turned the call light off. During an interview on 2/1/23 at 9:26 a.m., resident #230 stated, I was having to wait too long to go to the bathroom, so I had to become self-sufficient in here (the facility). Some days I feel neglected here. Last night, they only gave me chicken. When I asked for some salad, they told me the kitchen was closed. One nurse brought me the wrong inhalers because there is another resident with the same initials as me. I cry at least one time a day over something going on here. I had to wait 45 minutes for my pain medication last night. I don't get showers on a consistent schedule. They said we would get showers twice a week. I refused showers a couple of times, but that was because I was in too much pain, and they had not given me my pain medication on time. They did not come back and offer another shower after the medication kicked in. There just isn't enough staff here to take care of all of us. Review of resident #230's late medication audit, dated from 1/1/23 through 1/31/23, showed resident #230's oxycodone was over one hour late 24 times and over 30 minutes late 36 times. Review of resident #230's bath record, dated from 1/12/23 through 1/31/23, showed the resident received two showers, and refused two showers, out of five opportunities. During an observation and interview, on 1/31/23 at 9:40 a.m., resident #235 stated, I have only had one shower, and I am supposed to get one two times a week. Resident #235 said she was admitted to the facility on [DATE]. Resident #235 stated, I feel hot and sweaty, and I get sinus headaches when I don't get a shower often enough. They don't even give us a bed bath. I asked once, and they told me they were too busy. I get told there are 'two or three people ahead of you,' when I use my call light. Resident #235's hair appeared unkempt and had a hair clip that was falling out. Review of resident #235's bathing record, dated from 1/10/23 through 1/31/23, showed the resident received two showers out of seven opportunities. During an interview on 2/2/23 at 8:53 a.m., staff member Q stated, We don't have time to look at care plans. You have to understand the staffing around here. I had to take over this cart (medication) in the hall that I don't know hardly anyone, and there is over twenty people here that I have to give meds to. Most nurses won't even do this job anymore because it is just too hard since there isn't enough staff. Hopefully, we get changes in care information from report, but some nurses are good at giving report, and others are not. Sometimes we don't even have time for any report. I usually just ask the resident how they transfer or what kinds of things we do for them. Review of the Resident Council Minutes, dated 8/8/22, showed the residents stated they were turning their call lights on, and not getting a timely response. They also stated they felt bad when reporting grievances related to the concerns. Review of the Resident Council Minutes, dated 9/8/22, showed Less and less showers are being given. Review of the Resident Council Minutes, dated 10/3/22, showed Copper West - only 1 CNA, need more help. Review of the Resident Council Minutes, dated 11/10/22, showed the call lights were getting turned off, and then staff left. This is still happening. Review of the Resident Council Minutes, dated 1/12/23, showed Call lights are getting turned off by CNA's, leave and don't return. Residents are having to wait too long for their call lights. During an interview on 2/1/23 at 3:50 p.m., staff member A stated it was the responsibility of each department to address resident council concerns, but she may need to provide the oversight in the future.

Based on observation, interview, and record review, the facility failed to provide ongoing monitoring and interventions to prevent a severe weight loss of 22.67% in 180 days, for 1 (#39), of 4 sampled residents. Findings include: Review of the weight documentation for resident #39 showed her weight on 7/19/22 was 172 pounds, and on 1/13/23 it was 133 pounds, representing a severe weight loss of 22.67% in 180 days. Resident #39's weight on 12/26/22 was 140 pounds, representing a weight loss of 5.0% in less than 30 days. No weights were documented for the period between 12/26/22 and 1/13/23. No weights were documented for the period of 1/13/23 and 2/2/23. During an interview on 1/31/23 at 9:38 a.m., resident #39's breakfast had just arrived in her room. Resident #39 stated the food was always late, cold, and does not taste good. I never get a different choice; this is what I get. They never warm it up for me when I ask. I get no option for what I want, so I just don't eat. During an interview on 2/1/23 at 9:45 a.m., staff member V stated weights are only reviewed once a month unless the physician's assistant or physician requests something different. Staff member V stated, Resident #39 is on hospice/comfort care. When they are on hospice/comfort care, we don't have to do anything. The weight loss is considered unavoidable, we don't have to justify it. Staff member V stated she was unaware if the physician was notified of the weight loss. During an interview on 2/1/23 at 10:24 a.m., staff member G stated if a resident was on hospice or comfort care there needs to be on order in the EHR, addressed in the physician's progress notes, and a pertinent diagnosis. During a review of resident #39's EHR, there was no physician's order for hospice/comfort care, no physician's progress note addressing hospice or comfort care, no physician's note addressing weight loss, and no diagnosis indicating resident #39's weight loss was unavoidable. Record review of a dietary and progress note for resident #39, dated 10/27/22 showed: - .Data: WEIGHT WARNING VALUE: 138.0 VITAL DATE: 2022-10-17 16:46.00 -7.5% change [ 19.8%, 34.0 ] -10.0% change [ 29.9%, 59.0 ] Action: Monthly Dx includes: sepsis, UTI, obesity, T2DM, GERD Ht: 67 Wt: 138# IWR: 121-149# BMI: 21.6 (low normal) Response: Nutrition care to comfort . - .Weight change note: Wt trends: Still trending down since 5/25/22 Lost >7.5% in 3 months, lost > 10% in 5 months - .ENN still not being met. Noted refusals from resident for PO intake. When resident does eat poor PO intake. Recommend resident have food to comfort care. RD to monitor until next review . [sic] Review of resident #39's meal intake, showed from 1/4/23 to 2/1/23, the resident had no refusals of meals. During an interview on 2/2/23 at 9:02 a.m., staff member I stated resident #39 was, Not on hospice or comfort cares as far as I know. I do know that we are now working on getting a diagnosis for unexpected weight loss from the physician. Review of resident #39's physician's progress note, dated 7/14/22 at 5:28 p.m., showed, .Palliative evaluated but son is not ready for comfort measures at this time. He knows that she has very little time left . Refer to F580 - Notification of Changes, for more information related to the lack of notification to the physician for the weight loss.

Based on interview and record review, the facility failed to change a wound vacuum dressing on a diabetic ulcer, for 1 (#54), of 1 sampled resident, causing the resident increased skin breakdown above her original wound. Findings include: During an interview on 2/2/23 at 8:51 a.m., resident #54 stated having the wound vac treatment helped her wound to heal. Resident #54 stated, The nurses had some confusion in the beginning and didn't know when or how to change it (vac treatment). It went for a while not getting changed, but the wound clinic got it straightened out. Review of a physician order for resident #54, dated 10/18/22, showed: 1. Remove old dressing. 2. Cleanse with NS. 3. Protect the peri-ulcer area with Cavilon. 4. Use versitel/black foam as the primary dressing. 5. Use VacOpsite as the secondary dressing. 6. This order to be carried out 2 times per week . Please send patient with wound vac supplies so we can reapply it, please reapply wound vac when patient returns, set at 125mmHg. Review of resident #54's Wound Clinic Note, dated 11/22/22, showed, [Resident ] is being seen today for her reports of new area of breakdown above ulceration. Staff at [Facility] report they have not been changing wound vac as they do not know how often to change it . Review of a Facility Reported Incident, reported to the State Survey Agency, dated 11/25/22, showed, Interviews with nursing staff revealed [Resident #54] had complained of pain to her wound for a few days. Her medication was administered as scheduled per physician orders. Resident was seen at her wound care appointment on Tuesday 11/15/22. She had her wound vac changed at the appointment. The orders revealed the wound vac was to be changed 2 times a week on Thursday and Sunday. The wound vac did not get changed on Thursday 11/17/22. Record review did reveal the wound vac was changed on Sunday 11/20/22. The investigation was substantiated. Education was given to the nurses to follow physician orders on wound care. During an interview on 2/2/23 at 11:03 a.m., staff member C stated there was no additional investigation or documentation for resident #54's wound vacuum incident. The wound care nurse was not available for interview during the survey.

Based on observation, interview, and record review, the facility failed to prevent the development of a Stage 4 pressure ulcer, for 1 (#4), of 2 sampled residents. The deficient practice resulted in a longer stay in the facility for the resident. Findings include: During an observation and interview on 1/31/23 at 1:59 p.m., resident #4 stated he was initially admitted to the facility with a pressure ulcer acquired while the resident was at home. Resident #4 stated he had developed a new pressure ulcer since his admission in January of 2020. When asked the circumstances surrounding the development of the ulcer, resident #4 stated the ulcer, located in the resident's left groin area, was caused by improper use of a lift sling for the electronic lift. Resident #4 stated he could not remember exactly when the ulcer developed, but the resident did say, They (the ulcers) should never have happened. Resident #4 stated he did not have pain associated with the ulcers due to lack of sensation secondary to his paralysis. During an interview on 2/1/23 at 12:49 p.m., staff member F stated resident #4 had a wound vac dressing which had been changed earlier on 2/1/23, and was not due to be changed until 2/4/23, after the end of the survey. During an interview on 2/1/23 at 1:23 p.m., staff member P stated she was caring for resident #4 when the ulcer was found. Staff member P stated she, and another CNA, were transferring the resident using a lift sling. When the sling was pulled out from underneath the resident, staff member P saw an abnormal area of skin on resident #4's groin area. Staff member P stated she immediately reported the area to the nurse. Review of resident #4's nursing progress note, dated 3/3/22, showed staff member E assessed the wound, and documented the area was not present on the previous day (3/2/22). The note showed the wound was the size of a quarter, and the top layer of tissue was sheared back and open. The documentation did not show the stage of the ulcer. Review of resident #4's wound assessment, dated 1/30/23, showed a facility-acquired Stage 4 pressure ulcer, below the resident's left scrotum, which was initially identified on 3/5/22. The wound assessment showed undermining was present, the wound edges were reddened and moist, and there was a moderate amount of odorous drainage.

Based on interview and record review, the facility failed to notify a physician of a severe weight loss, for 1 (#39) of 4 sampled residents. Findings include: Review of resident #39's weight documentation showed her weight on 7/19/22 was 172 pounds, and on 1/13/23 was 133 pounds. This was a severe weight loss of 22.67% in 180 days. During an interview on 2/1/23 at 9:45 a.m., staff member V stated weights are only reviewed once a month unless the physician's assistant or physician requests something different. Staff member V stated she was unaware if the physician was notified of #39's weight loss. During a review of resident #39's medical record, no nurses notes were found noting that the physician was notified of the severe weight loss in six months. No notes were found noting that the weight loss was unavoidable. The Physician was unavailable for interview at the time. During a review of resident #39's physicians progress notes for 7/14/22, 8/5/22, 8/19/22, 9/7/22, 9/16/22, 11/16/22, 11/22/22, and 1/9/23, weight loss was not addressed. Please refer to F692, Nutrition/Hydration status Maintenance, for additional details related to severe weight loss for resident #39.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from significant medication errors for 1 (#432) of 1 sampled resident, which resulted in a resident experiencing a seizure related to the cumulative effect of the wrong dose for three days. Findings include: 1. Review of an incident reported to the State Survey Agency, dated 7/17/22, showed resident #432 was administered an incorrect dosage of aripiprazole, an antipsychotic medication, on 7/14/22, 7/15/22, and 7/16/22, and experienced seizure-like activity on 7/17/22. Review of the investigative file associated with resident #432s medication incident, provided by the facility on 1/31/23, showed the following events: - resident #432's discharge orders from acute care, dated 7/13/22, showed an order for aripiprazole 5 mg tablet, Take 1 tablet by mouth every day 7 days, then take 2 tab(s) by mouth daily thereafter, - resident #432's physician orders, dated 7/13/22, and entered into the EMR by staff member F on 7/13/22 at 4:09 p.m., showed aripiprazole, Give 5 mg by mouth one time a day related to OTHER SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS AND AWARENESS (R41.89) for 7 Days AND Give 10mg by mouth one time a day related to .(R41.89), - resident #432's MAR, dated July of 2022, showed the resident received a total of 15 mg of aripiprazole on 7/14/22, 7/15/22, and 7/16/22, and - resident #432's nursing progress note, dated 7/17/22, showed the resident had a seizure on 7/17/22 and the aripiprazole order was entered incorrectly resulting in a larger dose being administered, the aripiprazole was discontinued, and the resident's anti-seizure medication was restarted. Review of resident #432's nursing progress note, dated 7/17/22, showed the resident had been tapered off Keppra (an anti-seizure medication) recently, and the provider was unable to determine if the seizure was an adverse reaction to the high dose of aripiprazole or the recent tapering of Keppra. During an interview on 2/1/23 at 4:38 p.m., staff member B stated the incident was investigated by the previous DON who was no longer employed by the facility. Staff member B stated the entry error by staff member F resulted in a larger dose of aripiprazole being given to resident #432. Staff member B stated admission orders were supposed to be double checked by a second licensed nurse, and there was no documentation showing the double check had occurred. Staff member B stated she had left a message with the consultant pharmacist, but had not heard anything back regarding why the entry error was not identified during the medication regimen review which was done shortly after admission. 44770

Based on interview and record review, the facility failed to: - Provide ordered dressing changes for 2 (#s 5 and 212) of 3 sampled residents. For #5, the resident missed a wound care appointment, which was not rescheduled, and the wound was not treated as ordered. For resident #212, a wound went untreated, and worsened, requiring antibiotics, and the resident had pain from the wound. - Nursing staff neglected to send 1 (#12) resident to the emergency department when the resident requested to be sent, and the resident was later diagnosed with lower lobe pneumonia and antibiotics to treat the infection. - Failed to protect 1 (#4) of 1 sampled residents from two incidents of verbal abuse by staff. The failure, and action taken by the facility, did not ensure resident protection after the first incident of verbal abuse for resident #4, and it occurred again. Findings include: 1. A record review of a facility reported incident for a neglect allegation, dated 9/19/21, showed, On 9/17/21, it was reported by the wound nurse that the dressing to resident, [#5], was dated 9/9/21. Resident's dressing is scheduled to be changed on Tuesdays and Fridays. Per the schedule the dressing should have been changed on 9/10 and 9/14. The allegation of neglect was substantiated by the facility. During an interview on 2/16/22 at 9:56 a.m., staff member A stated she investigated the incident and found that resident #5 missed her appointment for wound care because she was not ready to go when the bus was ready to take her. The driver had another resident to take to an appointment and did not have time to wait for the nurses to get the resident ready for her appointment. Resident #5 would have had her dressing changed at that appointment, but since she did not go, the dressing was not changed. The TAR did not prompt the nurse to change the dressing. Staff member A stated they have changed the process so that on wound care appointment days it will need to be documented if the clinic does the dressing change or if the nurse does the dressing change. Although the resident did not attend the scheduled appointment, the facility staff did not ensure the resident's skin care needs were addressed related to the dressing change. A record review of resident #5's EMR, Skin Wound Note, dated 9/7/21, showed, Resident right lateral outer and calf are healing with no signs of infection noted, redness is resolved, area is light pink, will continue with current treatment order for protection. This was prior to the event of the resident not attending the scheduled appointment. A record review of resident #5's EMR, Communication with Resident Family, dated 9/17/21, showed, Family was notified of resident missing wound care appointment on 9/14/21. Due to the resident missing her appointment her wound care to the right calf was not completed. 2. During an interview on 2/14/22 at 3:56 p.m., with resident #12 and NF3, resident #12 stated, I needed to go to the hospital (1/16/22) because I couldn't breathe and the nurse (staff member II), told me 'We don't do that here.' NF3 stated she did not get a phone call about it, and that they diagnosed him (resident #12) with left lower lobe pneumonia. NF3 did not find out about it until the next day. Resident #12 stated, The doctor saw me here the next day during his regular rounds. I was given a nebulizer and a steroid. NF3 stated, in November, around the 11th (2021) she saw protective dressings on his feet that had been on since he had been in the hospital. NF3 stated the CNA gave him a shower with the dressings on, and then the water from the wet dressings soaked his socks and shoes. NF3 went to talk to the nurse to see if she could take the dressings off and was told by the nurse, I don't care what you do. During an interview on 2/15/22 at 2:41 p.m., staff member A stated, We follow the resident rights on change in condition, if he (resident #12) wanted to go to the hospital, he should have been sent. During an interview on 2/16/22 at 8:36 a.m., staff member CC stated if a resident tells her they need to go to the hospital, she would check the residents' vitals, call the MD, and provide any interventions needed for the resident. Staff member CC stated, But if the resident is requesting to go to the emergency room then I would send them. A review of resident #12's medical record showed an x-ray, dated 1/17/22, with clear lungs, and the lab testing was negative for influenza and Covid 19. On 1/24/22, a new x-ray showed the resident had left lower lobe pneumonia, and a Z pack ([MEDICATION(S)]) was ordered, along with [MEDICATION(S)] 40 mg for 5 days, and Duo Neb three times a day, to be started 1/24/22. Review of resident #12's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/16/22 at 2:38 p.m., resident #12 stated, I did tell the CNA and the dayshift nurse that the night nurse told me I couldn't go to the hospital. But nobody did anything about it. 3. A record review of a facility reported incident for a neglect allegation, dated 9/20/21, showed, On 9/20/21, it was reported by night shift that the dressing to resident, [#212], was dated 9/8/21 . An allegation of neglect has been submitted . the allegation of neglect is substantiated. According to the facility reported incident the facility found that a nurse falsified a record, documenting she had changed the dressing on 9/14/21, but she had not, and on 9/17/21 another nurse documented on the TAR that she changed the dressing because she thought that the wound care nurse had done the dressing change, but the dressing was not changed on 9/17/21 either. During a telephone interview on 2/15/22 at 4:15 p.m., resident #212 stated, the wound was now healed but he remembered the incident. Resident #212 stated, It was very painful. I had a hell of a time for it to heal. It was healed once then it got a blister under the dressing. It took it months for it to heal after they found it like that. During an interview on 2/16/22 at 9:56 a.m., staff member A stated it was her understanding that resident #212's wound was healed and then the nurse placed a dressing on it to protect it. When it was discovered that the protective dressing did not get changed on schedule, when they took the protective dressing off they found a new blister. During an interview on 2/17/22 at 7:55 a.m., staff member A stated, [Staff member HH] was terminated for falsifying documentation. She was educated on wound care. [Staff member HH] admitted that she falsified the document that she had changed the dressing but then didn't do it. That is all I remember about that. A record review of resident #212's TAR, dated August 2021, showed, the protective dressing was changed on 8/4/21, 8/14/21 and 8/18/21, but it was not changed as ordered on 8/7/21 or 8/11/21. The bandage was left on and unchanged for 10 days. A record review of resident #212's TAR, dated September 2021, showed, the protective dressing was changed on 9/3/21, 9/21/21 and 9/24/21, but was not changed as ordered on 9/7/21, 9/10/21, 9/14/21 or 9/17/21. The bandage was left on and unchanged for 14 days. A record review of resident #212's skin/wound note, dated 7/28/21, showed, the left heal wound was healed and a protective dressing applied. A record review of resident #212's skin/wound note, dated 9/20/21, showed, the left heal dressing was not changed per physician order. There was no documentation to reflect any changes in the wound. A record review of resident #212's antibiotic note, dated 9/22/21, showed, Lt (left) heel wound, antibiotics x 5 days, dressing change. Date of infection 9/20/21. The wound required antibiotics at this point. A record review of resident #212's Health Status Note, dated 9/23/21, showed, wound to heel measures 0.5 x 3.5 x 0.1 serosanguinous drainage noted. This wound is due to resident receiving a shower with foam heel protector in place and was not changed per provider orders. There was no documentation to reflect the stage of the wound/ulcer. 4. Review of two facility reported incidents, dated 10/20/21 and 8/2/21, for verbal abuse toward resident #4 were investigated. a. On 8/2/21 an allegation of verbal abuse was reported. A CNA overheard a nurse tell resident #4 Maybe it would be better if you broke something, and we can get rid of you for a few weeks. You don't let me get my work done and I'm going to kill someone. Review of resident #4's clinical record showed, at the time of the incident, the resident was moderately cognitively impaired with Alzheimer's Disease, and [CONDITION(S)]. The facility did substantiate verbal abuse of resident #4. The nurse was suspended pending investigation. The nurse received a written disciplinary action, and was educated on customer service, and resident rights. b. On 10/20/21 a CNA was overheard saying, Don't you comprehend what I am saying (resident name). This was said in a harsh tone to Resident #4. Resident #4 was heard to respond with I am a pain in the butt. The facility did substantiate verbal abuse of resident #4. The CNA was suspended pending investigation. The CNA was disciplined by the facility, and educated on customer service. A review of the facility's policy, Abuse and Neglect, dated May 2019, reflected: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from .neglect . Neglect is the failure to provide necessary services and adequate (medical, personal or psychological) care .failure to care for a person in a manner, which would avoid harm .Staff may be aware or should have been aware of the service the resident requires, but fails to provide that service.

Based on observation, interview, and record review, the facility failed to ensure adequate nutritional interventions were provided and monitored for 1 (#51) of 2 sampled residents. This deficient practice contributed to the resident having an unplanned severe weight loss of 23.4% in under 3 months. Findings include: During an observation and interview, on 2/15/22 at 9:15 a.m., resident #51 received his breakfast which consisted of two eggs, one cup of yogurt, and a cup of orange juice. Resident #51 stated he did not get the 2 oz of ham he requested, and this was not the first time it had happened. The resident stated missing food items occurred about six out of ten meals. Review of the resident's food selection card on the resident's food tray showed the resident requested 2 oz of ham, in addition to two eggs, yogurt, and orange juice. During an interview on 2/16/22 at 8:29 a.m., staff member O stated the facility's system for nutrition monitoring was broken. Staff member O stated her vitamin recommendations, in addition to meat and other proteins, were needed to improve resident #51's wound healing. Staff member O stated the staff were not recording food intake every day. Staff member O stated the facility was supposed to have meetings to discuss residents who had severe weight loss, but the meetings did not happen. During an interview on 2/16/22 at 9:43 a.m., staff member N stated residents' food intake amounts were supposed to be documented every shift by the CNAs, and the CNAs were to let the nurses know if there was an amount eaten that was out of the normal range for the resident. Staff member N stated the food intake amounts were not completed if there were not enough staff, and documentation of food intake had been an issue for the past four months, which caused the lack of consistent food intake documentation for resident #51. Staff member N stated the facility's dietician often asked why meal intakes were not charted because it was important for her to do her job and assess the resident's needs. Review of resident #51's Care Plan, dated 10/24/21, reflected: Focus [Resident #51] is at risk for alteration in nutritional status related to: .wound areas. Goal No significant weight changes x 90 days. Date Initiated: 10/24/2021 . Review of resident #51's SBAR to a provider, dated 12/7/21, reflected, Background: .He has lost 5 lbs in the last couple weeks.Physician Orders: Will eval[uate]. Review of resident #51's Nutrition Progress Note, dated 1/10/21, reflected: Recommend: 1. CMP. 2. Multivitamins with minerals one po daily with breakfast. 3. 500 mg of vitamin C one po TID with meals for skin healing. 4. 220 mg of [MEDICATION(S)] one po daily x 10 days for skin healing. 5. Weekly weights . MD and DON were notified of the nutrition recommendations in writing. Review of resident #51's Nutrition Progress Note, dated 2/4/22, reflected: .Significant wt. [weight] loss x 3 mo [months] (23.4%/39.3# [pounds]). No labs are available to review .Nutrition recommendations from 1/10/22 were not accepted. To prevent further wt. loss and to heal the skin, the resident needs the following: 1. Glucerna one po BID between meals. 2. Multivitamins with minerals one po daily with breakfast. 3. 500 mg of vitamin C one po TID with meals for skin healing. 4. 220 mg of [MEDICATION(S)] one po daily x 10 days for skin healing. MD and the DON were notified of the above in writing. Review of resident #51's Order Details, dated 2/11/22, reflected, Glucerna one time a day for Wound Healing. Order Date: 2/11/2022. This order was started seven days after the staff member O's recommendations, and was not at the frequency staff member O recommended to prevent further weight loss. Review of resident #51's NUTRITION - Amount Eaten report, dated 12/1/21-2/15/22, reflected amounts of meals eaten were not documented for 45.3% of the days (34 out of 75 days). A review of the facility's policy, Intake and Output and Fluid Restriction, created March 2021, reflected: To maintain a relative balance intake and output is essential for well-being and life. Accurately recording intake and output will assist in the assessment of this balance . 5. Record the total intake and output at the end of each shift.

Based on observation, interview, and record review, the facility failed to ensure necessary services were provided for a resident who displayed behavioral outbursts, wandering, intruding on others, and calling out, and the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to use available medication to treat and attempt to decrease resident #4's agitation/behavior if there was no improvement shown after an antipsychotic medication was started. Resident #4's care plan lacked non-pharmacological interventions for the resident's behavioral needs. These failures continued over an extended period of time, without timely action taken to address the concerns, which affected the residents quality of life on a regular basis. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/14/22 at 3:53 p.m., Resident #16 said resident #4 wandered all around and would yell for help. The resident went into everyone's room at all times of the day and night, and resident #16 said that caused a huge lack of privacy. Resident #16 said she had filed a grievance report with the facility due to resident #4's wandering, and entering resident rooms. During an observation on 2/15/22 at 9:37 a.m., resident #4 was going down the hall calling hello. The resident rolled into a wall calling out Hello, I am here. I am coming in. Hello, hello, hello. A staff member came out of room [ROOM NUMBER], saw resident #4 and wheeled her back to her room. During an interview on 2/15/22 at 10:45 a.m., resident #9 said resident #4 always entered her room at night when she was sleeping and woke her up. Resident #9 said she did not sleep well. During an interview on 2/16/22 at 9:11 a.m., NF2 said the facility did not provide adequate care for resident #4. NF2 said the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said resident #4 would confabulate, which was part of the syndrome, and convince people she could see. The expectations of the facility staff were for resident #4 to be able to do the same things as a sighted person. NF2 said resident #4 had seen a neuropsychologist several times in the last couple of months. NF2 said the neuropsychologist told her that resident #4's short-term memory was to the point where it reset every 3-5 minutes. [Resident #4] can be combative, but if you let her know you are there and will be touching her she is calm. If you just walk up to her and she doesn't know you are there, it scares her and she will become combative. NF2 said given the limitations imposed by resident #4's short term memory problems, she felt resident #4 viewed the facility as her home, and therefore could not understand why she could not go into any room she chose, and when in those rooms perhaps she saw the other residents as intruders. NF2 said the facility had a recent care plan meeting for resident #4, and all disciplines were supposed to attend. NF2 said, It was me, the activity director, social services, and the ombudsman. NF2 said nursing should have been in attendance since resident #4's behaviors were all related to her medical problems. NF2 said she knew the facility did not want resident #4 in the facility due to all the behavior problems, but nursing would not document her behaviors consistently, good and bad, so the neuropsychologist could make a determination on the approaches and medications for the resident to improve her quality of life. NF2 said when she was at the care plan meeting she had specifically requested the facility come up with some kind of behavior tracking so the information could be provided to the neuropsychologist. During an interview on 2/16/22 at 11:28 a.m., staff member B said the facility staff were trying to track and document resident #4's behaviors to see what triggers her behaviors. She said staff member I was involved with this. Staff member B said the facility was working on education and plans were developed last week for resident #4, although the resident had admitted to the facility in early 2021. Review of a social service progress note, dated 2/11/22 at 2:48 p.m., showed: A quarterly care conference was held today, 2/11/22 @ 10:30 a.m. The following were present: daughter, Ombudsman, Activities, and Social Services. SS went through information that was on Multidisciplinary Care Conference UDA. Daughter had some concerns. SS spoke to Administrator and DON about those concerns. DON put behavior charting in MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Code status reviewed.Appointment scheduled next Thursday, 2/17/22 @ 1pm with [neuropsychologist's name]. SS will send updated progress notes early next week. SS will send a referral to [Hospital name] in [NAME]. SS will continue to follow resident. During an interview on 2/16/22 at 2:12 p.m., staff member S said she had not received any behavioral or dementia training for resident #4. The staff member said the social worker was going to provide training specific to resident #4's behavioral concerns, but it never happened. She said she would dump towels on the table for resident #4 to fold or she would call the activity staff to have someone take resident #4 to the activity room. Staff member S said there were some things she had shared with other staff to help intervene with resident #4's behaviors. Staff member S stated, We've just recently started documenting on resident #4's behaviors. Resident #4 wanders, and she goes into other resident rooms frequently. The other residents understand she can't see, and she has dementia, but they get upset with her coming in their rooms. Especially at 2 or 3 o'clock in the morning. Staff member S said resident #4 would be up for 36 to 48 hours at a time and then crash for a day. She said the other residents on [MEDICATION(S)] Crest West would get upset because when resident #4 is on the go, she needed constant supervision, and the other residents did not get their needs addressed. Staff member S stated, On this unit it's me . and the nurse to provide care for the residents. During an interview on 2/16/22 at 2:18 p.m., staff member FF said she had not received any education or training on minimizing or limiting resident #4's behaviors. Review of resident #4's neuropsychologist's report, dated 12/28/2021, showed, Plan: . - start [MEDICATION(S)] 0.5mg BID, after 2 days if no improvement in behavior increase to 1mg BID . During an interview on 2/16/22 at 3:16 p.m., staff member B said she was not aware the neuropsychologist had written, If no improvement in behaviors increase risperdone to 1 mg BID. During an interview on 2/16/22 at 3:26 p.m., staff member I said she had not provided actual training to facility staff in regards to resident #4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the nursing staff wrote the majority of the care plans for each resident. Review of the facility's Grievance and Satisfaction Form, dated 2/7/22, showed resident #16 had filed a grievance with the facility regarding resident #4's behaviors. Resident #16 wrote, [resident name] was being loud and disruptive all night 2/5 claiming there was fire. Approx. 5am 2/6 [resident name] opened my door and walked in while I was partially naked during check & change. [Staff name] removed her but my privacy was violated & I wanted it on the rec. The facility's resolution for this grievance showed, 1. Resident evaluated by physician. 2. Stop sign placed on door. The facility's investigation for this grievance showed, Residents upset c [with] other resident A [resident #4]. Resident A wanders & is blind. Resident A wandered into resident B room. Attempted re-direction unsucessful [sic]. Review of resident #4's nursing progress notes showed: - 1/27/22 at 9:47 p.m.: Continues to have adverse behaviors. Goes into other resident's [sic] rooms, continuously asks to go to the restroom when she has just been, asks to lay down and gets right back up, runs into staff and walls with wheelchair, constant yelling and screaming, and wanders the halls . Has not slept thus far this shift. will continue to monitor. No nonpharmacological or pharmacological interventions were documented at that time. - 2/4/22 at 12:27 a.m.: Resident continues with behaviors. Enters other resident's [sic] rooms, runs into staff with wheelchair, goes to bed and gets right back up, runs into walls ad [sic] equipment, and constantly yelling. Is very difficult to redirect. Denies any pain at this time. Will continue [sic] to monitor. No nonpharmacological or pharmacological interventions were documented at that time. - 2/9/22 at 10:26 p.m.: Resident was running chest into the table in the dinning [sic] room on the west unit. Non-Pharmacological Interventions: Redirected, resident stated that she did not know she was doing it. - 2/14/22 at 6:14 a.m.: Late note for 2/13/22, resident slept on and off throughout the morning. Up late afternoon with calling out help me, help me. The resident had snacks and a diet soda. She wandered around trying to get into other residents' rooms. Had to one on one to keep her from bothering others. No nonpharmacological or pharmacological interventions were documented. - 2/14/22 at 7:19 p.m.: Resident continuously wondering [sic] while she is awake. wanders into other rooms. constantly wanting someone by her side to talk to. A review of resident #4's monitoring record, dated 2/1/2022 to 2/28/2022 with a start date of 2/11/2022, showed, Nurse must enter progress note every shift regarding residents [sic] behavior. Identify wandering into rooms, yelling out, repetitive statements, or others, every shift for Behavior - 2/11/22 evening staff documented the resident was voicing repetitive statements and wandering. - 2/12/22 day staff documented the resident was voicing repetitive statements and wandering. - 2/12/22 evening staff failed to document the resident was exhibiting any behaviors. - 2/13/22 day staff documented the resident was wandering. - 2/13/22 evening staff documented the resident was voicing repetitive statements, wandering, and yelling all night. - 2/14/22 day staff documented the resident was voicing repetitive statements, and wandering. - 2/14/22 evening staff documented NA for repetitive statements, wandering, and yelling. Review of resident #4's Minimum Data Sets (MDS) from 2/25/21 to 2/2/22 showed the following: - Significant Change MDS, with an ARD of 8/2/21, showed resident #4 had wandered 4-6 days of the seven-day look-back period. The impact of the wandering behavior showed the behavior placed the resident at risk of getting into a potentially dangerous place and had a significant potential to affect other residents by intruding on their privacy. - The Quarterly MDS, with an ARD of 11/2/21, showed resident #4 had wandered daily during the 7-day look-back period. The impact of the wandering behavior to the resident and other residents was not completed. - The Quarterly MDS, with an ARD of 2/2/22, showed resident #4 had a severe cognitive deficit. The resident had wandered 4-6 days of the 7-day look-back period. The impact of the wandering behavior of the resident and other residents was not completed. A review of resident #4's Behavioral Symptoms CAA, with an ARD of 8/2/21, showed the resident was wandering 4-6 days of a 7-day look-back period, and the resident's wandering behavior had worsened since the last assessment. The seriousness of the resident's behavioral symptoms indicated she was an immediate threat to herself. A review of resident #4's current care plan showed: a. - Focus: anxiety: I have had medication changes, I are [sic] to revisit on [DATE]rd. The medication change [sic] helped maybe a couple of days. since then I am very restless, my behavior os [sic] becoming demanding, I am wandering all over, I am bumping into others. I am asking excessively for diet coke. nursing to keep in touch with my providers Date Initiated: 12/15/2021 - Goal: I will remain safe throughout my stay at [Facilty name] with the assistance of the staff. Date Initiated: 12/15/2021 Target Date: 03/31/2022 - Interventions: I need constant supervision when I am out of bed. I wander through the facility, and into others rooms. I ask for things nonstop, please monitor that I do not overeat, or drink too much at one time. toilet me often. Please have patience, as I just do not understand, I cannot sit still when IO [sic] am up. I do get very upset and can [sic] verbally abusive to others Date Initiated: 12/15/2021 b. - Focus: MOOD/DEPRESSION- My PHQ severity score was 7/27. Depression causal factors include diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I presented with symptoms of depression during the PHQ interview including being so fidgety or restless that I have been moving around a lot; Feeling down, depressed, or hopeless; Feeling tired, or having little energy. Date Initiated: 02/08/2022 - Goal: I will engage in mental health treatment and work on improving mood state and outlook, through my next review date. Date Initiated: 02/08/2022 Target Date: 03/31/2022 - Interventions: I will talk to staff that I feel comfortable with about ideas to moderate and reduce my mood distress symptoms such as: sharing thoughts and feelings that have contributed to depression. Staff will notify my Provider and Social Services if they see an increase in any signs and/or symptoms of depression. Date Initiated: 02/08/2022 During an interview on 2/17/22 at 8:03 a.m., staff member D said she did not write care plans. She said the unit managers did that. Staff member D said staff member C wrote the care plans for the unit the resident resided on. During observation and attempted interview on 2/17/22 at 8:06 a.m., staff member C was working at a medication cart. Staff member C verified she would have written the majority of resident #4's care plan. Staff member C was not available for further interviews prior to the survey team exiting the facility.

Based on observation, interview, and record review, the facility failed to protect residents from neglect of care for the following areas: - when nursing failed to perform appropriate follow-up assessments, vital signs, neurological checks, and provider notification for a resident who sustained a fall with a head injury, for 1 (#1), - when a resident's dressing changes were not completed daily as ordered by the provider, for 1 (#7), - when direct care staff refused to assist a dependent resident with incontinence care which resulted in feelings of embarrassment and being unwanted, for 1 (#6), - when a resident's [CONDITION(S)] was not set up, per provider orders, after returning from a hospital admission for 1 (#2); and, - the facility failed to protect a resident from retaliation when a staff member failed to communicate with direct care staff the presence of a special meal brought by family to celebrate the resident's birthday, for 1 (#2) of 10 sampled residents. Findings include: 1. During an interview on 9/13/21 at 9:32 a.m., NF3 stated she had just received information regarding possible neglect related to resident #1's fall on 9/9/21 and follow-up nursing care. NF3 stated she had been told the provider and family had not been notified about the fall until 9/10/21. She also stated she had been told the resident's head wound had not been cleaned. During an interview on 9/14/21 at 12:20 p.m., NF6 stated she received a call from a female travel nurse on the morning of 9/10/21. NF6 stated the nurse apologized for not calling sooner and told her resident #1 had fallen the previous evening, cutting her head; but that she, was fine. NF6 stated she received a call from the facility at approximately 10:20 a.m. informing her the provider was concerned about a head injury and was transferring resident #1 to the emergency room for evaluation. During an interview on 9/14/21 at 1:40 p.m., staff member C stated she was notified regarding resident #1's fall at 11:00 p.m. on 9/9/21. Staff member C stated she instructed NF1 to notify the provider and the family, and to start neurological checks on resident #1. Staff member C stated when she arrived at the facility on 9/10/21 at 6:00 a.m., she found out NF1 had not done the notifications or neurological checks as instructed. Staff member C stated the subsequent investigation did not identify the reason for NF1's lack of action, and did substantiate neglect of care by NF1. During an interview on 9/16/21 at 10:55 a.m., NF10 stated she was aware of resident #1's fall and had access to the provider's note from 9/10/21. NF10 stated the note showed no provider had been notified regarding the fall on 9/9/21 until rounds on 9/10/21. The note showed the provider was not able to observe the head wound because of dried, matted blood on her head and blood on her pillow, and was concerned about a head injury. A request was made on 9/14/21 at 3:50 p.m., for any documentation related to resident #1's fall and follow-up care. The only documentation provided was two nursing progress notes describing the provider's visit and subsequent transfer to the emergency room . See F658 for additional details related to resident #1's fall and follow-up care. A review of resident #1's nursing progress notes, dated between 9/9/21 at 6:00 p.m. and 9/10/21 at 10:00 a.m., failed to show a fall, notifications to the provider or the family, any assessments related to the circumstances of her fall, or any post fall assessments. A review of resident #1's nursing progress note, dated 9/10/21 at 11:20 a.m., showed the resident was examined at 10:30 a.m. by a provider. The note showed provider orders were received at 10:40 a.m. to send resident #1 to the emergency room for evaluation and a CT scan of her head. NF6 was notified of the transfer. At 11:20 a.m. resident #1 was transferred to the emergency room , and was, very lethargic, slow to respond, [complained of] pain pointing to head. Able to follow very simple direction after several prompts. 2. During an interview on 9/15/21 at 3:27 p.m., staff member A stated NF11 called the facility and made an allegation of neglect regarding missed dressing changes over the weekend of 6/19/21 and 6/20/21. As part of the investigation, staff member A stated several other residents were identified as at risk for having missed dressing changes. Staff member A stated resident #7 was identified as one of these residents. Staff member A stated her investigation failed to show resident #7 had missed any dressing changes on either 6/19/21 or 6/20/21. A review of resident #7's Treatment Administration Records, dated 5/2021 and 6/2021, showed 5/29/21, 6/8/21, 6/9/21, 6/15/21, and 6/18/21 did not have a check mark and initials which showed the treatment had been completed. A review of resident #7's nursing progress notes, dated 5/29/21, 6/8/21, 6/9/21, 6/15/21, and 6/18/21, failed to show any documentation about resident #7's dressing changes. During a follow-up interview on 9/16/21 at 8:20 a.m., staff member A stated when she investigated the issue of missed dressing changes, she only looked at 6/19/21 and 6/20/21. Staff member A stated she did not look at any other days and did not identify the five missed days noted above. Staff member A stated she should have, looked at the bigger picture, and did not identify other dates which were missed and why they were missed. 3. During an interview on 9/13/21 at 12:11 p.m., resident #6 stated she had submitted a grievance in July 2021 alleging neglect by a CNA who refused to change her soiled brief. Resident #6 stated she had turned on her call light because she was soiled and needed to be changed. Resident #6 stated the CNA told her she would need to wait until the next shift. Resident #6 stated she did wait until the night shift came, and the CNA was a male. Resident #6 stated she was embarrassed to have him clean her up. Resident #6 described a more recent incident, on 9/5/21, which involved the same CNA. The more recent incident occurred when resident #6 put her call light on at 4:30 p.m. requesting to have her brief changed and to get ready for bed. Resident #6 stated she saw the CNA assisting other residents, but not her. After she had waited approximately 45 minutes, resident #6 stated she called staff member A to report the incident. Staff member A told her she would take care of it. Resident #6 stated she did not want the CNA to take care of her anymore. During an interview on 9/15/21 at 10:08 a.m., staff member G, accompanied by staff member C, stated part of the corrective action for the CNA involved in the 9/5/21 incident had been to move her to another unit so she would not be taking care of resident #6. A review of the State Survey Agency's online incident tracking system showed an allegation of neglect was submitted on 7/6/21, by the facility. The submission showed resident #6 made an allegation of neglect related to a CNA refusing to assist her. The subsequent investigation substantiated neglect because the resident was left in a soiled brief for 45 minutes. 4. During an interview on 9/15/21 at 4:30 p.m., staff members A and C discussed grievances submitted by NF4 on behalf of resident #2. One of the grievances was submitted because resident #2's [CONDITION(S)] machine was not set up for use when she returned from a hospital stay on 8/9/21. Staff member A stated when resident #2 returned from the hospital on 8/9/21, she had a new bariatric bed. Staff member A stated the bed took up more room than a regular bed and made the power outlets difficult to access. Staff member C stated furniture would have needed to be moved. Staff member C stated resident #2 was moved to a larger room where the electrical outlets were accessible, and the [CONDITION(S)] could be plugged in. Staff member C stated the [CONDITION(S)] was set up and ready for use on 8/10/21. A review of the State Survey Agency's online incident tracking system showed an allegation of neglect was submitted by NF4 on 8/11/21. The alleged neglect on the part of the facility was for not setting up resident #2's [CONDITION(S)] on 8/9/21. The subsequent investigation substantiated the neglect. 5. During an interview on 9/13/21 at 9:32 a.m., NF3 stated she was aware of an incident which had occurred approximately two weeks ago. NF3 stated a family member had brought a birthday dinner for resident #2. She stated the meal remained at the nurse's desk for a while. When resident #2 was called by her family to see if she enjoyed her birthday dinner, resident #2 told them she had not gotten anything special. During an interview on 9/16/21 at 8:20 a.m., staff members A and C stated a family member brought resident #2 a surprise birthday dinner. As the facility was on lockdown because of a COVID-19 outbreak, the family member called beforehand to explain the dinner was a surprise for resident #2's birthday. The dinner was left with staff member S at the front desk. Staff member A stated staff member S called the unit to let them know there was something for resident #2. Staff member A stated staff member S, not able to reach the unit by telephone, delivered the bag to the empty nurse's station on the unit. Staff member A stated as there was no name on the outside of the bag, the staff on the unit did not look into the bag. Staff member A stated when the family member called later, resident #2 still had not received the bag. The conclusion of the investigation was staff member S could and should have done more to facilitate resident #2 getting her birthday dinner, and determined staff member S was retaliating because of a previous incident with resident #2's family. A review of the State Survey Agency's online incident tracking system showed an incident was submitted by the facility on 9/10/21 which substantiated the allegation of retaliation by staff member S. A review of the facility's policy titled, Abuse and Neglect, last revision date 5/15/19, showed neglect to be the failure to provide necessary and adequate (medical, personal, or psychological) care, and All retaliation in any manner against residents for reporting abuse is considered abuse.

Based on interview and record review, the facility failed to ensure contracted nursing staff used professional judgement when caring for a resident taking an anticoagulant medication, who sustained a fall with a head injury, increasing the risk of harm due to a delay in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #2) of 3 sampled residents. Findings include: 1. During an interview on 9/13/21 at 9:32 a.m., NF3 stated she had been notified resident #1 had fallen and injured her head at approximately 6:00 p.m. on 9/9/21. NF3 stated she had been told the wound had not been cleaned as of the morning of 9/10/21. The provider had not been notified on 9/9/21, regarding the fall with injury, and was not aware of the fall until she arrived at the facility on 9/10/21 to do resident rounds. During an interview on 9/14/21 at 12:20 p.m., NF6 stated she was notified of resident #1's fall early on the morning of 9/10/21. NF6 stated she was, in shock, when the nurse apologized for not calling the evening before. NF6 stated the nurse told her she did not call because she was, so busy. NF6 stated she called the facility back about 10:00 a.m. to check on resident #1 and found out the resident had not been seen by a provider yet. NF6 stated someone from the facility called her at about 10:20 a.m. to say the provider had a concern for a head injury and was sending the resident to the emergency room for an evaluation. During an interview on 9/14/21 at 1:17 p.m., staff member R stated the facility's process for handling falls included protecting the resident from further injury, performing vital signs and neurological checks as part of a resident assessment, and notifying the provider, family, DON, and administrator. Staff member R stated an incident report and documentation associated with the Fall Check List were completed and then forwarded to the unit manager for review. During an interview on 9/14/21 at 1:40 p.m., staff member C stated the fall protocol included a resident assessment, vital signs, and neurological checks if the fall was unwitnessed or if there was a head injury. Staff member C stated she was notified by NF1 at 11:00 p.m. of the fall sustained by resident #1 at 6:05 p.m. on 9/9/21. Staff member C stated she told NF1 to notify the on-call provider, the resident's family, and to begin performing neurological checks on resident #1. Staff member C stated when she arrived in the facility at 6:00 a.m. on 9/10/21, she found out NF1 had not done the notifications as instructed and had not been performing neurological checks on resident #1. Staff member C stated NF1 was immediately suspended, and the subsequent investigation showed there had been a miscommunication between NF1, the night shift nurse, and NF2, the day shift nurse. Each nurse believed the other was performing the required notifications. When asked why NF1 did not document resident #1's vital signs and neurological checks, staff member C stated, I don't know why it (vital signs and neurological checks) didn't happen. Staff member C stated there was a binder at each nurse's station which contained training documents including falls management. Staff member C stated during the investigation of resident #1's fall and subsequent care, the facility identified a gap regarding orientation and training of agency or contract nursing staff. Staff member C stated the facility had started a performance improvement project in response the the findings of this investigation. A review of the facility's policy titled, Falls Management, dated 11/2019, showed post fall resident management included a complete assessment, obtain vital signs, obtain neurological checks with evidence of an injury to their head, contact the provider and the resident representative and document in the medical record. A review of the facility's Fall Check List, not dated, provided by staff member R on 9/14/21, showed the following tasks were to be completed after a resident fall: -Contact DON, -Contact provider, -Contact family, -Fill out Fall Scene Investigation (paper form), -Complete Risk Management in electronic medical record, and -Initiate neurological checks if resident hits their head or if the fall is unwitnessed. A request was made to staff members A and C on 9/14/21 at 3:50 p.m. for any documentation associated with resident #1's fall and post fall care. The only documentation received prior to the end of the survey was the two nursing progress notes identified below. No documentation of the Fall Check List, the Fall Scene Investigation, resident #1's assessments, vital signs, or neurological checks was provided prior to the end of the survey. A review of resident #1's nursing progress note, dated 9/10/21 at 11:20 a.m., showed the resident was examined at 10:30 a.m. by a provider. The note showed provider orders were received at 10:40 a.m. to send resident #1 to the emergency room for evaluation and a CT scan of her head. NF6 was notified of the transfer. At 11:20 a.m. resident #1 was transferred to the emergency room , and was, very lethargic, slow to respond, [complained of] pain pointing to head. Able to follow very simple direction after several prompts. A review of resident #1's nursing progress note, dated 9/10/21 at 4:59 p.m., showed she returned from the emergency room , x-rays of her head, right hip and right hand were negative for injury. Resident #1 was, . alert, oriented times one only, disoriented and argumentative. Easily becoming agitated, wheeling self in [wheelchair]. Knocking into furniture, unable to redirect as she continues argumentative. 2. During an interview on 9/13/21 at 2:00 p.m., resident #2 stated the nurses have not been giving her pills on time and it has caused her to gain weight. Resident #2 stated it was an ongoing problem. On 9/15/21 at 10:26 a.m., the surveyor received a voicemail from NF4 regarding the issue of proper administration of certain medications. NF4 stated he had spoken with resident #2's provider, staff member T, and the improper administration of specific medications which was raising a health issue for resident #2. During an interview on 9/16/21 at 11:21 a.m., staff member T stated there was an issue with the administration of [MEDICATION(S)] and [MEDICATION(S)]. Staff member T stated [MEDICATION(S)] was a thiazide diuretic and [MEDICATION(S)] was a loop diuretic, and it was imperative the [MEDICATION(S)] was given no more than 30 minutes before the [MEDICATION(S)]. If the medications were given more than 30 minutes apart, the potentiating effect was lost. Staff member T stated this had been explained to nursing several times, and the order specified the [MEDICATION(S)] was to be given 30 minutes before the [MEDICATION(S)]. Staff member T stated the facility's inability to give the medications as ordered had caused resident #2 to gain weight. Staff member T stated the order specified [MEDICATION(S)] was to be given 30 minutes before [MEDICATION(S)] to have the proper effect. A review of resident #2's Medication Administration Audit Report, dated 9/16/21, showed the following: -7/7/21 [MEDICATION(S)] 5 mg given at 7:25 a.m., [MEDICATION(S)] 2 mg given at 8:41 a.m., 76 minutes apart, -7/9/21 [MEDICATION(S)] 5 mg given at 8:49 a.m., [MEDICATION(S)] 2 mg given at 9:57 a.m., 68 minutes apart, -9/5/21 [MEDICATION(S)] 5 mg given at 8:38 a.m., [MEDICATION(S)] 2 mg given at 9:48 a.m., 70 minutes apart, -9/7/21 [MEDICATION(S)] 5 mg given at 8:38 a.m., [MEDICATION(S)] 2 mg given at 9:50 a.m., 72 minutes apart, -9/11/21 [MEDICATION(S)] 5 mg given at 9:11 a.m., [MEDICATION(S)] 2 mg given at 9:54 a.m., 43 minutes apart, -9/12/21 [MEDICATION(S)] 5 mg given at 9:25 a.m., [MEDICATION(S)] 2 mg given at 10:21 a.m., 56 minutes apart, and -9/14/21 [MEDICATION(S)] 5 mg given at 8:15 a.m., [MEDICATION(S)] 2 mg given at 9:55 a.m., 100 minutes apart. A review of resident #1's weights showed the following: -8/9/21, return from hospital admission, 294 pounds, -9/11/21, 315.5 pounds, and -9/15/21, 310.5 pounds.

Based on observation, interview, and record review, the facility failed to ensure staff performed wound care for a wound VAC as ordered, provided regular wound assessments, and performed dressing changes for a wound VAC using clean aseptic technique for an Unstageable Pressure Ulcer of the Sacral Region which required a wound VAC for healing for 1 (#31) of 21 sampled residents. This deficient practice resulted in a sinus tract from the resident's sacral wound to an opening in the resident's rectum. Findings include: During an interview and observation on 9/28/20 at 2:13 p.m., resident #31 was lying in bed, he had a wound VAC device on his side table. The wound VAC device had a piece of tape dated 9/24/20. There was a small amount of thin, brown yellow drainage in the canister with a small amount of dry solid white dusting debris at the bottom of the canister. The resident stated he was a paraplegic and had developed a pressure ulcer on his back while he was at home. He said he came to the facility about a year ago to help heal his pressure ulcer, and as soon as it was healed, he could go home again. He stated he was supposed to have a surgery to repair the pressure ulcer but was not sure when that was scheduled. He stated he had a wound VAC for his pressure ulcer, which staff were to change the dressing and the wound VAC system twice a week. He also went to the Wound Clinic on Fridays were they changed the dressing and wound VAC system. He said he had the dressing changed for his wound VAC on Friday (9/25/20) at the wound clinic. He was not sure why there was a date for (9/24/20) on the wound VAC canister, he thought everything was supposed to be changed out at the clinic. He stated he had a previous infection in his wound but that was a while ago and did not think he had an infection in his wound at this time. During an observation the resident's room had a strong foul odor which could be smelled from the hall outside of his room. During an observation on 9/29/20 at 8:40 a.m., resident #31 was laying in his bed on his back and the alarm on his wound VAC was sounding. His room had a strong foul odor. During an interview and observation on 9/29/20 at 9:07 a.m., resident #31's wound VAC was still alarming loudly with a warning that there was either a line leak or missing canister. The resident stated the alarm had been going off for a while, but he didn't notice it. The resident stated he did not have any pain associated with his wound because he did not feel anything down there. During an interview on 9/29/20 at 9:39 a.m., staff member Q stated resident #31's wound vac was alarming because there was most likely a leak in the negative air pressure of the wound VAC. She stated she was not aware how long the alarm had been sounding. She stated she needed to patch the leak for the alarm to quit alarming and the [DEVICE] to work appropriately. During an observation and interview on 9/29/20 at 9:42 a.m., staff member Q entered resident #31's room and donned gloves but did not wash her hands. She gathered the needed supplies for the wound care from a spare bed in his room, and placed those items on the stand next to his bed. The canister for the wound VAC was on the same bedside stand. The staff member did not place a clean drape barrier between the items for the wound care, and the dirty bedside stand. Staff member Q stated she was only going to patch the dressing where the air was leaking. She said when the dressing was changed for the resident's wound VAC the entire system was changed including new tubing and a new canister. She stated she was not sure when the resident's last dressing change occurred but believed he had been to the wound clinic on Friday (9/25/20) and should have had the dressing for his wound VAC changed at that appointment. She could not explain why the canister was dated for 9/24/20, unless it was the last time the canister was changed. She drew back the resident's top bed sheet to reveal the dressed pressure ulcer on the resident's sacrum. The wound was covered with a clear dressing, that was not dated, and there was an opening in the dressing where the air was leaking above the dimple of the resident's buttocks. The bedding under the resident's rectum was soiled with a large amount of malodorous brown-yellow, and pink drainage. The drainage on the sheets were dry around the outer edges, while the center of the drainage on the sheets, was saturated and wet. Staff member Q then removed the pillows from behind the resident's back and from between his knees and placed those pillows on the clean wound supplies which were kept on the spare bed in the resident's room. She then tucked the drainage soiled sheets under the resident's bottom and then covered those soiled sheets with the non-soiled portion of the resident's bedding. The staff member noted the drainage and stated the resident had a [MEDICAL CONDITION] and sometimes he would have a little discharge from his rectum. She also stated she believed the drainage on the resident's sheets was from the wound itself because it was open at the end and not draining into the canister. Staff member Q then performed peri-care and wiped the leakage from the resident's rectum. The leakage on the rectum was a cloudy, brown-yellow, thin drainage with a strong odor. She cleansed the resident's rectum again with a second wipe that she removed from the green container. She noted another glob of drainage had appeared at the top of the resident's rectum, so she wiped that away with the same wipe. She then assessed the opening of the wound where the seal had broken and needed to trim back some of the dressing so she could apply the patch to the wound dressing to create an airtight seal. She could not find scissors with the rest of the resident's supplies on the spare bed, so with the same soiled gloves she used to perform peri-care with, she preceded to open the top drawer of resident's bedside table, then walked over and opened the top drawer of his dresser, then walked over to the bedside table on the left side of the resident and open that drawer. When she could not find the scissors, she removed the soiled gloves and left the resident's room and walked back to her medication cart. She did not perform hand hygiene when she removed her gloves or left the resident's room. Staff member Q then returned to resident #31's room, put on a new pair of gloves. She did not perform hand hygiene when she re-entered the resident's room or before she put on a clean pair of gloves. She then placed a clean transparent dressing to be used to patch the wound on the bed next to the soiled linen without placing a clean barrier between the soiled linen and clean transparent dressing. She cleansed the scissors with an alcohol wipe and trimmed the defective dressing away from the resident's wound. She then placed the soiled scissors on top of the clean transparent dressing. She then used a peri-wipe, from the same container she accessed multiple times while providing peri-care for the resident, to cleanse the skin around the opening in the dressing. She did not apply a skin prep to the skin after cleansing the area. With the same gloves she used to clean the scissors and cleanse the wound, she picked up the scissors and trimmed a small piece of it away from the transparent dressing that she was going to use to patch the wound. She did not change her gloves or wash her hands. While applying a barrier dressing to the skin under the inside of the wound dressing, she pushed her soiled gloved pointer finger into the open portion of the wound dressing, right below the wound. She stated she was trying to create a barrier on the skin before putting the patched dressing on the wound. Staff member Q then changed her gloves because some of the transparent dressing stuck to her gloves and she could not get it off. She did not disinfect her hands before putting on a clean pair of gloves. She then finished placing the second transparent dressing over the rest of the dressing. When the staff member was done with placing the patch on the wound VAC dressing, she checked the seal of the wound VAC, it was airtight and working. The staff member then removed her soiled gloves but did not perform hand hygiene. She then noted there was more drainage accumulating above the resident's rectum. There was a new glob of cloudy brown-yellow foul-smelling drainage around the resident's rectum and on his sheets. Staff member Q donned a clean pair of gloves but did not disinfect her hands. She then wiped away the drainage and asked staff member L to change the resident's bedding. Staff member Q then replaced the resident's bedding over him and removed her gloves. She did not wash her hands. She then left the resident's room and did not disinfect her hands after leaving the room and returning to her medication cart. During an interview on 9/29/20 at 10:22 a.m., staff member Q stated resident #31 was to have his wound VAC changed by the facilty on Mondays, Wednesdays, and on Fridays the Wound Clinic changed his dressings. She stated she was not sure when he last had his wound VAC changed and believed it must have been changed at the Wound Clinic on Friday (9/25/20). She could not explain why the wound VAC canister was dated for 9/24/20 but believed that must be when he had the wound last changed by the facility. She stated usually the canister was changed at the same time as the wound. She said the resident was due on Monday (9/28/20) for a dressing change for his wound VAC, but she did not do the dressing change on Monday because the EHR never prompted her to complete the dressing change for the wound VAC. Staff member Q could not say how long there had been drainage from the resident's rectum, but still thought the majority of the drainage on the resident's bedding was from his wound not being properly sealed. During an interview on 9/29/20 at 12:54 p.m., staff member Q stated it was the expectation to wash her hands when she entered and exited a resident's room, when she changed her gloves and between dirty and clean tasks. She stated she did feel like she changed her gloves a lot but did not always have time to disinfect her hands between the glove changes. She stated during wound care, items should be kept clean and away from contamination, but that could be difficult when there was not a lot of space to work in a resident's room. She stated she was planning on performing a dressing change for resident #31's wound VAC that afternoon since she had not done it the day before. During an interview on 9/29/20 at 2:16 p.m., staff member R stated she had performed wound care and dressing changes for resident #31's wound VAC at least once a week since he was admitted . She stated she worked closely with the IDT members, the Wound Clinic, and the resident's physician regarding his wound. The resident had been on and off a wound VAC to heal his pressure wound. He has made great progress with his healing and has been scheduled to have a surgical flap created to close his pressure sore. She stated it was important for the resident to remain free from an infection in his wound, especially now as he was scheduled for surgery. She said he had a previous infection in his pressure ulcer, but had not had one in a long time, and did not currently have an infection in the wound. She stated the entire wound VAC system was to be changed three times a week, typically the orders were for Sundays, Tuesdays, and Fridays, which the Wound Clinic changed the resident's dressing on Fridays. She stated she did not know the current orders for the residents wound VAC since she was out of work for the last three weeks. She stated she would confirm those orders before she performed any wound care for the resident. She said it was important to follow the orders provided by the wound clinic to ensure his wound healed optimally. Staff member R explained the purpose of a wound VAC was to suck out the drainage from the resident's wound to help healing. She stated the wound VAC only worked when the dressing had an airtight seal. She stated it was important to change the entire wound VAC system including the canister, tubing, and sponge gauze at every dressing change. She stated it was the expectation staff date and time the dressing and the canister when the system was changed. She said she had provided all nursing staff who perform wound care for the resident's wound VAC, with hands-on training and then return demonstration education to ensure wound care competency. And it was important that staff perform proper hand hygiene and maintain clean technique during the resident's wound care. The wound should be cleansed with vashe or sterile normal saline, and a skin prep used to protect the resident's skin from the adhesive and sponge. Staff member R stated she would call the wound clinic for the resident's most current orders, and then change the resident's wound VAC. During an interview on 9/29/20 at 4:25 p.m., staff member R stated she had heard back from the Wound Clinic and had received clarification on resident #31's wound orders. She said they wanted the endoform left in the wound if possible, no collagen matrix, they wanted the wound cleansed with a gentle pat and sterile normal saline, then put in iodasorb and an oil [MEDICATION NAME] before sealing the wound with the transparent dressing. She stated the wound clinic wanted the dressing for the resident's wound VAC changed three times a week but did not care which three days. She said it would be important for the facility staff to have a scheduled order for his wound care, so the dressing change for the wound VAC was not missed. During an observation and interview on 9/29/20 at 4:40 p.m., staff member R performed wound care for resident #31. She noted the resident did have a large amount of thin drainage that was a cloudy brown yellow, with a slight pink tinge on the bedding by the resident's buttocks. She initially thought this drainage was from his wound, but then noted the wound had an airtight seal. She then noted another glob of drainage covering the resident's rectum. She wiped clean the drainage and reassessed the area. She did not initially note any skin changes surrounding the resident's rectum. But when she applied pressure to the bottom side of the resident's rectum a large amount of foul-smelling thin drainage that was a cloudy brown yellow, with a pink tinge, drained from a pin sized opening above the resident's rectum. She continued to assess the drainage site and noted the surrounding tissue was not hard or warm. She said the pin size opening must be a sinus tract but could not say for sure where the sinus tract began. She stated it could be from his wound, but it could also be from his bowels, or bladder. She said however, based on the small amount of drainage in the wound VAC canister since it was last changed (9/24/20) the drainage was most likely from the resident's wound. She stated if the wound VAC did not have an airtight seal and it could not suck the drainage from the wound, the drainage had to go somewhere. She stated she would notify the Wound Clinic and the resident's physician immediately with the findings to find out what they want to do about the newly identified sinus tract. During an interview on 9/29/20 at 5:36 p.m., staff member Q stated, she had noticed some drainage but did not realize what it was, she thought it was only coming from the opening in the wound dressing. During an interview on 9/29/20 5:45 p.m., staff member L stated he noticed some drainage on the resident's bed but thought it was coming from his wound. He said he did not recall if he notified the nurse of this drainage. During an interview and record review on 9/30/20 at 2:26 p.m., staff members B and F stated resident #31 had been treated for [REDACTED]. Staff member B stated resident #31 did not currently have an infection in his wound, but it was important to maintain asepsis with wound care to prevent further infection. Staff member F stated it was also important to provide wound care for resident #31 as ordered by the Wound Clinic to facilitate healing and prevent further skin breakdown. Review of resident #31's Skin Evaluations, showed the resident had skin assessments on the following dates, which the assessments showed the resident's skin appeared normal: - 9/1/20, - 9/8/20, - 9/15/20, - 9/22/20, - 9/29/20; there was no further documentation in the Skin Evaluations which described the resident's sacral pressure ulcer, the wound measurements, or any changes to the resident's wound. Review of resident #31's Wound Care Provider Orders, dated 8/28/20, showed, Sacrum wound, enodform, [MEDICATION NAME], alginate, [MEDICATION NAME] border, change outer dressing daily with alginate and border. Hold diathermy treatments, Hold Wound VAC. Next visit scheduled for 9/4/20. (sic) Review of resident #31's MAR/TARs from 8/28/20 to 9/4/20, showed an order was started on 8/29/20 and discontinued on 9/1/20, for, Endoform to sacrum, [MEDICATION NAME], alginate, [MEDICATION NAME] border. Change outer dressing daily (alginate and [MEDICATION NAME] border). in the afternoon for wound care. (sic) Review of the resident's MAR/TAR, Progress Notes, and Skin Assessments, failed to show the resident was provided a dressing change or a wound assessment on 9/1/20. Review of resident #31's MAR/TAR from 9/2/20 to 9/4/20, showed a new order was written on 9/2/20, with a discontinuation date of 9/25/20, which showed, Endoform to sacrum, [MEDICATION NAME], alginate, [MEDICATION NAME] border. Change outer dressing daily (alginate and [MEDICATION NAME] border). every day shift every Wed, Sat for wound care (sic). A review of the resident's MAR/TAR, Progress Notes, and Skin Assessments, showed the resident did not receive a dressing change for his wound on 9/3/20. This new order did not follow the orders provided by the Wound Clinic Physician from 8/28/20. Review of resident #31's Wound Care Provider Order, dated 9/4/20, showed, Sacrum wound, endoform, [MEDICATION NAME], alginate, [MEDICATION NAME] border. Change outer dressing daily with alginate and border. Hold diathermy treatments. Hold Wound VAC. Next visit scheduled for 9/11/20. Review of resident #31's MAR/TAR, Progress Notes, and Skin Assessments from 9/4/20 to 9/11/20, showed the facility did not provide daily dressing changes to the resident's outer dressing on: 9/6/20 and 9/7/20. The wound care orders in the resident's MAR/TAR did not reflect the orders provided from the Wound Clinic. Review of resident #31's Wound Care Provider Orders, dated 9/11/20, showed, Sacrum wound, endoform, iodosorb, [MEDICATION NAME], alginate, [MEDICATION NAME] border. Change dressing three times a week PRN. Apply wound VAC: endoform, iodosorb, [MEDICATION NAME], NPWT at 100 mmHg continuous. Hold diathermy treatment. Next visit scheduled for 9/18/20. Review of resident #31's MAR/TAR, Progress Notes, and Skin Assessments from 9/11/20 to 9/16/20, showed the facility did not perform wound care or dressing changes to the resident's wound VAC from 9/11/20 to 9/18/20. The facility did not update the resident's wound VAC orders from the wound clinic on 9/11/20, until 9/16/20. A new order was placed in the residents MAR/TAR dated 9/16/20, with a discontinuation date of 9/25/20, which showed, per wound care: wound vac set to 100 mg continuous. Wound care Fridays. Change 3 X per week endoform, Iodosorb, [MEDICATION NAME] wound vac. every day shift every Mon, Wed for skin/wound care nursing to change wound vac Monday and Wednesday, WC changes on Fridays. (sic) Review of the resident's MAR/TAR, Progress Notes, Physician Orders, and Skin Evaluations, failed to show the resident's wound VAC was changed, assessed, or monitored from 9/11/20 to 9/18/20. Review of resident #31's Skin/Wound Note dated 9/18/20, showed, Res. returned from wound clinic with orders for sacrum. Wound vac intact Sacrum to be changed 3 X per week with endoform, iodosorb, make to drape under the foam. (NPWT) to sacrum blackfoam 100 mmHg continuous. Change dressing 3 X's per week. Next Friday appt. 09/25/20. (sic) Review of the resident's MAR/TAR from 9/18/20 to 9/25/20, failed to show the resident's wound VAC order from 9/18/20 was updated on the MAR/TAR until 9/21/20. The resident's MAR/TAR had two separate orders which over-lapped from 9/18/20 to 9/21/20. Review of resident #31's MAR/TAR from 9/18/20 to 9/25/20, showed an order was started on 9/21/20, with a discontinuation date of 9/29/20, for, Wound vac to be changed 3 x's / week M, T and Friday. WC to change on Fridays. using endoform foam, iodosorb. [MEDICATION NAME] NPWT 100 mmHg. Make to drape under the foam. every 60 hours. (sic) Review of the resident's MAR/TAR from 9/18/20 to 9/25/20, showed documentation that the wound VAC had been changed on Monday 9/21/20. There was no further documentation in the resident's Skin Assessments or Progress Notes which described the condition of the wound or provided wound measurements for this dressing change, or the status of the resident's skin at the time of this dressing change. Review of the resident's MAR/TAR showed the wound VAC was changed on Thursday 9/24/20. A Medication Administration note dated 9/24/20 at 4:10 a.m., showed, wound vac dressings are to be done in AM. - per unit manager. do not change time. (sic) A second Medication Administration Note dated 9/24/20 at 8:43 a.m., showed, .odor from wound is foul. Due to be changed today. There was no further documentation in the resident's skin assessments or progress notes which described the condition of the wound, the wound measurements, or the status of resident's skin for the dressing change on 9/24/20. Review of resident #31's Wound Care Provider Order, dated 9/25/20, showed, Sacrum wound, endoform, idosorb, [MEDICATION NAME], NPWT at 100 mmHg continuous. Change wound dressing three times a week. Make sure to place wound VAC drape under foam. Next visit scheduled for 10/2/20. Review of the resident's MAR/TAR from 9/25/20 to 9/29/20, showed an entry in the TAR which showed the resident's wound vac was changed on 9/26/20. Further review showed an Administration Note, dated 9/26/20 at 4:49 p.m., changed yesterday. There was no further evaluation of the wound or the status of the wound VAC. During an interview on 9/30/20 at 8:54 a.m., staff member G stated he had made a note on 9/26/20, on the resident's MAR/TAR that the wound was changed by the Wound Clinic on 9/25/20. He stated he did not note any changes to the resident's wound at that time. Review of the resident's MAR/TAR showed the resident was due for a dressing change for his wound VAC by the facility on Monday 9/28/20. This dressing change did not occur. During an interview on 9/29/20 at 12:54 p.m., staff member Q stated the resident's wound VAC was due for a dressing change yesterday (9/28/20). She stated she did not do the dressing change on Monday because the EHR did not prompt her that the resident was due for a dressing change. She stated if the orders were not entered into the MAR/TAR correctly it could be impossible to know when to change everyone's dressings. She stated she was not sure when his last dressing change for his wound VAC was completed but was sure he went to the Wound Clinic on Friday. She stated they always changed his dressing at those appointments.

Based on observation, interview, and record review, the facility failed to provide a resident adequate assistance for eating; failed to assess the effectiveness of the weight loss and nutritional interventions and implement new interventions; and failed to provide a breakfast and lunch tray to a resident. The accumulation of the failures increased the risk of the resident's continued severe weight loss of 15 percent in six months, for 1 (#17) of 30 sampled residents. Findings include: During an observation on 4/16/19 at 9:09 a.m., resident #17 was sleeping in her reclining chair. No breakfast tray had been delivered to the resident. During an observation on 4/16/19 at 10:43 a.m., resident #17 had not appeared to have moved from her position, observed earlier that morning. During an observation on 4/16/19 at 12:20 p.m., resident #17 continued to appear to be in the same position from the morning observations. No lunch tray had been delivered to the resident. The resident responded to her name, smiled, and nodded 'yes' when asked if she was hungry. She was attempting to eat sugar free cookies. During an observation on 4/16/19 at 12:39 p.m., resident #17 was sleeping. An unwrapped Rice Krispee bar was on her bedside table. Review of resident #17's physician order, dated 4/1/19, showed she was on a pureed diet. During an observation on 4/16/19 at 1:43 p.m., staff member F entered resident #17's room and provided toileting care. No food or fluids were offered to the resident. During an observation and interview, on 4/16/19 at 6:23 p.m., resident #17 received a dinner tray consisting of pureed soup and ice cream. Staff member H stated the resident did not eat very much, but liked ice cream. During an interview on 4/17/19 at 8:40 a.m., staff member G stated she did not know why resident #17 did not get the pureed meal, as specified on the therapeutic breakdown sheet. She stated the resident room trays on resident #17's hall were delivered one at a time, by the CNAs, because the facility did not have a food delivery cart. She stated the facility did not serve the room trays until the CNA came to the kitchen to pick them up. During an interview on 4/17/19 at 8:30 a.m., staff member T stated the resident had been refusing meals for the past six months. Staff is offering her snacks and sandwiches. She needs more help now with eating. Staff member T stated the CNAs were responsible for making sure every resident eating in their room received a meal tray. Review of resident #17's Quarterly MDS, with the ARD of 6/20/18, showed a weight of 160 pounds. Review of resident #17's weight record, dated 11/4/18, showed the resident weighed 137 pounds. On 4/2/19, the resident weighed 120.2 pounds. Review of resident #17's Physician Order, dated 2/15/19, showed, Glucerna, one BID. During an observation and interview on 4/18/19 at 9:45 a.m., the nutritional supplement closet did not contain Glucerna. Staff member G stated she did not know any residents were to receive Glucerna. Review of resident #17's Physician Order, dated 3/26/19, showed the resident was too tired to chew her food, and her food texture was downgraded to a mechanical soft texture. No other interventions were implemented for resident #17's 40 pound weight loss. Review of resident #17's Care Plan, dated 11/15/18, showed one new intervention for the mechanical soft texture. All other interventions were dated 4/11/18. Review of resident #17's Notification to the Physician for weight loss, dated 4/10/19, showed a 15 percent weight loss in 90 days, and intakes variable but less than 50 percent. Supplements in use, sometimes accepted. No new interventions were recommended by the facility or physician. Review of resident #17's most current Dietary Evaluation, dated 2/4/19, showed Resident unwilling to accept food supplement or to eat more than 3 meals a day. Staff are providing cues and encouragement for nutrition and hydration. Recommend Glucerna or house equivalent supplementation with meals tid. No supplement was observed with the dinner meal served 4/16/19 at 6:23 p.m.

Based on interview, observation, and record review, the facility failed to reduce multiple falls, one with a pelvis fracture, for 1 (#3); failed to monitor and modify interventions and failed to identify meaningful root causes for falls, for 2 (#s 3 and 11); and failed to ensure Hoyer lifts, used for transfers, were completed with sufficient staffing, for 1 (#5) of 11 sampled residents. Findings include: 1. Review of the facility Fall Report showed resident #11 fell 12 times from 10/25/17 through 3/16/18. On 12/14/17, she fell and fractured her pelvis. a. Review of resident #11's Follow-Up Report for the fall on 10/25/17, showed she fell out of her wheelchair. Her socks were slippery, and she landed on her bottom. The root cause was her non-skid socks were worn out and slippery. The recommendation for the prevention of future falls was for newer socks with a non-skid bottoms. During an observation on 3/20/18 at 10:00 a.m., resident #11 had regular socks on, and not non-skid socks. b. Review of resident #11's Follow-Up Report for the fall on 10/27/17, showed she slipped and fell on her buttocks, as she transferred herself from the wheelchair to the bed. The root cause was Pt. transferring herself said she slipped and fell . The recommendation was to lock wheelchair brakes and keep next to the bed. Automatic wheelchair brake to be installed by maintenance. Review of a second fall on 10/27/17, showed the wheelchair was not locked, and it rolled away and she fell on the floor. The facility failed to implement the locked brakes on the wheelchair. She was not wearing slipper socks. Review of the Maintenance Log, dated 10/30/17, showed Please put back up brakes on wheelchair. c. Review of resident #11's Follow-Up report for the fall on 10/28/17, showed she fell out of her wheelchair. The intervention for future fall prevention was, Dycem placed beneath and on top of her wheelchair cushion. During an observation on 3/20/18 at 10:01 a.m., resident #11's wheelchair did not have dycem on the cushion. It did have a towel. d. Review of resident #11's Follow-Up report for the fall on 10/30/17, showed she was seen slipping to the floor and was holding on to arms of wheelchair. A transfer pole was installed in her room. During an observation on 3/20/18 at 10:05 a.m., resident #11's room do not have a transfer pole. Staff member D stated the therapy department removed it, because it was not safe for the resident. The transfer pole installation and removal were not documented on the Care Plan, or in the Nursing Progress Notes. e. Review of resident #11's Follow-Up report for the fall on 11/18/17, showed she was found sitting on the floor on her bottom. Resident's cushion had slid out of the chair with her and was still under her bottom when she was sitting on the floor. PT to evaluate wheelchair cushion for proper fit and stability. The dycem intervention to prevent slipping was not mentioned in the report. No evidence was provided for the PT evaluation for the cushion. f. Review of resident #11's Follow-Up report for the fall on 12/4/17, showed she was found on the floor, laying on her back. She stated the chair flew out from under me. The investigation did not include whether the wheelchair antilock breaks were in use. The root cause was Resident fell during self-transfer. g. Review of resident #11's Follow-Up report for the fall on 12/14/17, showed the resident stated she was transferring herself to the bathroom. The wheelchair was found in a corner of the room, away from the resident. The report did not specify why the wheelchair was in a corner. The root cause was toileting need. The resident complained of right hip pain, but no injury could be noted. The resident requested to go to the emergency room . Nurse asked the resident if she was certain she felt she needed to go and pointed out that no injury at this time could be found. Resident #11 was sent to the emergency room , and returned to the facility with a [DIAGNOSES REDACTED]. h. Review of resident #11's Fall Detail report for the fall on 1/21/18, showed the resident was found on her knees, next to the bed. She was on a fall mat. The root cause was toileting needs and restlessness. No new interventions were implemented. The need to anticipate resident #11's toileting needs was not addressed in the investigation. i. Review of resident #11's Fall Detail report for the fall on 2/4/18, showed her bed was in the low position, and she rolled out of bed. She hit her head and had a right eye hematoma. No root cause was identified, or new interventions implemented. Supervision was not addressed as an intervention, or lack of, for a root cause for resident #11's 12 falls. j. Review of resident #11's Fall Detail report for the fall on 2/27/18, showed she was barefoot, and found lying on the floor in her room. She stated she was taking herself to the bathroom. No root cause we identified; signs were placed in her room to remind her to call for assistance. During an observation on 3/20/18 at 10:06 a.m., resident #11's bed was not in the low position, and there was not a fall mat in the room. Resident #11 stated she moved the bed up and down, as she needed. During an interview on 3/21/18 at 8:40 a.m., staff member A stated the facility did discuss falls in their quality assurance meeting, and noted the fall rates were higher than the facility wanted. She stated the root causes on the fall reports were not meaningful. 2. Review of resident #3's Observed Fall report, dated 3/15/18, showed CNA called this nurse to resident's room, resident was on the floor sitting in front of her wheelchair with her legs on the EZ lift; sling was off and she was still hanging on to the right handle. CNA hooked her up to the sling for the EZ stand; everything was going OK, then the left sling slipped off and down to the floor. (The resident) landed on her bottom and tweaked her back and head, had a pain level of seven. The action taken was CNA was reinforced to use a 2 person transfer. The report did not include a signature or any other interventions. During an interview on 3/20/18 at 3:30 p.m., resident #3 stated she was hysterical and cried after the fall. My butt slugged the floor hard, and it hurt my sores that were just healing. During an interview on 3/21/18 at 8:50 a.m., staff member F stated she had been the staff member transferring resident #3 the day she fell . She stated she was frazzled that day, and so she did not check the placement of the sling. She stated she still transferred resident #3 by herself, and the resident was OK with that. She stated even with two people transferring the resident the day of the fall, she would still have fallen, but would not have hit the ground so hard. 3. During an interview on 3/19/18 at 3:30 p.m., resident #5 said staff transferred him using a Hoyer lift. Resident #5 said when using the Hoyer lift, only one CNA had been in the room operating the lift. Resident #5 said he did not feel safe when that happened. Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident was a total assist of two staff for transfers. During an interview on 3/20/18 at 2:28 p.m., staff member A said the Hoyer lift is to be used by two staff members when transferring a resident. Staff member A said a representative of the lift manufacturer was in the facility two months ago and did training for all the staff on the proper techniques used for the sit to stand and the Hoyer lifts. Staff member A said she did have a CNA come to her recently and tell her she had been using the Hoyer lift by herself to transfer residents. Staff member A said she asked the CNA why she had done that. The CNA said because there was no one to help her. Staff member A said she told the CNA the Hoyer lift required two staff members during a resident transfer, and if she couldn't find another CNA or nurse to help her, she needed to get the DON or anyone from the front office to assist her with the Hoyer lift transfers.

Based on record review, interview, and observation, the facility failed to prevent the development of one unstageable pressure ulcer on the spine; and failed to have the supplies necessary for the physician-prescribed treatment order for a Stage IV pressure ulcer on the coccyx, for 1 (#2) of 11 sampled residents. Findings include: 1. Review of resident #2's At Risk report, dated 2/20/18, showed During rounds licensed nurse called writer to room of resident. Resident was lying on left lateral side. There were two red and blanchable skin spots on her posterior spine. There was one 1 X 1 unstageable on mid- [MEDICATION NAME]. The root cause was resident is very kyphotic and tends to lean against the back of the wheelchair, creating pressure points on back. Referral to therapy. Review of resident #2's physician order, dated 2/21/18, showed Skin prep wipes every morning and at bedtime for skin breakdown. And Resident to return to bed after each meal due to skin breakdown along spine, limited to one hour up maximum. Review of resident #2's Progress Note, dated 2/22/18, showed apply [MEDICATION NAME] dressings to spinal area and change every two days. During an observation on 3/20/18 at 1:20 p.m., resident #2 was up in her chair, after the 12 o'clock meal. There was no cushion to the back of her chair. At 2:30 p.m., resident #1 was still up in her chair. During an interview on 3/20/18, staff member E stated resident #2 did not like to return to her bed. Review of resident #2's Physician order, dated 3/9/18, showed PT to evaluate for back cushion in wheelchair 17 days after the pressure area and root cause were discovered. Review of resident #2's therapy evaluation for a back cushion for pressure relief, showed it did not occur until 3/20/18, during the survey investigation, and one month after the pressure ulcer was identified. Review of resident #2' Care Plan, dated 11/15/17, showed no identification of the spine pressure ulcer, or evidence of pressure relief for the spine. During an interview on 3/21/18 at 8:10 a.m., staff member D stated the facility had been watching the pressure area very closely, and she believed the resident had, at one point, a cushion for the back of the wheelchair. Weekly skin documentation for resident #2 was requested on 3/20/18. No skin checks were provided for the unstageable pressure area on the spine. 2. Review of resident #2's Progress Note, dated 3/9/18, showed the [DEVICE] was discontinued, for the Stage IV coccyx pressure ulcer. The treatment was changed to cleanse wound with normal saline, apply Iodosorb to alginate and pack in wound, cover with foam dressing. During an interview on 3/20/18 at 1:20 p.m., staff member C stated the facility was out of Iodosorb, and could not complete resident #2's dressing change. She stated staff member G was out of the facility looking for the treatment. During an interview on 3/20/18 at 1:30 p.m., staff member G stated the facility did not carry the Iodosorb, and the Hospice nurse would bring the supplies to the facility, and do the dressing change. Review of resident #2's Physician order [REDACTED]. During an interview on 3/21/18 at 8:40 a.m., staff member C stated Hospice did not have the Iodosorb dressing, so the order was changed. The facility was unable to determine if the prescribed Iodosorb treatment was provided from 3/9/18 to 3/20/18. During an interview on 3/20/18 at 10:40 a.m., staff member E stated the nursing department had difficulties getting the medications and supplies they needed from central supply. It does not flow well and it is not safe for the residents. During an observation on 3/21/18 at 9:10 a.m., of a dressing change to resident #2's pressure ulcer, the dressing from the day before was not dated, and there was no packing removed during the dressing change, as ordered by the physician.

Based on observation, interview and record review, the facility failed to recognize, identify, and assess the underlying cause(s) of pain. The pain increased in frequency and intensity and the resident, who had dementia and severe cognitive deficits, was later identified to have a [MEDICAL CONDITION] for 1 (#16); and failed to follow up timely and document action taken or status of a skin abrasion identified during a bathing session for 1 (#3) out of 21 sampled residents. Findings include: 1. Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Annual MDS, with an ARD of 9/15/15, showed the resident was coded as a four (severely impaired cognition). The Quarterly MDS, with an ARD of 12/15/15, showed the resident had declined in cognition, and was coded as a two. A score of 13-15 was cognitively intact. The resident was also coded as having a pain intensity of 2 (moderate pain). A review of the resident's Clinical Notes showed the resident had a fall on 10/3/15. The resident complained of right hip pain after the fall. A range of motion assessment was completed, and the resident was able to move her legs, but complained of pain when doing this. The resident was given pain medication, which provided little relief. The resident was instructed to call when she needed help. The clinical record lacked evidence of nursing documentation for the monitoring of potential injuries, pain, or complications from the resident's fall. The next consecutive nursing documentation entry was made on 10/15/15, which pertained to broken glasses. On 10/18/15 the nursing documentation showed, Continues to complain of right hip pain and weakness. She also stated it hurts in her right leg too. Tylenol was given and was slightly helpful. The physician was notified by way of the written communication book. The resident denied falling. The nursing documentation lacked evidence of an assessment to determine the underlying cause of the pain. During an interview on 3/24/16 at 11:00 a.m., staff member GG, NP, stated a communication log was utilized by the nurses when they wanted to notify the provider of a resident's non-emergent medical concern. If the log was used, the NP would go through the communication book, identify the concern, and visit with the nurse on the concern noted. If a concern was considered emergent, then the nurse would contact the provider's office for further direction. The provider stated she was typically at the facility three times each week. On 10/19/15, the nurse documented the resident had a lot of pain when being assisted to bed. She was unable to rate the pain, but yelled out loud with movement. Her pain is definitely worse than last week when this nurse cared for her. Tylenol given x 2 thus far tonight with little relief. She has not been able to sleep all night and yelling out loud with movement. Resident wanted to use the bedpan tonight. Will pass onto next shift. The documented entry was completed at 3:16 a.m. The nursing documentation lacked evidence of an assessment to determine the underlying cause of the pain. At 10/19/15 at 8:17 a.m., the nurse documented the resident was complaining of pain in the right hip, which was rated at a 9/10. The FNP was notified. At 9:46 a.m., the resident was assessed and hollered when pressure was applied to the right hip, and with small movement. There was a fall documented 10/3/15 with c/o hip pain. Over the weekend she has complained of worsening pain. The resident was sent to the emergency room for an evaluation, which later confirmed a fractured right hip. A review of the resident's September 2015 Medication Administration Records showed the resident had the availability to be given [MEDICATION NAME] 325 mg (650 mg) oral, as needed, every six hours. The resident was given the medication one time during the month of September, which was on 9/18/15. A review of the October 2015 Medication Administration Records showed the resident had the availability to take the [MEDICATION NAME] for a headache, but was given the medication 10 times between 10/2/15 and 10/18/15. Six times the medication was given for pain in the right hip/lower area. The resident also had pain in her back, and one time in her lower left area. The pain was rated as: - 10/02/15 - 2 out of 10 - 10/03/15 - 2 out of 10 - 10/05/15 - 5 out of 10 - 10/06/15 - 4 out of 10 - 10/12/15 - 4 out of 10 - 10/13/15 - 3 out of 10 (nurse rated for resident) - 10/18/15 - 8 out of 10 - 10/18/15 - 5 out of 10 - 10/19/15 - 4 out of 10 - 10-19/15 - 9 out of 10 The resident was sent to the ER. The clinical record lacked evidence to show the nurses giving the medication attempted to determine the underlying causal factor for the pain, for which the medication was given. The resident's pain showed an increase in frequency and intensity beginning on 10/5/15. During an interview on 3/23/16 at 2:40 p.m., staff member BBB stated the resident did not use the call light, and did not comprehend well. She stated when the resident was found to have the [MEDICAL CONDITION] in October 2015 the resident's pain had continued to get worse over time, and then she was sent to the emergency room , and the fracture was diagnosed . Staff member BBB stated if the resident had pain she would act out more, which included impulsiveness, and the resident's mood would change. During an interview on 3/24/16 at 10:50 a.m., staff member C stated the resident's pain had gotten worse at the end of the duration between the fall on 10/3/15, and when she was sent out to the emergency roiagnom on [DATE]. A review of the resident's Provider Notification Form showed an entry dated 10/3 which was for the fall on 10/3/15. The nurse documented the resident had a fall and Complained of right hip pain, but can move her lower legs well. No injury noted. The provider signed and acknowledged the entry on 10/5/15. The clinical record did not show evidence that the provider had reviewed the resident's pain level, or assess the resident for a potential injury to the right hip. A review of the resident's Alteration in Comfort Care Plan showed the plan had interventions for offering medication when the resident had pain, observing for changes in status, notifying the physician, offer non-pharmacological interventions, and monitoring for complaints, and non-verbal indicators of pain. The care plan lacked evidence for the resident's individual characteristics of pain, impact of pain on her daily life, or identified strategies to reduce her pain for improved comfort due to the resident's dementia, and cognitive deficits. During an interview on 3/23/16 at 12:25 p.m., staff member E stated the clinical interdisciplinary team meeting, which occurred daily, followed a resident after a fall to identify any concerns. During this process, nursing administration reviewed the events, the clinical record, and talked about any changes to the plan of care which may have been needed. A review of a document received by the facility on 3/28/16, showed the facility reviewed pain and falls during the morning clinical meetings. Questions the team would discuss for pain included: - What is the pain level? - What are we doing about it? - Have our efforts been effective? 2. Resident #3 was admitted to the facility on [DATE]. During an observation on 3/22/16 at 7:20 a.m., the resident was observed sitting at the dining table in a wheelchair. The resident had a large brace supporting his upper torso, which extended down to his abdomen. The resident had slid down on the chair so his feet were extended out in front of him, and off the foot pedals. The resident attempted to adjust himself in the chair, and slightly grimaced with the movement. Review of the Clinical Notes showed the resident had a fall on 2/29/16, which resulted in an ORIF [MEDICAL CONDITION]. The resident returned to the facility with a brace to support the fractured area. A review of the resident's Clinical Notes dated 3/14/16 at 7:26 p.m., showed the resident had a bath that day. The nurse documented, Blisters much improved on R and L side. Does have some wet drainage on R side of blister. Bath given today. The nurse did not document the type of skin condition on the resident's back, or that she had awareness of the skin concern. Clinical documentation for the days following the bath lacked evidence relating to the resident's back. A request was made for the assessment of the skin area to the back, and documentation relating to it. During an interview and observation on 3/23/16 at 9:20 p.m., staff member GGG stated she documented resident skin conditions on a form. Staff member GGG reviewed the form for resident #1, which was dated 3/14/16, and pointed out areas circled on a picture of a body, depicting locations she identified with skin concerns. She stated the resident had two areas on his sides, which were caused from the brace. The resident also had a skin area circled on the left side of the back. Staff member GGG stated she did not write descriptions of the skin areas because she was not supposed to diagnose a resident. The staff member stated she reported the concern to the nurse, which she usually did at the end of her shift. If the skin condition was severe, then she would report it immediately to the nurse and have her look at it. A review of the resident's Skin Risk Assessment, dated 3/8/16, showed the resident scored a 14 on the Braden Scale. The form showed the nurse incorrectly checked the category for a score of 15-18. A score of 14 showed moderate risk for skin breakdown, and 15-18 was for At Risk for skin breakdown.

Based on observation, interview, and record review, the facility failed to utilize the resident's fall history, individual behaviors, and daily patterns to identify risk factors, and implement effective interventions for the prevention of future falls for 2 resident's with cognitive deficits who had outcomes of a hip and/or a L1 fractures; who had increased vulnerability to hazards due to mobility deficits; failed to adequately document fall details in the resident's record to show if the accident was avoidable; and failed to update the resident's care plan with interventions identified after a fall for 2 (#s 3 and 16) out of 21 sampled residents; and failed to maintain a hazardous free environment by not storing oxygen bottles properly in 1 of 1 oxygen storage rooms in the facility. Findings include: 1. Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's MDS, with an ARD of of 9/15/15, showed the resident was coded as a four (severely impaired cognition). The MDS, with an ARD of 12/15/15, showed the resident had declined in cognition, and was coded as a two. A review of the resident's Physician order [REDACTED].>- 3/1/16 - Fall mat, and a low bed in place. - 3/2/16 - Bed in the lowest position. - 3/3/16 - The physician ordered physical, and occupational therapy services. A review of the resident's Fall Risk Assessment, dated 3/14/16, showed the resident was scored as a 21 (high risk) for falls. A review of the resident's Interdisciplinary Notes, Occurrence Reports, Neurological Flow Work Sheets, and Physician Notification Forms, showed the resident had seven falls between 8/27/15 and 2/29/16. Fall details included: - 8/27/15 - The resident was found on the floor. She complained of back pain, had bumped her head, and she had a skin tear on her right knuckle. The resident was unable to state why she fell . The nursing documentation lacked measures for future fall prevention, and details of what was observed in the resident's surroundings, other than that she was by the bed. The Occurrence Report, completed on 9/1/15, showed a recommendation of keeping the resident's door open, for staff to anticipate the needs of the resident, and have the call light readily available. The Root Cause of the fall was determined to be due to the resident's actions, or internal risks. A review of the Neurological Flow Work Sheet lacked evidence of the neurological exams for the last day of the resident's monitoring period. During an interview on 3/21/16 at 11:00 a.m., staff member G stated the resident did not comprehend information well, and did not ask for assistance. During an observation of the resident's room, a star symbol on a green piece of paper was posted on the resident's door. Staff member G stated this was part of the fall program, which alerted staff for the resident who had a recent fall, or was at high risk for falls. - 9/13/15 - The resident was found sitting on the floor in her room. She was unable to give details of the fall. She was redirected by staff to use the call light. The nursing documentation lacked measures for future fall prevention for the confused resident, or describe the resident's environment. The nurse documented the resident was possibly ambulating. The Occurrence Report showed the resident's wheelchair had been locked at the foot of the bed. The resident was returned to the wheelchair. Recommendations made on 9/15/15 showed Staff to continue with attempting to anticipate resident needs, if she appears restless at night assist her to get out of bed and to be around staff. The Root Cause of the fall was determined to be due to the resident's actions, or internal risks. The medical record lacked a Neurological Flow Work Sheet for the fall. - 10/3/15 - The nursing note entry was made on 10/4/15. The resident was observed falling when she became unbalanced. She complained of right hip pain after the fall. A range of motion assessment was completed, and the resident was able to move her legs, but complained of pain. The resident was given pain medication, which provided little relief. The resident was instructed to call when she needed help. The nursing documentation lacked evidence for monitoring of the resident after the fall from 10/4/15 to 10/18/15. The documentation at the time of the fall lacked evidence what the nurse determined to be a potential cause of the fall. The Occurrence Report showed the resident had not locked the wheelchair brakes. The recommendations made on 10/6/15 showed staff were to continue to attempt to anticipate the resident's needs, remind her to call for help, and have the call light available, although these interventions were unsuccessful on the two falls prior. The Root Cause of the fall showed it was determined to be due to the resident's actions, or internal risks. On 10/18/15, a nursing documentation entry showed the resident continues to complain right hip pain and weakness. She also stated it hurts in her right leg too. Tylenol was given and slightly helpful. The physician was notified by way of the written communication book. The resident denied falling. On 10/19/15, the nurse documented the resident had a lot of pain when being assisted to bed. She was unable to rate the pain, but yelled out loud with movement. Her pain is definitely worse than last week when this nurse cared for her. Tylenol given x 2 thus far tonight with little relief. She has not been able to sleep all night and yelling out loud with movement. Resident wanted to use the bedpan tonight. Will pass onto next shift. The documented entry was completed at 3:16 a.m. On 10/19/15 at 8:17 a.m., the nurse documented the resident was complaining of pain in the right hip, which was rated at a 9/10. The FNP was notified. At 9:46 a.m., the resident was assessed and hollered when pressure was applied to the right hip, and with small movement. There was a fall documented 10/3/15 with c/o hip pain. Over the weekend she has complained of worsening pain. The documentation showed it was unclear if the resident sustained [REDACTED]. The resident was sent to the emergency room for an evaluation, which later confirmed a fractured right hip. During an interview on 3/23/16 at 2:40 p.m., staff member BBB stated the resident had poor comprehension, transferred herself to bed and toilet, and did not use the call light. During the time when the resident was found to have the fracture, staff member BBB stated the resident would go to her room right after a meal and transfer herself. Staff member BBB stated the nurse does not update the care plan for a resident, but this is done by the unit managers, or upper management. She stated a head to toe assessment would be completed for all falls, to include obtaining vital statistics, how the resident was lifted off the floor, what the resident's status was prior to the fall. During an interview on 3/23/16 at 11:20 a.m., staff member C stated the facility Risk Watch interdisciplinary meeting would look at the details for each fall at the facility, review the interventions on the care plan, look at medications as contributing factors, and then implement a fall intervention if needed. A review of the Nursing Documentation Requirements for the facility showed under the falls category that the nurse should document the resident's status after a fall for 72 hours, and for a fall with injury, continued charting would occur until the injury was resolved. - 11/8/15 - The resident was yelling for help, and staff found her laying on the floor in her room. She was next to the bed. Her right leg appeared shorter than the left, and she would say ouch when her head was touched. A large bump was felt on the back of the resident's head. The resident was sent to the emergency room for an evaluation, and was found to have no further injuries. The nursing documentation lacked evidence for any preventative measures for future fall prevention. The Occurrence Report showed the recommendations of a transfer pole next to the resident's bed, and staff was to keep the wheelchair locked at bedside to prevent ambulation. - 12/6/15 - The resident was transferring herself, without using the call light for assistance, and slipped to the floor. The fall resulted in a scrape to the left side of the resident's back. After the fall the nurse documented the call light was in reach, and encourage her to use call light for assistance with transferring. Neither an Occurrence Report, nor a Neurological Work Sheet was available for review. - 2/29/16 at 2:30 a.m. - The staff heard a noise, and then the resident began yelling help me. The resident was found lying on the floor by the dresser, and the wheelchair was by the bed. The Occurrence report showed the nurse entered the event as occurring on 2/29/16 at 3:20 a.m. The nurse documented on the report, Continue to encourage to use her call light. Staff to anticipate needs as able. The nurse also documented the resident had very poor memory. The Root Cause was found to be the resident's actions, or internal risk factors. The Conclusion section included information that the resident self-transferred from the wheelchair to the bed, and she wanted to retain her independence with activities of daily living as much as possible. During an observation on 3/23/16 at 12:00 p.m., the resident was observed propelling herself down the hall. The resident was searching for her room, and saying she wanted to go to bed. Three staff members passed by the resident in the hall and spoke to her. The resident went to her room door, opened it, wheeled inside, and shut the door on her own behind her. The door to the room was observed until 12:30 p.m., and no staff entered to assist the resident. - 2/29/16 at 7:42 p.m. - The resident was found on the bathroom floor at 11:30 (a.m., or p.m., was not documented). The resident had a laceration on the right side of the forehead, and was sent to the emergency room for an evaluation, and sutures to the forehead. The resident also received a skin tear to the right cheek, and right elbow. The Occurrence Report showed the wheelchair was at the resident's bedside, and the resident was unable to explain what she was doing. The Root Cause showed the resident's actions continued to be an issue. The Recommendation made for future fall prevention included, Continue to encourage her to call for help. Transfer pole in place by bed, call light with resident when in bed resting, wheelchair at bedside, and reminders as resident has dementia. During an interview on 3/23/16 at 12:05 p.m., staff member AAA stated she was present on the day the resident fell , and was sent to the emergency room . She stated the resident was found in the bathroom, and her wheelchair was by the bed. Staff member AAA stated they thought the resident had gotten up and walked on her own. Staff member AAA stated she did not recall what was on the resident's care plan for falls, but could read it (on computer), or ask the nurse. A review of the resident's Fall Care Plan, and Summary POC, showed interventions were implemented for fall safety, however the resident continued to have falls. The care plan for falls did not identify the resident's independent behavioral patterns, personal preferences, or daily routines which may have put her at risk for falling. During an interview on 3/24/16 at 10:35 a.m., a family member stated she did not feel the facility had the quality of help needed for the care, and supervision of the residents. She stated the resident had dementia, but she did not understand why she started to have falls, and has kept falling, and it did not seem like the facility was doing anything to figure out a cause. 2. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Annual MDS, with an ARD of 7/21/15, showed the resident was coded as being severely impaired for cognition. The Quarterly MDS, with an ARD of 1/29/16, showed the resident was coded as being moderately impaired for cognition. A review of the resident's Fall Risk Assessment, dated 3/4/16, showed the resident was a high fall risk. A review of the resident's Physician orders [REDACTED]. A review of the resident's Psychotropic Drug Use care plan showed the antidepressant medication was used for depression and insomnia. The medication side effects staff were to observe for were listed as: dizziness, tremors, nervousness, irritability, fatigue, insomnia, unsteadiness with transfers or ambulation. The Fall Care Plan showed the antidepressant drug was identified in the care plan problem for falls as a contributing factor. A review of the resident's Clinical Notes showed the resident had three unwitnessed falls, which occurred on 2/29/16, 3/3/16, and 3/9/16. Details included: - 2/29/16 - The resident was found on the bathroom floor. He denied hitting his head, but had a red area to the back of the head. The clinical notes lacked evidence to show the assessment of the environment, contributing factors to the fall, or what the resident had said regarding the fall. The resident was sent to the emergency room , and found to have a L1 fracture. A review of the resident's occurrence report showed the resident was modest with ADLs and he did not use the call light. A review of the resident's Fall Care Plan, lacked information relating to the resident's modesty, or that he did not use his call light. During an interview on 3/24/16 at 10:00 a.m., staff member I stated she reminded the staff to check on the residents often. Staff member I stated if a task was not completed by the nurse for resident care, then she would attempt to complete the task. Staff member I stated she expected the nurses on the floor to update the care plan for the resident at the time of a fall, to assist with preventing future falls. - 3/3/16 - The resident had rolled out of bed, and was found unresponsive. He was sent to the emergency room . A review of the resident's Summary POC showed the resident was to have his bed in the lowest position for fall risk and a floor mat by the bed. During an observation on 3/21/16 at 11:50 a.m., staff member G pointed out the green star alert on the resident's door, and stated he was a high fall risk. The resident had a transfer pole next to his bed, and a fall pad was placed up by the bed. The bed was in a high position. At 4:45 p.m., the resident was observed in bed, and the bed remained in the high position. The fall pad was by the bed. A review of the resident's Care Plan (date not documented) relating to the low bed, fall pad, or that the resident was identified to be a high fall risk, and on a facility monitoring program for falls. - 3/9/16 - The resident was found on the floor after lunch. He was at bedside. The documentation lacked further detail on how the resident fell , the environment at the time of the fall, what the resident was doing at the time of the fall, or the resident's statement of why he may have fallen. A review of the facility Occurrence Report for the fall showed it was unclear what the resident was doing at the time of the fall. The resident was documented as independent, had been getting himself up and around his room, to the bathroom and his ambulation had slowed. A review of the resident's Fall Care Plan and Summary POC lacked evidence to show his wish to be independent, or if the independence increased his fall risk. The care plan lacked evidence for his individual patterns, or habits which may have contributed to the falls. During an interview on 3/26/16 at 2:05 p.m., staff member CCC stated the resident had a transfer bar, fall pad, and a gait belt was used for fall interventions measures. She stated he was a high fall risk, and she tried to keep a close eye on him. Staff member CCC stated if she needed to look at the interventions she would look at the resident's Summary POC. A review of the Accidents and Incidents Policy showed under section three, Preventative Measures, All falls are investigated, so that the residents can be assessed for causes and preventative measures in place with an analysis of whether or not those preventative measures are effective and re-evaluations and/or revisions as necessary. A review of a document received by the facility on 3/28/16, showed the facility reviewed falls during the morning clinical meetings. Questions the team would discuss for falls included: - Did the resident get hurt? - What interventions were made to prevent the next fall? - Does the resident need to be special focus? - Did we update the care plan? 3. During an observation on 3/21/16 at 4:42 p.m., the oxygen storage room at the end of the 200 hall was inspected. There were two bottles, an E tank and an M-sized tank standing on the floor, unsupported by a rack or chain. During an observation on 3/22/16 at 8:11 a.m., the tanks in the oxygen storage room remained unsupported. In an interview on 3/23/16 at 1:30 p.m., staff member C stated the tanks are only used by hospice; the CNAs of the facility refill the portable liquid oxygen tanks. She stated the tanks had been removed.

Based on observation, record review and interview, the facility failed to: -ensure an effective quality assurance process was in place; -ensure diabetic residents with abnormal blood glucose readings were appropriately assessed and monitored closely for changes; -ensure appropriate documentation was completed for residents with abnormal blood glucose readings; -ensure physician orders [REDACTED]. -ensure physician orders [REDACTED]. IMMEDIATE JEOPARDY: The facility failed to ensure that abnormal blood glucose readings were rechecked. The facility failed to ensure that diabetic residents with abnormal blood glucose readings were appropriately assessed and monitored closely for changes. The facility failed to ensure physician orders [REDACTED]. The facility failed to ensure a physician order [REDACTED]. On 4/30/15 at 4:20 p.m., the facility administrator, director of nursing, and quality assurance and infection control nurse were notified that an immediate jeopardy situation existed for 8 (#s 2, 4, 7, 8, 9, 10, 11, and 15) of 21 sampled residents. The facility submitted an acceptable plan to remove the immediate jeopardy on 5/1/15 at 1:28 p.m. The plan to remove the immediate jeopardy was verified onsite on 5/1/15 at 1:28 p.m. After the immediacy was removed, the scope and severity remains at an E. A summary of the facility's plan was as follows: -All staff onsite and the oncoming shift were trained on a new step by step of directions developed with the guidance of the medical director to address blood glucose monitoring effective 4/30/15. All nursing staff will be trained on the new process prior to being able to work. -All staff not educated on 4/30/15 or 5/1/15 will be educated prior to their next shift. This included calling all staff on 5/1/15 to come to the facility and attend within 24-48 hours. -The step by step set of directions changed the process of provider notification. -The new process reduced the time between monitoring to be compliant with ADA (American Diabetes Association) guidelines for re-evaluation. -The monitoring of residents with abnormal blood glucose readings was changed to every ten minutes or by direct observation. -The new process was reviewed and approved by the acting medical director. -A full review of the diabetic management program will be scheduled when the medical director returns with the quality team and a diabetic educator. 1. RESIDENT'S RIGHTS F157 Notification of Changes a. Physician Notification The QAA committee was not proactive in identifying, developing, and implementing an appropriate plan of action to accurately notify the physicians of high or low blood glucose levels. Reference F157 for detailed information. 2. RESIDENT ASSESSMENT F281 Professional Standards a. Blood glucose levels The QAA committee did not effectively identify, develop, and implement an appropriate plan of action to ensure staff appropriately assessed factors that placed the residents at risk for hypoglycemic and hyperglycemic complications, for 12 diabetic residents out of 26. b. Following physician's orders [REDACTED].>The nurses where not following physician's orders [REDACTED]. Nurses gave insulin without a physician's orders [REDACTED]. c. Following Facility Protocol The nurses were not following the facility protocol for diabetics with abnormal blood glucose levels. Reference F281 for detailed information. 3. QUALITY OF CARE F309 Highest Practical Well Being The QAA committee was unproductive in recognizing, managing and implementing an appropriate plan of action to assess the factors that place diabetic residents at risk for hypoglycemic and hyperglycemic complications. Thirteen of 26 diabetic residents were not monitored for their response to preventative efforts and treatments for abnormal blood glucose levels. physician's orders [REDACTED]. Reference F309 for detailed information.

Based on observation, record review, and staff and resident interviews, the facility failed to provide treatment and services to promote the healing of a pressure sore. Specifically, the facility failed to provide nutritional interventions to promote wound healing, provide effective pain management, and demonstrate proper wound dressing change for 1 (#12) of 12 sampled residents. Findings include: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS, with an ARD of 8/1/14 indicated resident #12 required extensive assistance from one staff with bed mobility, transfer, dressing, toileting, and personal hygiene. Section K, nutritional status, indicated the resident was receiving a mechanically altered diet. Section M, skin conditions, indicated the resident had a Stage III pressure ulcer that had worsened since the prior assessment. Skin and ulcer treatments included pressure device for chair and bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, application of nonsurgical dressing, and application of ointments/medications. The skin integrity notes from 9/4/13 through 9/4/14 indicated a wound to the sacrum which progressively worsened to a stage three pressure ulcer with undermining (full thickness tissue loss with destruction of tissue extending under the skin edges indicating the pressure ulcer is larger at its base than at the skin surface). Review of the care plan, dated 11/24/2012-present, showed the following interventions for nutritional status: -monitor food intake at each meal, offer appropriate substitutes for uneaten food -reassess dietary preferences, portion sizes, and time of meals as needed -offer and encourage between meal snacks -Ensure, when resident requests The care plan lacked evidence of attempts at implementing any additional nutritional interventions for wound healing including: increased protein and zinc in diet, nutritionally enhanced meal options, and/or calorie and protein count to determine actual intake. Staff member M, dietitian, was interviewed on 9/11/14 at 12:52 p.m. He stated the resident, "has been drinking up to two cans daily" of nutritional supplement. He also stated the resident, "has gained weight so her nutritional needs are being met. Actually, she is clinically obese." When asked whether any other nutritional interventions have been tried/implemented, he stated, "no." Obese individuals, despite their size, may lack adequate nutrients to support healing of pressure ulcers.? The care plan, dated 11/24/2012-present, showed the following interventions for pressure ulcers and skin care: -encourage resident to be out of bed and reposition appropriately as needed; -pressure reduction mattress for bed, and cushion for wheel chair; -observe skin during ADLs and personal care tasks. Report any skin integrity issues to nurse; -encourage resident to reposition every 2-3 hours and as needed; -provide peri-hygiene cares routine and as needed; -skin care per policy; -weekly assessment for sacral wound by primary nurse; and -resident is checked and changed every 2-3 hours and as needed. On 9/11/14, at 6:15 a.m., the following was observed including a dressing change to the sacrum and peri care: -staff member N, CNA, positioned the resident on her left side with the head of the bed lowered to 30 degrees -staff member H, LPN, removed the dressing, cleansed the area surrounding the wound with normal saline, and applied a topical anesthetic; -staff member H, measured the wound including width, length, depth and undermining; -the resident was verbally expressing pain with touch and showed physical signs by tensing and moving away, but the nurse did not address the pain and continued with the procedure; -an absorbent brief was place under the resident's left side ? ; -The resident was observed urinating during the process. The pad was not changed prior to the dressing change, following the resident urinating; -the wound was cleansed with normal saline (0.5 cc in a small disposable vial.)? ?; -the wound was packed with alginate packing and an Allevyn dressing was applied; -staff member N performed peri care; -Staff member M did not don sterile gloves for cleansing the wound or applying the dressing.? During the procedure the following was noted: the resident stated multiple times, "you didn't deaden it. The other nurse deadens it more." Staff member H did not, at any time, stop the procedure and attempt additional interventions to minimize pain. Staff member H stated multiple times "you're okay," and "you're doing fine" during the procedure, despite the resident's verbal and non-verbal expressions of pain. The physician order [REDACTED]." The Skin Evaluation Record from 3/27/14 through 9/4/14 indicated evidence of pain related to wound care including verbal and non-verbal signs. Resident #12 was interviewed on 9/10/14 at 2:00 p.m. She stated she was supposed to receive pain medication at 5:00 a.m., prior to her dressing change but, "That doesn't always happen. Sometimes they bring them later." Resident #12 stated she was supposed to get turned every 3 hours, however, she often, "refuses because they are supposed to leave me on my side for 15 minutes and then turn me back, but they forget and don't come back until later." Resident #12 stated she was supposed to be changed every three hours, but today (9/10/14), "they changed me at 8:00 a.m., and didn't come back in until 2:00 p.m." The facility policy and procedure for, skin pressure/wound treatment recommendations showed, "the facility policy will follow current recommended treatment protocols and physician order [REDACTED]."? Cleanse the pressure ulcer and surrounding skin at the time of each dressing change. Cleanse the pressure ulcer using irrigation solution, and apply sufficient pressure to cleanse the wound without damaging tissue or driving bacteria into the wound. Generally, irrigation pressure between 4 and 15 pounds per square inch (PSI) should be adequate to clean the surface of the pressure ulcer without causing trauma to the wound bed. Staff member H did not cleanse the wound with the recommended amount of normal saline and syringe.? Establish a sterile field with all the equipment and supplies needed. Put on sterile gloves, gown, and goggle, if indicated. Fill the syringe, (recommended syringe is 35-ml piston with 19 gauge catheter) with irrigating solution. Gently instill a slow, steady stream of irrigating solution into the wound until the syringe empties. Irrigate with a bulb syringe if the wound is small or not particularly deep or if a piston syringe is unavailable. However, use a bulb syringe cautiously because this type of syringe doesn't deliver enough pressure to adequately clean the wound. Staff member H did not establish a sterile field during the dressing change.? ?European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2014 ?Lippincott, W. a. (6th edition). Nursing procedures. Ambler, PA: Lippincott Williams & Wilkins; 2012

Based on observations, record review, and staff interviews, the facility failed to ensure the resident environment remained free of accident hazards. Specifically, the facility failed to ensure an assistive device functioned and was applied properly in order to prevent a leg injury for 1 (#2) of 14 sampled residents. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record showed resident #2 fell out of her wheel chair on 7/18/14, and was transferred to the E.D. (emergency department) at 9:39 a.m. Resident #2 was readmitted to the facility on [DATE] following treatment for [REDACTED]. The medical record showed the following related to the fall on 7/18/14: -The Facility Transfer Form indicated resident #2 slid out of her wheel chair, onto the floor. The resident was noted to be sitting on her buttocks with her right knee bent backwards into a flexed, unnatural position. Under the primary reason for sending the resident to the E.D. was "the resident fell out of the wheel chair and is complaining of right leg, knee, and hip pain with movement." -The Occurrence Report, dated 7/18/14, revealed the following: "resident slid from w/c (wheel chair) to floor on buttocks, w/c moved backwards and she laid back on the floor." The form indicated, at the time of the occurrence, resident #2 was wearing non slippery socks, seated in a reclining wheel chair, and a quick release seat belt was in use -The Follow Up Report, dated 7/18/14, showed the following: "resident slid from w/c to floor, seat belt did not prevent resident from sliding out of wheelchair. Unknown cause of seat belt failure, possible equipment failure. Replaced existing seat belt with new one to help prevent further falls." -The root cause was determined to be equipment failure. The medical record lacked evidence that the facility had evaluated the resident for underlying causes and the effectiveness of the current interventions. Resident #2's care plan dated 10/20/2012-present indicated she was a two person transfer, and utilized a quick-releasing seat belt in her wheel chair. The care plan further indicated the resident was not able to release her seat belt when requested and staff was to release the seat belt per facility protocol. The care plan indicated staff was to ensure the seat belt was in proper working condition. A physician order, dated 5/26/11, showed an order for [REDACTED].#2 for the safety of the patient. A nursing note, dated 7/15/14, indicated that a "...restraint reduction of w/c (sic) seat belt was attempted, but failed. Within a few minutes, she was leaning forward in her w/c (sic) and touching her shoe..." The record lacked evidence of a reduction trial period beyond "a few minutes" with implementation of alternative interventions. Staff member F, CNA, was interviewed on 9/10/14 at 9:30 a.m. She stated she was, "not sure if her (resident #2's) seat belt was buckled. She was at the dining room table across from where she usually sits. I didn't see her fall, but when I got to the dining room she was twisted and her leg was behind her. There was another person working that day and may not have known that the belt had to be buckled. "She (resident #2) can wiggle herself down so she can get under the seat belt." Staff member J, maintenance supervisor, was interviewed on 9/11/14 at 10:10 a.m. He stated he had received an order to replace the seat belt on resident #2's wheel chair. He reported when he changed the seat belt, he did not observe any broken, torn, or defective evidence. Staff member J provided a copy of the Work Oder, dated 7/18/14 at 9:00 a.m., which indicated the seat belt was damaged. Staff member C, RN-unit manager, was interviewed on 9/10/14 at 3:00 p.m. She stated she could neither confirm nor deny whether the seat belt was buckled immediately before or after the resident fell . Staff member D, RN-unit manager, was interviewed on 9/11/14 at 9:15 a.m. She stated there was no "set schedule" regarding how often devices are checked for proper functioning. She reported the CNAs do this during cares. When asked what the expectation of the staff was regarding the condition and functioning of resident devices, she stated that, "if there is a problem to let unit manager know right away." She reported there was no documentation regarding inspection of devices, however, any repairs or replacements would require a work order. Staff member A, administrator, was interviewed on 9/10/14 at 2:15 p.m. She stated, "The seat belt was still fastened but had loosened up enough so she (resident #2) could slide out. The seat belt was replaced."

Based on observation, staff and family interview, and record review, the facility failed to adequately provide supervision to prevent accidents for 1 (#1) of 9 sampled residents. Findings include: On 4/27/11 at 4:45 p.m., resident #1 was observed in the dining room on the Mountainview unit. Resident #1 was sitting in her wheelchair at a table looking at some greeting cards with a visitor. The visitor was resident #1's daughter. An interview with her daughter at 5:00 p.m. revealed that resident #1 fell on [DATE], the day she was admitted back to the facility from the hospital. Within 15 minutes of returning to her room, resident #1 fell after having been left alone in her room. The resident broke her left hip as a result of this fall. An attempt was made to interview resident #1, however, she could not answer any questions except with garbled speech. The resident's daughter was present during the attempted interview and she was able to clarify some of the responses from her mother. On 4/28/11 at 9:00 a.m., resident #1's medical record was reviewed. Resident #1 was admitted initially on 3/23/11 for rehab after a fall at an assisted living facility in which she had sustained fractures of the right wrist and the right hip. A nurse's note written on 3/27/11 at 10:18 p.m., read, "...continues to attempt to get out of bed un assisted (sic). Encouraging aides to monitor resident for safety. Tabs alarm on and pillows placed to promote safety..." On 4/5/11 at 1:20 p.m., the resident was transported to (local hospital) with a [DIAGNOSES REDACTED].#1 was described in a nurse's note as "alert to self and was able to answer questions. Resident is a Re-admit and here becouse (sic) a dementia." The Patient Transfer Form from the hospital dated 4/11/11 indicated resident #1's mental status as: Forgetful and Confused. Another nurse's note written on 4/11/11 at 8:16 p.m., read, "At aprox. (sic) 1435 (2:35 p.m.) heard resident yelling out from her room. When arrived @ (at) resident's room found resident on the floor on her left side by her w/c (wheelchair). She was crying out in pain. She stated that she was just getting up. A head to toe assessment was done with extream (sic) pain noted apon (sic) palpation of resident's left hip. Phone call placed to (physician) with new orders received per (Family Nurse Practitioner). One time dose of roxiinal (sic) given for pain and (ambulance service) called to transport resident to the hospital per new orders. Residents VS (vital signs) were 99.1 (temperature), 144/66 (blood pressure), 60 (pulse), 24 (respirations), 93% (oxygen saturations) on RA (room air). Resident left VHC (Valley Healthcare Center) per (ambulance service) stretcher @ aprox. (sic) 1505 (3:05 p.m.) on way to (local hospital) ER (emergency room ). Phoned resident's daughter (daughter's name) regarding this new issue. Phone call latter (sic) received from the (local hospital) ER department to comferm (sic) that she had broken her left hip." Resident #1 was admitted back to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The Patient Transfer Form from the hospital dated 4/18/11 indicated resident #1's mental status as: Forgetful and Confused. On 4/28/11 at 8:55 a.m., staff member A, a CNA (Certified Nursing Assistant) was interviewed regarding the procedure after a resident falls. She stated, "After a resident falls, you don't touch or move the resident, get the nurse to do an assessment, then right away start neurological checks and vital signs, and try to make the resident as comfortable as possible." The unit manager, staff member B, was interviewed at 9:00 a.m., regarding the procedure if a resident falls. Staff member B stated, "If a resident falls, the CNA gets the nurse right away, if the resident is injured, such as a laceration, you control the bleeding and then call the doctor who makes the decision to send the resident to the hospital. Staff Member B also stated, "For any unwitnessed fall, neurological checks are started right away." After the fall, an incident report and orange fall assessment form are filled out and sent to the IDT (Interdisciplinary Team). Staff member C, the admitting nurse, was interviewed at 10:00 a.m., regarding the admission process for resident #1. She stated, "Resident #1 had just gotten back from the hospital on [DATE]. The first thing she did was take resident #1 to her room and assess her though she didn't do a fall assessment on admit because she didn't have time. She gave resident #1 her call light and walked out of the resident's room. She didn't go ten feet and the resident fell ." When asked if resident #1 used her call light regularly, staff member C stated, "She didn't know, but resident #1 seemed a lot less confused and she seemed to understand the use of the call light." When asked if this was the first time staff member C had admitted resident #1 to the facility, she stated, "No, she had admitted her on her previous admission." Staff member A was interviewed at 1:30 p.m., as to resident #1's usage of the call light. She stated resident #1 never used her call light that she knows of except for pulling it from the wall. Staff member B was interviewed at 3:45 p.m., as to resident #1's usage of the call light. He stated he didn't know if resident #1 could use her call light, but when a resident is admitted they are shown how to use their call light. He also stated that he had answered resident #1's call light a couple of times, but he didn't know if resident #1 or her daughter had put on the call light. In addition, he stated that most of the residents on this unit (Mountainview) know how to use their call light. Staff member D, the charge nurse on the Mountainview unit on 4/28/11 at 4:20 p.m., stated that resident #1 can use her call light and it is the unit manager who evaluates whether the resident can use the call light. On 4/28/11 at 4:30 p.m., staff member D and the surveyor went to resident #1's room to see if she could use her call light. Resident #1 was unable to demonstrate pushing the button on her call light when asked to do so. Resident #1's medical record contained an orange form titled, 'Valley Health Care Center Post Fall Assessment.' The form was dated 4/11/11 and indicated that resident #1 had a history of [REDACTED]. On the same form the written IDT review/recommendations were dated 4/12/11 and listed tabs monitor placement and staff attendance which was crossed out leaving tabs monitor placement as the written recommendation. An 'Evaluation for Falls and Safety' was completed on 4/12/11 at 10:46 a.m., at the indicated date and time, resident #1 was in the hospital for treatment of [REDACTED]. Resident #1 was not readmitted to the facility from the hospital after repair of her fractured left hip until 4/18/11.