Every finding on record at Stevens Point Health Services

Based on staff interview and record review, the facility did not ensure the State Long-Term Care Ombudsman was notified of transfers or discharges for 4 residents (R) (R41, R43, R5, and R6) of 4 sampled residents.R41 was transferred to the hospital on 7/1/25. The Ombudsman was not notified of the transfer.R43 was discharged home on 5/2/25. The Ombudsman was not notified of the discharge.R5 was transferred to the hospital on 5/9/25. The Ombudsman was not notified of the transfer.R6 was transferred to the hospital on 1/29/25, 3/17/25, and 6/15/25. The Ombudsman was not notified of the transfers.Findings include: The facility's Transfer and Discharge policy, dated 7/15/22, indicates: The facility permits each resident to remain in the facility, and not transfer or discharge the resident except as initiated by the resident, necessary for the health and safety of the resident .6. Non-Emergency Transfers or Discharges .B. At least 30 days before the resident is transferred or discharged , the Social Services Director or designee will notify the resident and resident representative in writing (notice) .d. A copy of the notice shall be provided to a representative of the Office of the State Long-Term Care Ombudsman .Emergency Transfers/Discharges .a. Obtain physician orders for emergency transfer or discharge .The physician shall document medical reasons for the transfer or discharge in the medical record .K. Social Services Director or designee shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via a monthly list . 1. On 7/23/25, Surveyor reviewed R41’s medical record. R41 was admitted to the facility on [DATE] and had diagnoses including displaced transverse fracture of shaft of humerus, dysphagia, weakness, diabetes, and multiple myeloma not having achieved remission. R41 made R41's own medical decisions. R41's Minimum Data Set (MDS) assessment, dated 6/21/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R41 had intact cognition. R41’s medical record indicated R41 was transferred to the hospital for evaluation on 7/1/25. 2. On 7/23/25, Surveyor reviewed R43’s medical record. R43 was admitted to the facility on [DATE] and had diagnoses including esophagitis, cognitive communication deficit, and chronic obstructive pulmonary disease (COPD). R43 had an activated Power of Attorney for Healthcare (POAHC) who made medical decisions for R43. R43's MDS assessment, dated 5/2/25, had a BIMS score of 11 out of 15 which indicated R43 had moderately impaired cognition. R43’s medical record indicated R43 discharged home from the facility on 5/2/25. 3. On 7/23/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility in 2024 and had diagnoses including type 2 diabetes mellitus with long-term insulin use, non-pressure chronic ulcer to left thigh and part of right lower leg with fat layer exposure, chronic obstructive pulmonary disease (COPD), lymphedema, anxiety disorder, pressure ulcer of left buttock stage 3, and chronic respiratory failure with hypoxia. R5's MDS assessment, dated 5/28/25, had a BIMS score of 15 out of 15 which indicated R5 had intact cognition. R5’s medical recorded indicated R5 was transferred to the hospital on 5/9/25 for a change of condition related to shortness of breath. R5 returned to the facility on 5/15/25. 4. On 7/21/25, Surveyor reviewed R6's medical record. R6 was most recently admitted to the facility on [DATE] and had diagnoses including bullous pemphigoid (an autoimmune skin disease causing blisters), COPD, malignant neoplasm of peritoneum, liver, ovary, gallbladder and bile ducts, anxiety, and schizophrenia. R6's MDS assessment, dated 6/25/25, had a BIMS score of 14 out of 15 which indicated R6 had intact cognition. R6 made R6's own healthcare decisions. On 1/29/25, R6 had a change in condition and was transferred to the hospital and diagnosed with septic shock from UTI or skin etiology. R6 was readmitted to the facility on [DATE]. On 3/17/25, R6 was transferred to the hospital and diagnosed with sepsis/Escherichia (E). coli bacteremia in setting of UTI. R6 was readmitted to the facility on [DATE]. On 6/15/25, R6 was transferred to the hospital and diagnosed with urosepsis. R6 returned to the facility on 6/23/25. On 7/23/25 at 10:42 AM, Surveyor requested the facility's monthly Ombudsman reporting list. Nursing Home Administrator (NHA)-A indicated the facility had not reported any transfers or discharges to Ombudsman (OMB)-E. NHA-A provided documentation of education with Social Services Director (SSD)-D for reporting transfers and discharges to OMB-E in a monthly report. The education was signed by SSD-D and dated 7/21/25. NHA-A provided a copy of an email NHA-A sent to OMB-E that contained a list of the facility's transfers and discharges since January 2025.

Based on staff interview and record review, the facility did not monitor for adverse consequences or the effectiveness of psychotropic medication for 1 resident (R) (R44) of 6 sampled residents. The facility did not monitor for adverse consequences or the effectiveness of trazadone (an antidepressant medication) and sertraline (an antidepressant medication) for R44. Findings include:The facility's Medication Monitoring: Medication Management policy, dated 1/2025, indicates: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs .The facility's medication management supports and promotes .The monitoring of medications for efficacy and adverse consequences .Additional specific guidelines are applied to psychotropic drugs which are defined as any drug that affects brain activities associated with mental processes and behavior. This includes, but are not limited to antipsychotics; antidepressants .The intent of this requirement is that: Each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being .On 7/21/25, Surveyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] and had diagnoses including urinary tract infection (UTI), chronic respiratory failure, chronic obstructive pulmonary disease (COPD), encephalopathy, anxiety, and insomnia. R44 had an activated Power of Attorney for Healthcare (POAHC) who made medical decisions for R44. A Minimum Data Set (MDS) assessment was not completed for R44. An admission nursing progress note indicated R44 was alert to self. On 7/21/25 at 2:53 PM, Surveyor reviewed R44's Medication Administration Record (MAR) and Treatment Administration Record (TAR) and noted R44 was prescribed sertraline HCL 100 milligrams (mg) once daily for anxiety on 7/19/25. R44 was also prescribed trazadone HCL 100 mg at bedtime for sleep on 7/17/25. R44's medical record did not contain monitoring for the efficacy or adverse consequences of sertraline, including sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, photosensitivity of skin, excess weight gain, and anxiousness. R44's medical record also did not contain monitoring for the efficacy or adverse consequences of trazadone, including sedation, drowsiness, dry mouth. blurred vision, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, photosensitivity of skin, excess weight gain, and sleeplessness.On 7/22/25 at 1:05 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R44 should have been monitored for medication efficacy and adverse consequences of the antidepressant medications. DON-B indicated DON-B added adverse consequence monitoring to R44's TAR for nurses to initial after completing. DON-B indicated medication monitoring including effectiveness should have been added to R44's baseline care plan.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R3 and R34) of 5 sampled residents had documentation that indicated the residents or their legal representatives were informed in advance of the risks and benefits of prescribed medications. R3 was prescribed divalproex sodium (Depakote) (an anticonvulsant medication) and clindamycin phosphate external solution 1% topical (an antibiotic medication). Verbal consent for the medications was received from R3's activated Power of Attorney for Healthcare (POAHC), however, written consent was not obtained.R34 was prescribed Ambien (a sedative medication), quetiapine (an antipsychotic medication), hydroxyzine (an antihistamine medication used to treat anxiety), Lyrica (an anticonvulsant medication used to treat neuropathic pain), Lexapro (an antidepressant medication), and oxcarbazepine (an anticonvulsant medication used to treat bipolar disorder). The facility did not obtain consents for the psychotropic medications.Findings include:1.On 7/21/25, Surveyor reviewed R3's medical record. R3 was most recently admitted to the facility on [DATE] and had diagnoses including dementia, cognitive communication deficit, stroke, diabetes, seizures, and depression. R3's Minimum Data Set (MDS) assessment, dated 7/12/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R3 had moderately impaired cognition. R3 had an activated POAHC for healthcare decisions.R3's medical record contained the following orders: ~ Divalproex sodium (Depakote) tablet delayed release 125 milligrams (mg), give 1 tablet by mouth three times daily for seizures (dated 1/26/25).~ Buspirone HCL (Buspar) oral tablet 5 mg, give 1 tablet three times daily for depression (dated 12/24/24).~ Clindamycin phosphate external solution 1% topical, apply to underarms, breasts, groin topically in the morning for rash (dated 12/23/24).R3's medical record contained verbal consents (dated 6/4/25) for Depakote, buspar, and clindamycin that were not signed by R3's POAHC.2. On 7/21/25, Surveyor reviewed R34's medical record. R34 was most recently admitted to the facility on [DATE] and had diagnoses including diabetes, bipolar disorder, depression, anxiety, insomnia, and low back pain. R34's MDS assessment, dated 5/27/25, had a BIMS score of 15 out of 15 which indicated R34 had intact cognition. R34 made R34's own healthcare decisions. R34's medical record contained the following orders: ~ Quetiapine fumarate oral tablet 100 mg, give 1 tablet by mouth two times daily for bipolar disorder.~ Hydroxyzine HCL oral tablet 50 mg, give 1 tablet by mouth every 6 hours as needed for anxiety disorder (dated 6/4/25).~ Ambien oral tablet 10 mg, give 10 mg by mouth once daily for insomnia (dated 2/19/25).~ Lyrica (pregabalin) oral capsule 200 mg, give 1 capsule by mouth three times daily for neuropathic pain (dated 9/18/24).~ Lexapro (escitalopram oxalate) oral tablet 20 mg, give 1 tablet by mouth once daily for depression (dated 6/18/24).~ Oxcarbazepine oral tablet 150 mg, give 1 tablet by mouth once daily and give 2 tablets by mouth once daily for bipolar disorder (dated 1/8/24).On 7/23/25 at 3:31 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated signed medication consents should have been obtained for R3 and R34.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R5) of 4 residents observed during the provision of cares. R5 was on enhanced barrier precautions (EBP). On 7/21/25, staff did not follow EBP during high-contact cares for R5. Finding include:The facility's Transmission-Based (Isolation) Precautions (TBP) policy, revised 9/24/24, indicates: .10. Contact precautions: A. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment .C. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. D. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination .F. Contact precautions will be used for residents infected or colonized with multidrug-resistant organisms (MDROs) in the following situations: i. When a resident has wound secretions or excretions that are unable to covered or contained, and ii. On units or in facilities where, despite attempts to control the spread of MDROs, ongoing transmission is occurring. On 7/21/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility in 2024 and had diagnoses including type 2 diabetes mellitus with long-term insulin use, non-pressure chronic ulcer to left thigh and part of right lower leg with fat layer exposure, chronic obstructive pulmonary disease (COPD), lymphedema, anxiety disorder, chronic pain syndrome, pressure ulcer of left buttock stage 3, and chronic respiratory failure with hypoxia. R5's Minimum Data Set (MDS) assessment, dated 5/28/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition.R5's care plan and Kardex (an abbreviated care plan used by nursing staff) indicated R5 was on EBP. The care plan indicated R5 was at risk for infection related to colonization of an MDRO and had methicillin-resistant Staphylococcus aureus (MRSA) to the nares/wound. The care plan contained an intervention to use EBP during high-contact care activities. R5's Kardex indicated: Staff should follow EBP during high-contact care activities; Toileting assist of one - EBP; Clean peri-area with each incontinence episode - EBP wear gown and gloves with direct patient care; Toileting - uses bedside commode for bowel movements - EBP wear gown and gloves with direct patient care; and precautions wear gown and gloves with direct care.On 7/21/25 at 10:10 AM, Surveyor was waiting outside R39's room to interview R39 when Certified Nursing Assistant (CNA)-G indicated to R39 that CNA-G is told to wear blue gowns but will not put them on. Surveyor noted a sign outside R39's room that indicated R39 was on EBP.On 7/21/25 at 11:18 AM, Surveyor knocked on R5's door and attempted to interview R5. CNA-G indicated CNA-G was providing cares. Surveyor noted CNA-G was not wearing a gown while completing peri-care. A sign posted outside R5's door indicated R5 was on EBP. When CNA-G saw Surveyor, CNA-G indicated cares were halted because CNA-G needed to don a gown. After cares were completed, Surveyor interviewed CNA-G who confirmed CNA-G should have donned a gown at the start of cares because R5 was on EBP. On 7/21/25 at approximately 12:00 PM, Surveyor interviewed Infection Preventionist (IP)-H who indicated staff should follow a resident's precautions and don a gown and gloves during high-contact cares.On 7/22/25, Surveyor requested the facility's EBP policy but received the facility's TBP policy. When Surveyor asked Nursing Home Administrator (NHA)-A if the facility had an EBP policy, NHA-A indicated the facility did not have an EBP policy.

Based on observation, staff interview, and record review, the facility did not ensure accurate order transcription and medication administration for 1 resident (R) (R5) of 2 sampled residents.On 7/22/25, R5 was administered 81 milligram (mg) of enteric coated (EC) aspirin which differed from R5's order. In addition, the wrong dose of fluticasone propionate was administered. Findings include:On 7/22/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including diabetes and heart failure. R5's Minimum Data Set (MDS) assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. On 7/22/25 at 8:04 AM, Surveyor observed Registered Nurse (RN)-K administer R5's AM medication. RN-K administered 81 mg of EC aspirin and 2 sprays of fluticasone propionate nasal spray in each nostril. Surveyor reviewed R5's physician orders which indicated:~ Aspirin 81 mg capsule, give one capsule daily~ Fluticasone propionate, one spray in each nostril On 7/22/25 at 1:19 PM, Surveyor interviewed RN-K who was unsure why R5's aspirin order was transcribed in capsule form. RN-K was aware that the order indicated capsule form but stated the facility did not have aspirin in capsule form. RN-K and Surveyor reviewed R5's hospital discharge summary which contained an order for aspirin 81 EC tablet. RN-K verified the order was incorrectly transcribed and stated RN-K would fix the order in R5's MAR.On 7/22/25 at 1:23 PM, RN-K confirmed R5's fluticasone propionate order was for 1 spray in each nostril and confirmed R5 was incorrectly administered 2 sprays in each nostril.On 7/22/25 at 2:09 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B had not seen aspirin in capsule form and verified the aspirin administered to R5 was not in the form that was ordered. DON-B also indicated R5's fluticasone propionate should have been administered as 1 spray in each nostril.On 7/22/25 at 2:28 PM, DON-B approached Surveyor and indicated DON-B spoke with the pharmacy who indicated EC and chewable aspirin can be interchanged and aspirin does not come in capsule form. DON-B agreed R5's aspirin order was transcribed incorrectly as a capsule instead of a tablet.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R5) of 3 sampled residents. R5's continuous positive airway pressure (CPAP) and oxygen equipment were not cleaned and replaced in accordance with orders on R5's Treatment Administration Record (TAR). Findings include:The facility follows guidelines from Company (CP)-L which were provided to Surveyor on 7/23/25 at 11:06 AM by Nursing Home Administration (NHA)-A when Surveyor requested the facility's oxygen policy. The undated CP-L guidelines indicate for infection control and to reduce the risk of infections, it is important to keep your equipment clean. Care of your cannula/mask, tubing, and humidifier bottle: 1. (CP-L) recommends you replace your cannula or mask each week and oxygen extension tubing and humidifier bottle once every month. 3. The humidifier bottle must be cleaned between fills or once per week .CP-L guidelines labeled Cleaning your CPAP/Bilevel positive airway pressure (BiPAP) equipment indicate: Daily cleaning: 2. Wipe the portion of the mask that comes in contact with your skin with a damp cloth .3. Empty any remaining water from the humidifier chamber. 4. Fill the chamber with soapy water and shake vigorously. 5. Rinse the chamber with clean water. 6. Air dry. Weekly mask and tubing cleaning is recommended: 1. Hand wash the headgear in standard laundry detergent .2. Air dry headgear .3. Wash mask/nasal pillows and tubing in a mixture of warm water and a small amount of liquid dishwashing detergent or baby shampoo. Do not use detergents containing conditioners, moisturizers, or antibacterial additives .4. Rinse thoroughly. 5. Air dry. Filter Maintenance: Filter maintenance will depend on the model of CPAP/B-Level unit you use. Please review manufacturer's manual for your unit's specific maintenance recommendations. On 7/21/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility in 2024 and had diagnoses including type 2 diabetes mellitus with long term insulin use, non-pressure chronic ulcer to left thigh and part of right lower leg with fat layer exposure, chronic obstructive pulmonary disease (COPD), lymphedema, anxiety disorder, chronic pain syndrome, pressure ulcer of left buttock stage 3, and chronic respiratory failure with hypoxia. R5's Minimum Data Set (MDS) assessment, dated 5/28/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. On 7/21/25 at 11:15 AM, Surveyor interviewed R5 and noted a CPAP and oxygen concentrator in R5's room. R5 indicated the respiratory equipment had not been cleaned in 2 years. Surveyor reviewed R5's TAR which contained the following orders: ~ Change CPAP water chamber one time a day every 6 month(s) starting on the 1st for 1 day(s) related to chronic obstructive pulmonary disease and chronic respiratory failure (active 11/10/25). ~ Change (BiPAP/CPAP) filter every 6 months every day shift every 6 month(s) starting on the 5th for 1 day(s) for monitoring related to chronic obstructive pulmonary disease and chronic respiratory failure (active 6/5/25).~ Supplemental oxygen at 3 liters per minute (LPM) into CPAP device settings - 8.0-20.0 centimeters of mercury (cmHg) water every morning and at bedtime related to chronic obstructive pulmonary disease and chronic respiratory failure. On at bedtime and off in morning and as needed related to chronic obstructive pulmonary disease and chronic respiratory failure. Encourage use during naps (active 5/18/25).~ Clean CPAP machine wash with gentle soap and water, rinse thoroughly, and air dry one time a day every Saturday related to chronic obstructive pulmonary disease and chronic respiratory failure (active 5/24/25). ~ Change oxygen tubing and humidifier bottles weekly. Date tubing one time a day every Sunday and as needed for visibly soiled or known contamination (active 4/6/25).~ CP-L to manage settings and provide supplies as needed to include mask and headgear, cushion, filters, tubing and water chamber. No directions specified for order (active 6/1/25). R5's May 2025 TAR indicated:~ The oxygen tubing was not changed on 5/30/25.~ The oxygen tubing and humidifier bottles were not changed on 5/11/25 and 5/30/25.~ Clean CPAP machine wash with gentle soap and water, rinse thoroughly, and air dry was not completed on 5/10/25, 5/17/25, and 5/18/25.~ Change nebulizer tubing every nightshift every Monday and Sunday was not completed on 5/19/25.~ Change nebulizer tubing once a day every Monday and Sunday was not completed on 5/11/25 and 5/12/25.R5's June 2025 TAR indicated: ~ Change CPAP filter every 6 months was not completed on 6/5/25.~ Clean CPAP machine wash in gentle soap and water, rinse thoroughly, and air dry was not completed on 6/14/25. R5's July 2025 TAR indicated: ~ Clean CPAP machine wash in gentle soap and water. rinse thoroughly, and air dry was not completed on 7/12/25.~ Oxygen at 3 LPM connected to CPAP device was not completed on 7/9/25, 7/12/25, and 7/18/25. ~ Check oxygen saturation every shift was not completed on 7/9/25, 7/12/25, and 7/18/25.On 7/23/25 at 11:12 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who indicated LPN-F did not clean respiratory equipment unless a resident's TAR indicated to do so. LPN-F indicated the facility has specialized wipes for the mask and LPN-F uses water for the rest. LPN-F thought night shift staff cleaned the equipment.On 7/23/25 at 12:28 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility uses CP-L sheets that NHA-A provided to Surveyor as standard guidelines. NHA-A indicated the guidelines are standards of practice recommended by the respiratory company and what staff should follow. NHA-A also indicated staff should follow a resident's TAR and document when staff have completed the items.

Based on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 (Registered Nurse (RN)-I) of 8 facility and contracted staff reviewed for caregiver background checks.The facility did not ensure a thorough and timely caregiver background check was completed for agency RN-I.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: Potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation .On 7/22/25 at 1:59 PM, Surveyor reviewed background check information for 8 facility and agency staff, including RN-I. Surveyor noted RN-I's Background Information Disclosure (BID) form was not dated. RN-I's start date at the facility was 7/7/25.On 7/22/25 at 2:25 PM, Surveyor interviewed Business Office Manager (BOM)-J who indicated RN-I's agency may have sent the facility an incorrect BID form. BOM-J indicated BOM-J would review the file that was sent to the facility to see if there was a dated BID form for RN-I.On 7/22/25 at 4:12 PM, Surveyor interviewed BOM-J who indicated BOM-J did not notice that RN-I's BID for was not dated and should have followed up with the agency prior to RN-I's start date. BOM-J indicated BOM-J called RN-I's agency who sent RN-I's BID form with an effective date of 7/22/25.

Based on staff interview and record review, the facility did not ensure the comprehensive plan of care was revised in a timely manner for 1 resident (R) (R6) of 1 sampled resident.R6's care plan was not revised after R6 was readmitted from the hospital on 3/20/25 and 6/23/25 with diagnoses of sepsis/urosepsis (urinary tract infection (UTI) that spreads to the blood stream).Findings include: On 7/23/25, Surveyor reviewed R6's medical record. R6 had diagnoses including urosepsis, bullous pemphigoid (an autoimmune skin disease that causes blisters), chronic obstructive pulmonary disease (COPD), malignant neoplasm of peritoneum, liver, ovary, gallbladder and bile ducts, UTIs, schizophrenia, and anxiety. R6's Minimum Data Set (MDS) assessment, dated 6/25/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R6 had intact cognition. R6 made R6's own healthcare decisions.On 3/17/25, R6 was transferred to the hospital and diagnosed with sepsis/Escherichia (E). coli bacteremia (presence of bacteria in the blood) in the setting of UTI. R6 was readmitted to the facility on [DATE].On 6/15/25, R6 was transferred to the hospital and diagnosed with urosepsis. R6 returned to the facility on 6/23/25.On 7/23/25 at 5:15 PM, Nursing Home Administrator (NHA)-A provided Surveyor with a copy of R6's care plan and indicated there were areas in the care plan where monitoring for signs and symptoms of UTI were indicated, however, Surveyor noted the monitoring interventions were resolved. Surveyor noted R6's care plan was not revised after R6 was hospitalized on [DATE] and 6/15/25 for sepsis/urosepsis/UTI and returned to the facility on 3/20/25 and 6/23/25. R6's care plan contained a focus area that indicated actual infection UTI (initiated on 2/4/25 and resolved on 2/11/25). The goal indicated R6 would have no further complications related to infection and intervention. The care plan contained interventions to report to physician worsening signs and symptoms of infection or lack of improvement (initiated on 2/5/25 and resolved on 2/11/25). The care plan also contained a focus area that indicated R6 had a catheter (initiated on 3/13/24 and revised on 6/23/25), however, all interventions were resolved on 2/19/25.

Based on observation, staff, resident, and resident representative interview, and record review, the facility did not ensure food preferences were accommodated and/or individualized meal tickets were followed for 10 residents (R) (R1, R4, R6, R7, R9, R10, R11, R12, R13 and R14) of 16 sampled residents. Staff did not follow R1's individualized meal ticket on 6/13/25. Staff did not provide item listed on R4's individualized meal ticket on 6/13/25. Staff did not ensure R6, R7, R9, R10, R11, R12, R13 and R14 received drinks as indicated on their individualized meal tickets for lunch on 6/13/25. Findings include: The facility's Meal Distribution policy, revised 9/2017, indicates: .1. All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences .4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents. 5. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individualized meal card and present it to the resident or care staff for delivery to the resident. 1. On 6/13/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including morbid obesity, congestive heart failure and bariatric surgery status. R1's Minimum Data Set (MDS) assessment, dated 3/7/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact cognition. On 6/13/25 at 12:40 PM, Surveyor interviewed R1 who verified R1 was on a cardiac diet. Surveyor observed R1's lunch tray which contained a piece of cod, mashed potatoes, cucumber salad, a full-size brownie, a white roll, chocolate milk, and coffee. Surveyor reviewed R14's meal ticket which indicated R1 should have received 4 ounces (oz) of summer herb cod, 1 piece lemon wedge, half cup parsley new potatoes, 1 wheat roll, half brownie, 4 oz chocolate milk, and 8 oz coffee; small portions and no desserts. 2. On 6/13/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on 4/1/21 and had diagnoses including dysphagia (difficulty swallowing). R4's MDS assessment, dated 5/23/25, had a BIMS score of 10 out of 15 which indicated R4 had moderate cognitive impairment. On 6/13/25 at 12:35 PM, Surveyor interviewed R4 who stated butter isn't provided with meals and R4 has to ask for it. Surveyor observed R4's lunch tray which contained ground cod, a package of tartar sauce, mashed potatoes, peas, a slice of white bread, a brownie, milk, coffee, and a Magic Cup (nutritional supplement). Surveyor reviewed R4's meal ticket which indicated R4 should have received 4 oz ground summer herb cod, 1 package tartar sauce, half cup soft-cooked cabbage, half cup mashed potatoes with gravy, 1 slice white bread, 1 margarine, 1 frosted brownie, 8 oz 2% milk, 8 oz coffee, 1 Magic Cup, and soup of the day. When Surveyor asked if R4 had soup, R4 did not know R4 was supposed to get soup and said R4 had enough to eat. Surveyor noted R4 did not receive margarine, cabbage, or a frosted brownie. 3. On 6/13/25 at 12:02 PM, Surveyor observed staff deliver R6's lunch tray. Surveyor observed R6's meal ticket and noted R4 did not receive 8 oz skim milk, 8 oz coffee, and 4 oz juice of choice. At 12:04 PM, Surveyor interviewed R6's spouse who was assisting R6 with the meal and confirmed R6 did not receive any beverages. At 12:30 PM, Surveyor returned to R6's room and interviewed R6's spouse again who confirmed staff did not bring R6 any milk. 4. On 6/13/25 at 12:05 PM, Surveyor observed R7's lunch tray which did not contain any beverages. Surveyor reviewed R7's meal ticket which indicated R7's should have received 8 oz skim milk, 8 oz coffee and 4 oz juice of choice. 5. On 6/13/25 at 12:11 PM, Surveyor observed R9's lunch tray and meal ticket. Certified Nursing Assistant (CNA)-E indicated R9 will not eat a pureed meal so a meal was not delivered. Surveyor noted R9 received 8 oz thickened milk, juice, and 4 oz Mighty Shake (a nutritional supplement). R9's meals ticket indicated R9 should have received 4 oz chocolate milk, a Mighty Shake, juice-nectar thick, and 8 oz coffee-nectar thick. 6. On 6/13/25 at approximately 12:15 PM, Surveyor observed staff deliver R10's lunch tray. Surveyor observed R10's meal ticket and noted R10 did not receive 4 oz juice of choice. 7. On 6/13/25 at 12:17 PM, Surveyor observed R11's lunch tray and meal ticket and noted R11 did not receive 4 oz chocolate milk, 6 oz coffee, or 4 oz juice. R11's meal ticket also indicated R11 should have received 2 oz healthy shake, however, R11 received 4 oz healthy shake. 8. On 6/13/25 at approximately 12:19 PM, Surveyor observed R12's lunch tray and meal ticket and noted R12 did not receive 8 oz 2% milk or 4 oz juice of choice. 9. On 6/13/25 at 12:20 PM, Surveyor observed R13's lunch tray and meal ticket and noted R13 did not receive 8 oz skim milk. 10. On 6/13/25 at 12:26 PM, Surveyor observed R14's lunch tray and meal ticket and noted R14 did not receive 8 oz 2% milk or 4 oz juice of choice. On 6/13/25 at 12:27 PM, Surveyor interviewed CNA-H who indicated staff offer residents beverages from their meal tickets. CNA-H indicated residents can have whatever they want except for those on a fluid restriction. On 6/13/25 at 12:28 PM, Surveyor interviewed Registered Nurse (RN)-G who confirmed residents should receive the beverages that are on their meal tickets. On 6/13/25 at 1:59 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should offer items off the cart at meals. When Surveyor asked about R11's meal ticket which indicated R11 should receive 2 oz healthy shake but was provided 4 oz, DON-B confirmed staff should follow the meal ticket. On 6/13/25 at 2:09 PM and 2:12 PM, Surveyor interviewed Dietary Manager (DM)-C via phone who indicated there was an issue with the food truck which was supposed to deliver on Thursday. DM-C indicated the food truck arrived that day and cucumber salad was served instead of coleslaw. DM-C indicated DM-C was not in the facility and was unsure of the procedure for changing meal tickets to reflect updated meals. DM-C indicated if R1's meal ticket said no dessert, then R1 should not have been given a brownie. If R4's meal ticket indicated soup of the day, R4 should have been given soup. DM-C indicated meal tickets are printed daily for each meal and are individualized to meet residents' needs, therapeutic diet, portion sizes, and substitutions for food allergies. DM-C indicated margarine was currently out of stock with the contracted food company and there were no individual butter cups despite the fact DM-C had requested substitutions multiple times. DM-C indicated dinner rolls were available in white yeast only. DM-C confirmed nursing staff should provide beverages to residents on their trays when delivered and should follow what is listed on residents' meal tickets when serving beverages. DM-C verified meal tickets should reflect what residents receive during meals and should be followed as written.

Based on observation, staff interview, and record review, the facility did not ensure a medication cart was locked when unattended. This practice had the potential to affect more than 4 of the 38 residents residing in the facility. On 6/13/25, Surveyor observed an unattended and unlocked medication cart on the second floor by the nurses' station. Two residents were in the vicinity. Findings include: The facility's Administering Medication Storage/Storage of Medication policy, dated 1/2025, indicates: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration .Procedure: .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as Medication Aides) are allowed to access medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access. On 6/13/25 at 9:50 AM, Surveyor observed an unlocked and unattended medication cart in front of the second floor nurses' station and noted two residents were in the area. One resident walked by the medication cart with a walker and another resident was sitting in the common area watching television. On 6/13/25 at 9:57 AM, Surveyor observed Registered Nurse (RN)-D exit a resident's room and walk from hallway 3 toward the medication cart. RN-D then pushed the medication cart down hallway 2 and parked the cart outside a resident's room. On 6/13/25 at 9:59 AM, Surveyor interviewed RN-D who indicted RN-D was pulled away from the medication cart quickly and did not normally leave the medication cart unlocked. RN-D indicated RN-D should not have left the medication cart unlocked and unattended. On 6/13/25 at 1:47 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated medication carts should always be locked when nurses are not around.

Based on observation, staff interview, and record review, the facility did not provide adaptive eating equipment for 1 resident (R) (R5) of 16 sampled residents. Staff did not provide R5 with lidded cups and a divided plate per R5's meal ticket. Findings include: The facility's Assistive Devices policy, revised 9/2017, indicates: .Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's ability to eat or drink independently On 6/13/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, cerebral ischemia (reduced blood flow to the brain) and dysphagia (difficulty swallowing). R5''s Minimum Data Set (MDS) assessment, dated 5/9/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R5 had severe cognitive impairment. R5 had a legal Guardian. On 6/13/25, Surveyor reviewed R5's meal ticket which indicated R5 should receive cups with lids and a divided plate. On 6/13/25 at 12:27 PM, Surveyor observed lunch and noted R5 was not provided cups with lids or a divided plate as indicated on R5's meal ticket. On 6/13/25 at 1:47 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R5 should have cups with lids and food on a divided plate per R5's meal ticket. On 6/13/25 at 2:12 PM, Surveyor interviewed Dietary Manager (DM)-C who indicated if R5's meal ticket indicates R5 should receive cups with lids and a divided plate, R5 should receive them. DM-C indicated lidded mugs should be on the unit or sent with the beverage cart and staff should request them from the kitchen if they don't have them. DM-C also indicated the cook should have put food on a divided plate for R5.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R17) of 2 residents observed during the provision of care. Staff did not ensure enhanced barrier precautions (EBP) were followed for R17 during high-contact cares. Findings include: The facility's Enhanced Barrier Precautions policy, revised 8/8/24, indicates: The facility will implement enhanced barrier precautions (EBP) for prevention of the transmission of multidrug-resistant organisms (MDROs) .EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities .4. High-contact resident care activities include: a. dressing .c. transferring . On 6/13/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including presence of prosthetic heart valve, colostomy, stroke, type 2 diabetes, personal history of other infectious and parasitic diseases, and zoster. R17's Minimum Data Set (MDS) assessment, 4/16/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R17 had moderate cognitive impairment. R17's plan of care, dated 7/1/24, indicated R17 had a colostomy related to a history of colon cancer. On 5/2/25, an intervention was added for EBP during activities. On 6/13/25 at 9:28 AM, Surveyor observed Certified Nursing Assistant (CNA)-E and CNA-F transfer R17 with a sit-to-stand lift. Surveyor observed a sign on R17's door that indicated R17 was on EBP. Surveyor interviewed CNA-E after the transfer. CNA-E indicated CNA-E and CNA-F got R17 dressed and transferred R17 into a wheelchair. When Surveyor asked if R17 was on EBP and if CNA-E and CNA-F should be wearing personal protective equipment (PPE), CNA-E indicated CNA-E and CNA-F should have donned PPE, including gowns and gloves. At that time, CNA-F was assisting R17 with putting on R17's shoes and wheelchair peddles. On 6/13/25 at 1:50 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should don a gown and gloves prior to completing high-contact resident cares for a resident on EBP.

Based on observation, staff interview, and record review, the facility did not ensure proper footwear was worn during a mechanical lift transfer for 1 resident (R) (R17) of 1 sampled resident. R17 had diabetes and was at risk for foot injury. Staff did not ensure R17 wore proper footwear when they transferred R17 with a sit-to-stand lift. Findings include: The facility's Safe Lifting and Movement of Residents policy, revised 11/28/22. indicates: In order to protect the safety and well being of staff and residents and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Procedure: 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. WisTech Open under Nursing Assistant Section 8.4-Assisting Clients to Transfer indicates staff should check that the resident is wearing non-skid footwear before transferring. https://wtcs.pressbooks.pub/nurseassist/chapter/8-4-assisting-clients-to-transfer/ On 6/13/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including stroke, type 2 diabetes, anxiety, personal history of other infectious and parasitic diseases, and zoster. R17's Minimum Data Set (MDS) assessment, dated 4/16/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R17 had moderate cognitive impairment. R17's fall risk care plan, dated 7/1/24, indicated R17 was a fall risk related to a recent stroke and left-sided hemiparesis (paralysis on one side of the body). R17's endocrine system care plan, dated 7/15/24, indicated R17 was at risk for foot injuries related to diabetes and needed diabetic foot care. R17's alteration in skin integrity care plan, dated 7/1/24, indicated R17 was at risk related to diabetes and impaired mobility. On 6/13/25 at 9:28 AM, Surveyor observed Certified Nursing Assistant (CNA)-E and CNA-F transfer R17 with a sit-to-stand lift. During the transfer. R17 wore non-gripper socks. After the transfer, CNA-F assisted R17 with putting on R17's shoes and wheelchair peddles. On 6/13/25 at 1:50 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R17 was diabetic and should have worn shoes or gripper socks during the transfer.

Based on staff and resident interview and record review, the facility did not ensure all allegation of abuse/neglect was thoroughly investigated for 1 resident (R) (R2) of 11 sampled residents. The facility did not thoroughly investigate on allegation of abuse/neglect reported by R2 and R2's family member. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse .V. Investigation of Alleged abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. 1. Written procedures for investigations include: Identifying staff responsible for the investigation .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation .6. Providing complete and thorough documentation of the investigation. On 4/8/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including obesity, muscle weakness, anxiety, and depression. R2's Minimum Data Set (MDS) assessment, dated 3/7/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 was not cognitively impaired. R2 did not have an activated Power of Attorney for Healthcare (POAHC). On 4/8/25 at 9:30 AM, Surveyor interviewed R2 who indicated staff did not provide care over the previous weekend due to shift change. R2 indicated R2's call light was on for an hour and R2 was incontinent of urine. Staff did not complete care until the PM shift arrived. R2 told Medication Technician (MT)-C about the incident on Monday (4/7/25). R2 did not want to share the name of the staff who did not provide care. On 4/8/25 at 10:32 AM, Surveyor interviewed MT-C who confirmed R2 informed MT-C of an incident that occurred with Certified Nursing Assistant (CNA)-F over the weekend. MT-C reported R2's concern to Social Worker (SW)-E on 4/7/25 and saw SW-E speak with R2 that day. MT-C was not sure of the outcome and indicated it was not MT-C's business. On 4/8/25 at 12:03 PM, SW-E confirmed MT-C spoke with SW-E on 4/7/25. SW-E indicated MT-C said MT-C thought CNA-F needed a break from working on the unit but did not report an incident between R2 and CNA-F. SW-E did not ask why MT-C thought CNA-F needed a break and did not document the conversation. SW-E spoke to R2 on 4/7/25 about R2's future plans for placement but not about an incident that occurred over the weekend. On 4/8/25 at 12:27 PM, Surveyor interviewed SW-E about previous contact with R2's family. SW-E received a voicemail from R2's family member but could not recall the date. SW-E indicated R2's family member was upset and irate after staff told R2 that R2 could sit there and wait until R2 was tired. There was also a concern about staff using a Hoyer lift versus an EZ stand lift. SW-E immediately contacted R2's family member and let them know that was unacceptable. SW-E contacted therapy who assessed R2 and changed R2 to an EZ stand lift for transfers. When asked if the comment from staff about R2 having to wait until R2 was tired was addressed, SW-E indicated it was not but should have been. SW-E indicated there was no documentation of the conversation with R2's family member or investigation for the family member's allegation. On 4/8/25 at 1:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of the allegation of abuse/neglect and confirmed the allegation should have been thoroughly investigated.

Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse/neglect was reported to the State Agency (SA) in a timely manner for 1 resident (R) (R2) of 11 sampled residents. R2 and R2's family member reported an allegation of abuse/neglect to staff. The facility did not report the allegation to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: IV. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse .VII. Reporting Response: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames. On 4/8/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including obesity, muscle weakness, anxiety, and depression. R2's Minimum Data Set (MDS) assessment, dated 3/7/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 was not cognitively impaired. On 4/8/25 at 9:30 AM, Surveyor interviewed R2 who indicated staff did not provide care on the weekend due to shift change. R2 indicated R2's call light was on for an hour. R2 was incontinent of urine and staff did not complete care until the PM shift arrived. R2 told Medication Technician (MT)-C about the incident on Monday (4/7/25). R2 did not want to share the name of the staff who did not provide care. On 4/8/25 at 10:32 AM, Surveyor interviewed MT-C who confirmed R2 informed MT-C of an incident that occurred with Certified Nursing Assistant (CNA)-F over the weekend. MT-C indicated MT-C reported R2's allegation to Social Worker (SW)-E on 4/7/25 and saw SW-E speak to R2 the same day. On 4/8/25 at 12:03 PM, Surveyor interviewed SW-E who confirmed MT-C spoke with SW-E on 4/7/25. SW-E indicated MT-C said CNA-F needed a break from working on the unit but did not inform SW-E of an incident between R2 and CNA-F. SW-E did not ask why MT-C thought CNA-F needed a break from the unit. SW-E indicated SW-E spoke with R2 on 4/7/25 about R2's future plans for placement but not about a concern that occurred over the weekend. On 4/8/25 at 12:27 PM, Surveyor interviewed SW-E about previous contact with R2's family. SW-E indicated R2's family member left a voicemail but SW-E could not recall the date. SW-E indicated R2's family member was upset and irate and indicated staff told R2 that R2 could sit there and wait until R2 was tired. SW-E also indicated there was a concern about staff using a Hoyer lift versus an EZ stand lift. SW-E immediately contacted R2's family member and let them know that was unacceptable. SW-E contacted therapy who assessed R2 and changed R2 to an EZ stand lift for transfers. When asked if the comment from staff about R2 having to wait until R2 was tired was addressed, SW-E indicated it was not but should have been. On 4/8/25 at 1:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of the allegation and confirmed the allegation should have been reported to the SA.

Based on staff interview and record review, the facility did not provide the necessary care and services to promote healing and/or prevent pressure injuries from developing for 1 resident (R) (R1) of 2 sampled residents. R1 was admitted to the facility with a pressure injury (PI) on the left heel. The facility did not complete accurate assessments of R1's left heel PI. Findings include: The facility's Pressure Injuries and Non Pressure Injuries policy, revised 7/20/22, indicates: The center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity .The staging of a pressure injury is consistent with the recommendations of the National Pressure Injury Advisory Panel (NPIAP) and the Resident Assessment Instrument (RAI) Manual, Section M .Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema .Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer .Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because the wound bed is obscured by slough (non-viable tissue, usually tan and stringy) or eschar (dead tissue, usually black or brown) .2. Weekly: .b. Assess current wounds at least every seven days . On 4/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, non-pressure chronic ulcer of bilateral lower legs, pressure injury of left heel (admitted with), chronic kidney disease, and unspecified dementia without behavioral disturbances. R1's Minimum Data Set (MDS) assessment, dated 2/20/25, stated R1's Brief Interview for Mental Status (BIMS) score was 4 out of 15 which indicated R1 had severe cognitive impairment. R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. R1 was transferred to a hospital on 3/18/25 and did not return to the facility. R1's medical record contained the following Pressure Injury Weekly Tracker assessments for R1's left heel PI: ~ A Pressure Injury Weekly Tracker, dated 2/14/25, indicated R1 had a stage 1 PI on the left heel that was present upon admission. The PI measured 1.2 centimeters (cm) (length) x 0.01 cm (width) with 100% skin tissue. R1 was being followed by a wound clinic provider. ~ A Pressure Injury Weekly Tracker, dated 2/21/25, indicated R1 had a stage 1 PI on the left heel that measured 1.2 cm x 0.01 cm with 50% skin tissue and 50% granulation tissue (pink-red tissue that fills an open wound as it heals). ~ A Pressure Injury Weekly Tracker, dated 3/13/25, indicated R1 had an unstageable PI that measured 4.5 cm x 3.5 cm x 0.01 cm (depth) with 50% granulation tissue. The assessment did not indicate what type of tissue was in the other 50% of the wound. On 4/8/25 at 2:04 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. NHA-A indicated the facility noted discrepancies with completion of wound assessments and started an action plan. DON-B indicated the action plan included review and auditing of pending and completed wound assessments in the facility's electronic medical record system to ensure completion. DON-B indicated staff education was being completed and the facility had a plan for audits. DON-B indicated the first staff education meeting was on 4/8/25 at 6:00 AM. DON-B indicated the staff education meeting scheduled for 2:30 PM on 4/8/25 was canceled because State Surveyors entered the facility at 8:00 AM. On 4/8/25 at 2:41 PM, Surveyor interviewed DON-B who provided documentation of the facility's action plan. DON-B indicated a scheduling report from the electronic medical record system was reviewed daily to ensure wound assessments were completed. Incomplete wound assessments were listed on an audit tool to track and follow-up with nursing staff. DON-B did not indicate if the facility looked at the accuracy of completed assessments. On 4/8/25, Surveyor reviewed a wound clinic note, dated 2/18/25, that indicated R1 was seen in the wound clinic for a chronic left heel PI since 10/24/24. Notes indicated R1's left heel PI measured 4.6 cm x 3.7 cm x 0.1 cm on 1/30/25 and measured 4.5 cm x 3.4 cm x 0.1 cm with 100% granulation tissue on 2/1/25. The notes indicated R1's wound continued to improve. On 4/8/25, Surveyor reviewed the facility's action plan which included an education sign-in sheet, dated 4/8/25, for the 6:00 AM staff education meeting. Topics listed on the sign-in sheet included: Skin pressure/non pressure ulcers, Point of Care (POC) (a program in the electronic medical record), alerts, and User Defined Assessments (UDAs). The sign-in sheet contained eight staff signatures and did not mention accuracy of assessments. On 4/8/25 at 3:00 PM, Surveyor interviewed DON-B who indicated there were no wound care certified nurses on staff at the facility. DON-B indicated the facility contracted with a wound care provider who came to the facility for weekly rounds. DON-B verified R1 did not see the wound care provider because R1 was followed by an outside wound care facility.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R9, R6, and R5) of 7 residents observed during medication administration and the provision of care. During observations of medication administration for R9, R6, and R5, Medication Technician (MT)-C and Licensed Practical Nurse (LPN)-D did not complete appropriate hand hygiene. MT-C and LPN-D did not adhere to contact precautions during medication administration for R6 and R5. Findings include: The facility's Transmission-Based (Isolation) Precautions policy, dated 9/24/24, indicates: .Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment .c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Recommendations for PPE: .Contact: Gloves-Whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). [NAME] gloves upon entry into the room or cubicle. Gowns-Whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. [NAME] gown upon entry into the room or cubicle. The facility's Contact Precautions Signage indicates: Clean hands, including before entering and when leaving room; Put on gloves before room entry; Discard gloves before room exit; Put on gown before room entry; Discard gown before room exit; Do not wear the same gown and gloves for the care of more than one person. 1. On 4/8/25 at 9:17 AM, Surveyor observed medication administration for R9. Surveyor noted MT-C did not complete hand hygiene prior to preparing medication for R9, entering R9's room, administering R9's medication, or providing water. MT-C also did not complete hand hygiene after exiting R9's room. 2. On 4/8/25 at 9:30 AM, Surveyor observed medication administration for R6 who was on contact precautions. Surveyor noted MT-C did not complete hand hygiene prior to preparing medication for R6, entering R6's room, assisting R6 to a sitting position at the edge of the bed, or administering R6's medication. MT-C also did not complete hand hygiene after removing 2 plastic water cups and exiting the room. Surveyor also noted MT-C did not wear a gown prior to entering R6's room, assisting R6 to a sitting position, or administering R6's medication. On 4/8/25 at 9:37 AM, Surveyor interviewed MT-C regarding hand hygiene. MT-C verified MT-C did not complete hand hygiene prior to entering or exiting R6 and R9's rooms during medication administration. MT-C stated MT-C was not aware MT-C needed to wear a gown in R6's room. 3. On 4/8/25 at 9:38 AM, Surveyor observed medication administration for R5 who was on contact precautions. Surveyor noted Licensed Practical Nurse (LPN)-D did not complete appropriate hand hygiene after exiting R5's room. LPN-D removed soiled gloves, held the gloves in LPN-D's right hand, and completed hand hygiene with the soiled gloves and insulin pens in hand. LPN-D then disposed of the soiled gloves at the nurses' station, disposed of pen needles in a Sharps container, and put insulin pens in the medication cart. LPN-D did not complete hand hygiene after putting insulin pens in the cart. Surveyor also noted LPN-D did not don a gown prior to entering R5's room, lifting R5's shirt, and administering R5's insulin. On 4/8/25 at 9:44 AM, Surveyor interviewed LPN-D regarding hand hygiene. LPN-D indicated hand hygiene should be completed prior to preparing medication, entering a resident's room, and existing a resident's room. LPN-D indicated LPN-D should have disposed of gloves and completed hand hygiene. LPN-D was not aware LPN-D needed to wear a gown in R5's room. On 4/8/25 at 1:09 PM, Surveyor interview Director of Nursing (DON)-B regarding hand hygiene and PPE. DON-B indicated staff should complete hand hygiene prior to medication preparation and prior to entering and exiting residents' rooms. DON-B stated staff should follow the PPE directions on the door for a resident who is on precautions.

Based on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition for 1 resident (R) (R1) of 4 sampled residents. R1 experienced an overall decline including changes in transfer ability and eating habits during November and December of 2024. The changes were not communicated to R1's court-appointed Guardian. Findings include: The facility's Change in Condition of the Resident policy, revised 9/20/22, indicates: A facility should immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there is .a significant change in the resident's physical, mental or psychosocial status (that is deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment .4. Notify the resident's family/responsible party as applicable and in accordance with the resident's wishes . On 2/11/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia (a group of symptoms associated with a decline in memory severe enough to reduce a person's ability to perform everyday activities). R1's Minimum Data Set (MDS) assessment, dated 9/20/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R1 had moderate cognitive impairment. R1's medical record contained a BIMS score of 3 out of 15 (completed on 1/7/25) that indicated R1 had severe cognitive impairment. R1 had a court-appointed Guardian who was responsible for R1's healthcare decisions. R1 was emergently transferred to a hospital on 1/9/25 and did not return to the facility. R1's medical record indicated the following: ~On 10/1/24, R1 weighed 207.6 pounds (lbs). ~On 11/1/24, R1 weighed 194 lbs (which was a 6.55% loss). ~On 12/4/24, R1 weighed 184.5 lbs (which was a 4.90% loss). ~On 1/6/25, R1 weighed 158 lbs (which was a 14.36% loss). R1's medical record indicated on the morning of 1/9/25, staff found R1 unresponsive except to painful stimuli. R1 had a fever of 103 degrees Fahrenheit (F) and mottling (patchy irregular discoloration of the skin which occurs when the heart is no longer able to pump blood effectively) on the lower extremities. R1 was immediately transferred to the hospital. A note in R1's medical record, dated 1/9/25, indicated R1's Guardian was upset with a lack of communication in the previous weeks regarding R1's care. On 2/11/25 at 8:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated R1 was a little confused, had a good appetite, and was able to walk with assistance when R1 was admitted to the facility. CNA-C indicated during the last month or so of R1's stay, R1 had a harder time communicating with staff, often refused to eat, and would shut (R1's) mouth and shake (R1's) head when staff attempted to assist R1 with eating. On 2/11/25 at 11:25 AM, Surveyor interviewed CNA-D who indicated R1's transfer ability changed a month or more prior to R1's transfer to the hospital. CNA-D indicated R1 was able to walk with assistance and then required a mechanical lift for transfers. CNA-D indicated staff document transfer ability every shift and stated, I think (R1) declined because (R1's) dementia advanced. On 2/11/25 at 11:30 AM, Surveyor interviewed Medication Technician (MT)-E who indicated MT-E provided care to R1 on 1/9/25 when R1 was transferred to hospital. MT-E indicated R1 had a fever and did not look well when MT-E administered R1's AM medications. MT-E immediately informed the nurse and R1 was transferred to the hospital. On 2/11/25, Surveyor reviewed R1's care plan which indicated R1 required the assistance of one staff and a gait belt for transfers. The care plan did not indicate R1's ability to walk and did not indicate R1 needed a mechanical lift for transfers. On 2/11/25, Surveyor reviewed CNA documentation related to R1's meal intakes for November 2024, December 2024, and January 2025 which indicated a decline in intake over time including an increased number of meal refusals. On 2/11/25, Surveyor reviewed CNA documentation related to R1's transfers for November 2024, December 2024, and January 2025. At the beginning of November, R1 more often required limited assistance (R1 was highly involved in the activity and staff provided guided maneuvering of limbs or other non-weight-bearing assistance) to extensive assistance (R1 was involved in the activity but staff provided weight-bearing support) of one to two staff for transfers. Documentation in December indicated R1 more often required total dependence (R1 was unable to participate in the activity and required full-staff performance) with the assistance of two staff for transfers. Documentation in January indicated R1 required total dependence on two staff for transfers. On 2/11/25 at 11:55 AM, Surveyor interviewed Nurse Practitioner (NP)-F who was one of R1's primary care providers. NP-F could not recall if NP-F was notified by staff of R1's change in transfer status. NP-F was aware of R1's weight loss. NP-F indicated staff notified NP-F of R1's acute change of condition on 1/9/25 and NP-F ordered a hospital transfer. NP-F verified staff should have notified NP-F of R1's change in transfer status. NP-F indicated if NP-F had been notified, NP-F would have considered ordering therapy. NP-F indicated R1 likely had a decline related to dementia and indicated a goals of care conversation could have also been initiated. NP-F verified R1's medical record did not indicate a goals of care conversation was completed with R1's Guardian during the last months of R1's stay. NP-F reviewed R1's hospital records which indicated R1 was discharged from the hospital with Hospice services on 1/21/25 to the home of a family member. NP-F stated R1 passed away on 1/27/25. On 2/11/25 at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B with [NAME] President of Success (VPS)-G and Nursing Home Administrator (NHA)-A. DON-B indicated the facility's Interdisciplinary Team (IDT) reviews at risk resident records weekly, including meal intake documentation. DON-B stated, I was told some days they (staff) used a lift (mechanical lift for transfers) on (R1). DON-B indicated CNA staff are expected to tell a nurse when a resident's transfer status changes and the nurse is expected to update the resident's care plan. VPS-G verified a therapy consultation should be considered if a resident's transfer ability declines. VPS-G verified R1's medical record did not indicate of a goals of care conversation was held with R1's Guardian when R1's general mentation and transfer ability declined and R1 refused to eat. VPS-G verified staff should have had a goals of care conversation with R1's Guardian regarding R1's overall decline.

Based on observation, staff interview, and record review, the facility did not consistently monitor nutrition intake for 1 resident (R) (R1) of 4 sampled residents. R1 experienced a significant weight loss. Staff did not consistently monitor or document R1's meal intake to determine if nutritional interventions were effective. Findings include: The facility's Weight Monitoring policy, revised 12/21/22, indicates: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents .8. The threshold for significant weight change will be based on the following criteria .a. 1 month - 5% weight change is significant; greater than 5% is severe . On 2/11/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia (a group of symptoms associated with a decline in memory severe enough to reduce a person's ability to perform everyday activities). R1's Minimum Data Set (MDS) assessment, dated 9/20/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R1 had moderate cognitive impairment. R1's medical record contained a BIMS score of 3 out of 15 (completed on 1/7/25) that indicated R1 had severe cognitive impairment. R1 had a court-appointed Guardian for healthcare decisions. R1 was emergently transferred to a hospital on 1/9/25 and did not return to the facility. R1's medical record indicated the following: ~On 10/1/24, R1 weighed 207.6 pounds (lbs). ~On 11/1/24, R1 weighed 194 lbs (which was a 6.55% loss). ~On 12/4/24, R1 weighed 184.5 lbs (which was a 4.90% loss). ~On 1/6/25, R1 weighed 158 pounds (which was a 14.36% loss). R1's medical record indicated the facility's Registered Dietitian (RD) was updated regarding R1's weight changes and ordered nutritional supplements. On 2/11/25 at 8:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated R1 was a little confused, had a good appetite, and was able to walk with assistance when R1 was admitted to the facility. CNA-C indicated during the last month or so of R1's stay, R1 had a harder time communicating with staff, often refused to eat, and would shut (R1's) mouth and shake (R1's) head when staff attempted to assist R1 with eating. On 2/11/25, Surveyor reviewed CNA documentation related to R1's meal intakes for November 2024, December 2024, and January 2025 which indicated R1 had a decline in meal intake over time including an increased number of meal refusals. The documentation contained missing information for 38 of 207 meals which was 18.36% of meals. On 2/11/25 at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff are expected to document meal intake for every meal. DON-B indicated the facility's Interdisciplinary Team (IDT) reviews at risk resident records weekly, including meal intake documentation. DON-B verified the missing documentation should have been noted and addressed by the IDT during their reviews.

Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R1 and R3) of 3 sampled residents received the necessary care and services to prevent and heal pressure injuries. R1 was admitted to the facility following a fall with fractures and had bilateral splints to the lower extremities. The splints were not removed for skin checks and R1 developed an unstageable deep tissue injury (DTI) on the right heel. In addition, R1 had a pressure injury on the sacrum that was allegedly present upon admission on 10/1/24. Treatment was not initiated until 10/4/24 and air mattress was not ordered until 10/11/24. R3 was admitted to the facility on [DATE] with a pressure injury on the left heel. A wound assessment and treatment order were not obtained until 5/15/24. The facility did not complete weekly wound assessments or notify the wound clinic when the wound had purulent (containing pus) exudate and appeared infected. Findings include: The facility's Pressure Injuries and Non pressure Injuries policy, with a review date of 7/20/22, indicates: Pressure injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue .Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should not be staged using the staging system .A head-to-toe body evaluation will be completed on every resident upon admission/readmission .If skin is compromised: I. If pressure injury: Initiate the Pressure Injury Weekly Tracker; Ensure primary care physician is aware of wounds/location of wounds and current treatment orders; Ensure appropriate treatment orders for each wound area .2. Weekly: a. Complete a head-to-toe skin check and document findings on the Skin Review-Weekly. If new areas are present: Notify the Pysician; Initiate a treatment per order; .Update plan of care; b. Assess current wounds at least every seven days or more frequently. 1. From 11/5/24 to 11/6/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] following a fall with fractures and had diagnoses including chronic kidney disease, high blood pressure, and bilateral ankle fractures. R1's Admission Minimum Data Set (MDS) assessment, dated 10/8/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. The MDS also indicated R1 was at risk for pressure injuries, had no pressure injuries upon admission, and required moderate to max assistance with activities of daily living (ADLs) and mobility. R1's plan of care indicated R1 had potential/actual impairment to skin integrity related to incontinence and impaired mobility and a stage III to coccyx and a SDTI (suspected deep tissue injury) to the left (sic) heel. The care plan contained interventions for a cushion in wheelchair, heel boots/risers when in bed, float/elevate heels, and an air mattress. A hospital discharge summary, dated 10/1/24, indicated R1's left ankle X-ray showed an acute, nondisplaced infrasyndesmotic distal fibular (long bone in the lower leg that runs alongside the shin bone) fracture. R1's right ankle X-ray showed an acute, nondisplaced intra-articular medial malleolar (ankle) fracture. The discharge summary indicated R1 had bilateral splints placed on the lower extremities and was non-weight bearing status. On 10/4/24 at 4:49 AM, a Certified Nursing Assistant (CNA) reported an open area on R1's right buttock. An assessment indicated the area appeared to be shearing-related and measured 3.8 centimeters (cm) x 1.6 cm x less than 0.1 cm. The surrounding skin was blanchable and contained what appeared to be scar tissue. The wound bed was a mix of intact skin and granulation tissue. A treatment was entered on 10/4/24 to cleanse the wound and apply a foam dressing daily and as needed (PRN). A weekly skin review, dated 10/8/2024 at 3:27 PM, indicated R1 had a pressure injury on the right buttock and bilateral ankle surgical wounds that were healing. An orthopedic note, dated 10/8/24, indicated to fit R1 with an Ankle Stabilizing Orthosis (ASO) for the left ankle and a walker boot for the right ankle. The note indicated the right ankle boot should be on whenever R1 was up and about and a posterior splint should be used for comfort with sleep. The facility's Social Worker (SW) ordered an air mattress for R1 on 10/11/24 (which was 7 days after the discovery of the buttock wound and 10 days after R1 was admitted to the facility). A wound physician initial evaluation, dated 10/16/24, indicated R1 had an unstageable pressure wound on the right sacrum that measured 2.5 cm x 1.5 cm x 0.1 cm with necrosis and moderate serosanguinous (a combination of blood and serum that's often a sign of healthy wound healing) exudate that was present upon admission per staff. Recommendations indicated to off-load the wound and reposition per facility protocol. An orthopedic note, dated 10/22/24, indicated R1 had a posterior splint to the right ankle and an ASO to the left ankle. R1 complained of discomfort regarding the left ASO and took Tylenol for pain. The right splint was removed. There was resolving ecchymosis (bruising) and a healing abrasion on the right shin. R1 was switched to walker boots for both ankles. The note stated boots may be off for seated showering. A wound physician note, dated 10/30/24, indicated R1 had a stage 3 pressure wound on the right sacrum that measured 1.5 cm x 0.5 cm x 0.2 cm with light serous drainage that was improving and an unstageable DTI with undetermined thickness on the right heel that measured 3.0 cm x 2.0 cm. The note contained recommendations for a pressure off-loading boot, float heels in bed, off-load wound, and reposition per facility protocol. On 11/5/24 at 11:00 AM, Surveyor observed R1 in bed on an air mattress with a pillow between R1's knees. R1's heel boots were next to the bed. At 11:30 AM, Surveyor observed R1 in bed on a bedpan without heel boots. At 12:00 PM, staff completed cares in R1's room. At 12:30 PM, Surveyor observed R1 eating lunch in bed without heel boots. At 1:30 PM, Surveyor observed R1 in bed with heel boots on and heels floated. At 4:05 PM, Surveyor observed R1's right sacrum with Director of Nursing (DON)-B and Occupational Therapist (OT)-M and noted R1's sacral pressure injury was approximately 2.0 cm x 2.0 cm. The center of the wound contained moist granulation tissue and the surrounding tissue was intact. On 11/6/24 at 2:35 PM, Surveyor interviewed DON-B who indicated R1 wore a brace on the right lower extremity from 10/1/24 to 10/22/24. When Surveyor asked if the brace was removed for skin checks, DON-B indicated the brace was not removed. DON-B provided Surveyor with documentation from the orthopedic clinic, dated 11/5/24, that indicated R1's splints were to be kept on until follow-up with the orthopedic clinic. (The documentation was not obtained until after Surveyor inquired if the splints were removed for skin checks.) DON-B indicated the facility did not have a policy that addressed skin care and the use of medical devices. DON-B was unaware if staff contacted the orthopedic clinic prior to 11/5/24 regarding the use of the splints and if staff could remove or open the splints to complete skin checks. On 11/6/24 at 3:00 PM, Surveyor interviewed Nurse Practitioner (NP)-L regarding the cause of R1's right heel DTI. NP-L indicated the DTI was a facility-acquired wound and not a result of R1's fall prior to admission as R1 was not on the ground for an extended period of time following the fall. 2. From 11/5/24 to 11/6/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including sepsis with shock due to pyelonephritis (kidney infection) and possible right kidney abscess, diabetes mellitus, peripheral venous insufficiency, and chronic kidney disease. R3's Admission MDS assessment, dated 9/5/24, had a BIMS score of 14 out of 15 which indicated R3 was not cognitively impaired. The MDS also indicated R3 had a stage 2 pressure injury that was present upon admission. R3's plan of care indicated R3 had skin impairment due to a pressure ulcer on the left heel related to impaired mobility and indicated R3 chose to not elevate the foot or use a heel riser at times. Interventions included an air mattress, encourage and assist as needed to turn and reposition, use assistive devices as needed, use pillows and/or positioning devices as needed, and float heels/use heel riser as R3 allowed. Risk versus benefit education was provided regarding the importance of elevating the foot to help facilitate wound healing. R3's plan of care also indicated R3 had a left heel infection and contained interventions to monitor for side effects from antibiotic therapy and report worsening signs/symptoms of infection or lack of improvement from treatment to the physician. A note, dated 5/15/24, indicated R3 had stage 1 pressure injury on the left heel that measured 9.5 cm x 11 cm with no drainage and a left heel/ankle protector boot was placed. A treatment was initiated to paint the pressure injury with Betadine, apply Aquacel AG (a hydrofiber wound dressing that contains ionic silver), and cover with an adhesive heel foam dressing. A Pressure Injury Weekly Tracker, dated 5/17/24, indicated R3 had a left heel pressure injury that was present upon admission. The surface area was greater than 24 cm with moderate drainage. There was inflammation/induration surrounding the wound but no infection suspected. The tracker indicated it was the first observation of the wound. The Plan/Treatment section contained a late entry that indicated R3 was newly admitted to the facility and was referred to the wound clinic. The earliest appointment available was 6/12/24. The tracker indicated staff would continue the current treatment until a new order was received from the wound clinic. R3's medical record did not contain an assessment of the pressure injury from 5/18/24 to 5/28/24. R3 was admitted to the hospital on 5/28/24 and discharged from the hospital on 6/3/24 with diagnoses including severe sepsis due to urinary tract infection (UTI), hypotension, and acute respiratory failure. R3's medical record did not contain an assessment of the pressure injury from 6/3/24 to 6/23/24. A wound clinic note, dated 6/24/24, indicated R3 was seen for follow-up of the left heel ulcer which contained a copious (large) amount of purulent green exudate. The note indicated the facility did not notify the wound clinic of the change in condition. The note indicated R3 had an infected diabetic ulcer on the left heel with necrosis of muscle and the writer suspected R3 had pseudomonas (a bacterial infection that can be severe in people with weakened immune systems) due to the heavy green exudate. Recommendations indicated to change the left heel dressing daily due to infection, use heel foam boots to suspend heels when in bed, keep legs and feet dry/avoid soaking or getting wet, and follow-up on 7/15/24. Weekly skin reviews, dated 7/1/24, 7/8/24, and 7/15/24, indicated R3 had a pressure wound on the left foot. The reviews did not contain measurements or an assessment of the pressure injury. R3's medical record did not contain an assessment of the pressure injury from 6/25/24 to 7/14/24. An Advance Practice Nurse Prescriber (APNP) note, dated 7/15/24, contained a new treatment order, but no measurements or description of the left heel wound. R3's medical record did not contain an assessment of the pressure injury from 7/16/24 to 8/1/24. R3 was admitted to the hospital on 8/1/24 and discharged from the hospital on 8/12/24 with diagnoses including severe sepsis due to UTI and acute metabolic encephalopathy. On 11/5/24 at 2:15 PM, Surveyor interviewed R3 and observed an air mattress on R3's bed and a cushion on R3's wheelchair. R3 indicated R3's left heel wound developed in the facility. R3 indicated R3 refused heel boots, but allowed staff to elevate R3's heels with a pillow. On 11/5/24 at 11:10 AM, Surveyor interviewed DON-B and Assistant Director of Nursing (ADON)-C regarding the lack of weekly pressure wound assessments for R1 and R3. DON-B and ADON-C could not provide additional information and indicated the assessments were not completed. On 11/5/24 at 3:30 PM, Surveyor interviewed DON-B and Regional Consultant (RC)-F. DON-B indicated DON-B was aware of the facility's lack of weekly charting/documentation and indicated a Performance Improvement Plan (PIP) was put in place to address the facility's wound care process. DON-B and RN-F indicated the facility had a meeting last Friday (11/1/24) related to nutrition and wounds and were updating care plans. DON-B and RN-F indicated the facility would do skin assessments on all residents and then complete staff education. The PIP indicated the wound care process concern was identified on 10/28/24 and the facility would complete skin and Braden scale assessments on all residents from 11/4/24 to 11/9/24 and review and revise care plans as needed. The PIP also indicated licensed nursing staff would not be educated on the wound care process until a nurses' meeting on 11/13/24. On 11/6/24 at 12:16 PM, Surveyor interviewed RC-E regarding the facility's Pressure Injuries and Non pressure Injuries policy. RC-E indicated the policy stated weekly assessments should be done for pressure injuries. RC-E indicated staff did not follow the facility's policy when they did not complete weekly assessments. On 11/6/24 at 1:18 PM, Surveyor again interviewed RC-E regarding wound care. RC-E indicated staff did not follow standards of practice or the facility's wound care policy. X0440

Based on interviews and record review, the facility did not ensure that residents received care consistent with professional standards of practice to prevent Pressure Injuries (PI) from developing for 1 of 3 sampled residents (R). (R2). On 6/3/23, a new pressure area was identifiied on R2's coccyx. The faciltiy did not assess, call the MD, and add any new interventions to promote healing according to facility policy and standards of practice. R2's pressure injury was identified by the wound clinic on 6/7/23 and the facility recieved orders. The facility did not implement interventions on the care plan until 6/20/23, or initiate weekly assessements that would include weekly measurements, description, and staging of the pressure injury. R2's pressure injury developed slough on 6/12/23, developing into a stage 3 at a minimum or unstageable pressure injury. Facility failed to follow their own policy or initiate risk management to communicate the wound to all nursing staff. This is evidenced by: The facility policy titled Pressure Injuries and Non pressure Injuries states under compliance guidelines: Weekly: Complete a head to toe skin check and document findings on the Skin Review-Weekly. If new areas are present: 1. Notify MD 2. Notify resident/responsible party 3. Initiate treatment per order 4. Initiate appropriate UDA (risk management) 5. Update Care Plan 6. Discuss during shift to shift report process 7. Review with IDT Assess current wounds at least every 7 days or more frequently as needed. R2 was a [AGE] year-old admitted to the facility on [DATE] from an acute care hospital after an BKA (below the knee amputation) of left leg. R2 had other diagnosis of pneumonia, muscle weakness, Type II diabetes with neuropathy, chronic kidney disease and foot ulcers, mild cognitive impairment, and peripheral vascular disease. Minimum Data Set (MDS) of 4/22/23 notes a BIMS (brief interview for mental status) of 11 which indicates a mild cognitive deficit. Under the area of skin, it notes open areas to foot as diabetic ulcers. There is no pressure injury identified on the coccyx. It does identify that R2 is at risk for developing a pressure injury. R2 was being seen by the wound clinic for wounds to right heel and it was noted on 6/7/23 by the wound clinic that there was a wound on the coccyx they had not been informed of. Record Review: Physician Orders for June of 2023 for skin care. On 6/7/23 order for Coccyx/Buttocks ulcerations, to apply calazime cream TID as needed. Use foaming cleanser to remove the soiled cream. Do not scrub off cream, the purpose of the cream is to build a barrier, 3 times a day for wound care. This order ended on 6/14/23. On 6/12/23, an order reads apply bordered foam dressing to sacrum and monitor every shift 2 times a day for wound. Wound Clinic Notes: 5/3/23 and 5/17/23 being followed for wound to right lateral foot and posterior right heel, both identified as diabetic ulcers. Note no wound care appointment from 5/17/23 until 6/7/23. This was due to the wound care clinic canceling the appointment scheduled for 5/31 and rescheduling for 6/7/23. 6/7/23 noted wound to right buttocks/coccyx. Measurements 7 cm long, 2.8 cm wide and 0.1cm deep. Noted orders sent with patient and report called to nursing at the facility. The report was called to a nurse that is agency staff. 6/14/23 note wound to coccyx, measures 2.2 cm long, 2.5cm wide, and 0.1cm deep. Orders sent with patient and report called to RN E. Facility Skin notes: R2 had been readmitted to the hospital on 4/18/22 for an impaction and nausea and vomiting. On discharge 4/22/23 notes remark on wound to right foot, BKA area, and heel, no open areas to the coccyx area. Surveyor identified the facility is documenting skin condition in several areas. There is a weekly non pressure and pressure area tracker, weekly skin reviews, and daily Skilled Nursing Facility charting. Noted on Weekly pressure tracker, that there is not a note regarding the coccyx area until 6/15/23 which is after the wound clinic had notified the facility of the wound being present. Weekly Skin Reviews: 6/4/23 noted by LPN H that there was an open area to right buttocks that was 1.0cm x1.0 cm. No noted tx or description, or staging. 6/11/23 noted by RN E an open area to coccyx with treatment. No measurements or other descriptions. 6/18/23 noted by LPN D no skin impairments nor anything new. Daily Skilled Notes: 6/2/23 Notes speaks to wounds but not to any wound to coccyx. 6/3/23 Note done by LPN D notes pressure to coccyx. No other description or treatments or staging. 6/5/23 Note by RN E no mention of coccyx area but does describe other wounds being treated. 6/6/23 Note by LPN D no mention of coccyx area, does describe other wounds being treated. 6/7/23 Note by RN, speaks to coccyx area to apply Calazine cream TID, PRN use foam cleanser to area to remove cream. No measurements or other descriptions or staging. 6/12/23 Note by agency nurse. SBAR CNA reported wound to the sacrum, got new orders to apply border foam dressing and have wound care nurse assess in the AM. There is a description of the area, slough with minimal drainage. Of note on this date the pressure injury has slough. Of note slough with minimal drainage indicates worsening of the pressure injury, and as referenced below is now a Stage 3 PI, or unstageable if the wound bed is obscured by slough. The National Pressure Injury Advisory Panel (NPIAP) Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible .If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 2 Pressure Injury: Granulation tissue, slough and eschar are not present. Surveyor unable to determine if Stage 3 or Unstageable since there is no documentation as to how much slough was in the wound bed in documentation provided. 6/14/23 Note new orders for coccyx area: Resident seen today at wound clinic today new orders received to lie flat in bed HOB elevated less than 30 degrees, consume 5-6 servings of protein daily to optimize wound healing. Remove the Hoyer sling while sitting in w/c to avoid additional pressure to pressure injury. Reposition every 2 hours while in bed turning side to side. Avoid sitting up in w/c or recliner for more than 2 hours at a time. New wound care instructions coccyx/right buttock and left buttock ulcerations. Cleanse with NS pat dry apply AquaCel Ag advantage, cut slightly larger than ulcer, cover with a bordered foam. change daily and PRN. f/u in one week with NP or sooner if concerns. Care plan: A care plan was in place for skin addressing the heel and foot initiated on 4/11/23. This was revised on 6/20/23 to add pressure injury to coccyx. This is 17 days after the pressure injury was first indentified by LPN D. Interventions are to inform the residents/family on any new areas of skin breakdown, Monitor nutritional status, serve diet as ordered monitor intake and record. Monitor and report any new changes in skin status: appearance, color, wound healing, s/s of infection, wound size (length x width x depth), stage. Weekly treatment documentation to include measurements of each area of skin breakdown. Noted that the interventions of air mattress, cushion to W/C, boot to left foot were observed to be in place. Dietary note of 6/8/23 added a daily shake and boost at dinner to improve weight. Observation: 6/20/23 at approximately 11:00AM Surveyor observed LPN D do wound care to R2 coccyx. Noted there was a dressing dated 6/19/23 on the wound. This was removed. There was a small amount of brown drainage on the old dressing. Area was cleansed and patted dry with wound cleanser, then Aquacel dressing was applied and over this a foam dressing. This was dated. Infection control protocols followed. On 6/20/23 at approximately 11:10AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding R2's coccyx wound as per the records LPN D was first to note an area on the coccyx on 6/3/23 of pressure in coccyx. Surveyor asked what LPN D noted when they first viewed the area. LPN D stated that it was red and open, that it was cleansed, and a dressing applied. LPN D stated they let the nurse on duty know but could not remember who that was. They did not measure the wound. On 6/20/23 at approximately 11:30AM, Surveyor interviewed (Registered Nurse) RN E regarding R2's open coccyx wound. Surveyor asked when they first noticed the open area. RN E stated that they did not remember. Surveyor asked what the process was when a new open area was found. RN E stated that it should be measured, cleaned, dressed, and risk management filled out. It should be cleansed with skin cleanser unless there were special orders. On 6/21/23 at approximately 8:15AM, Surveyor interviewed LPN H who is the facility wound nurse. Surveyor asked what LPN H does when there is a new wound noted. LPN H stated that they measure the wound, do a risk management, and call MD for orders. Regarding R2, LPN H stated that on 6/14/23 they put a note in regarding that area after measuring and let the nurse know. LPN H stated they did not do a risk management form at the time and that they had not been aware of the area until CNA G had brought it to their attention. On 6/21/23 at approximately 9:15AM, Surveyor interviewed Senior DON C regarding wounds. Surveyor asked what the expectations were when a new open area is noted. DON C stated nursing should start a risk management, update the MD, get a treatment order, tell the resident and POA, and notify nurse management. Surveyor asked if DON C would agree that there is a lack of assessment being done. DON C stated there are issues with documentation and following processes. Regarding R2, DON C stated they felt it had been assessed but not documented. Surveyor asked how DON C knew it had been assessed as it had not been documented with measurements, staging or a complete description of the pressure injury. DON C stated she had been under the impression it was in paper but not on the computer. DON C stated that if a risk management is filled out, it triggers the system and notifies nursing by showing up on the MAR (Medication Administration Record) as this is something all nurses have to look at. Surveyor asked again if the expectations were met, and DON C stated no. On 6/21/23 at approximately 10:00AM, Surveyor interviewed DON B regarding open areas. Surveyor asked what the expectations were for the nursing staff if they noted a new open area. DON B stated they should document, put-on 24-hour report, tell the DON, call the MD to get orders and call the POA. They should also measure the wound, and add interventions to promote healing. Surveyor asked if DON B would agree that this is not being done and DON B stated yes, they would agree. The facility did not assess, treat or add interventions to promote healing of a newly identified pressure injury identified by staff on 6/3/23, and by the wound clinic on 6/7/23, according to facility policy or standards of practice, resulting in R2 developing a stage 3, or unstageable pressure injury.

Based on interview and record review the facility did not ensure 2 of 2 sampled residents (R1 and R5) receiving [MEDICAL TREATMENT] received the necessary care and services to promote and maintain the highest practicable well-being as it related to [MEDICAL TREATMENT] services, fluid balance, and significant changes in condition. 1. R1's medical condition was extremely complicated with significant fluid balance problems related to kidney and liver failure, and [MEDICAL CONDITION]. R1's liver failure required frequent paracentesis (removal of fluid from the peritoneal space of the abdomen). R1's kidney failure required [MEDICAL TREATMENT] via an external dual port catheter. This catheter accessed both R1's venous and arterial blood supply. R1 was also diagnosed with [REDACTED]. R1 was also a full code and desired aggressive treatment. Despite R1's significant medical [DIAGNOSES REDACTED]. ~Comprehensively, accurately, and timely assess and document R1's fluid status including monitoring R1's [MEDICAL CONDITION] and ascities, I&O (intake and output), and weights. ~Comprehensively complete a head to toe assessment when R1's condition warranted such. ~Identify, assess, and respond to R1's declining condition. ~Develop a care plan to direct staff on how to manage R1's fluid status. ~Develop a care plan to direct staff on how to manage R1's external [MEDICAL TREATMENT] catheter in the event of an emergency. ~Communicate on an on-going basis with the [MEDICAL TREATMENT] provider to ensure continuity of care. R1's decline in condition also resulted in extreme fluid build up in his abdomen, legs, and genitalia described as being as tight as a violin string. While the facility was to schedule paracentesis based on assessment and R1's request, paracentesis were not scheduled timely. A paracentesis completed on 2 separate occasions resulted in 7 liters, and 7.4 liters of fluid removed. 7 liters was equivalent to approximately 2 gallons of fluid. On [DATE], R1 returned from [MEDICAL TREATMENT] with a change in condition. The facility was made aware of the change. Despite that, there was no assessment completed of R1's condition. On the morning of [DATE] R1 was found unresponsive not breathing and with no heart rate. Resuscitation was attempted. R1 did not survive and subsequently expired on [DATE]. 2. R5 has [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) and receives [MEDICAL TREATMENT] three times a week. There is minimal communication between [MEDICAL TREATMENT] clinic and the facility. On 2 occasions, the [MEDICAL TREATMENT] center communicated potential changes in R5's condition (weakness and wheezing, and lethargy) which would have required a comprehensive assessment by the staff at the facility. No assessments were completed R5 [MEDICAL TREATMENT] care plan does not identify risk factors and potential complications related to [MEDICAL TREATMENT] and end stage [MEDICAL CONDITION], such as potential for bleeding, alteration in fluid volume, potential for infection, alteration in nutrition, alteration in skin integrity and the effect of [MEDICAL TREATMENT] on medication therapy. R5 was hospitalized on [DATE] through [DATE] [MEDICAL CONDITION] (blood infection) and a new [MEDICAL TREATMENT] catheter was inserted in the right chest area on [DATE]. On [DATE], R5 was sent to the emergency room after she was found to have bleeding from the catheter port. The facility documentation is scattered throughout on several forms with no clear direction of a complete assessment and/or if monitoring was occurring for the new [MEDICAL TREATMENT] catheter. This is evidenced by: R1 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. diff. R1's admission MDS (Minimum Data Set) dated [DATE] indicated R1; ~ Had a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 was cognitively intact; ~Was independent in all aspects of care including transfers, walking, bathing, eating, and using the bathroom; and ~Was expected to return to the community. A hospital discharge summary dated [DATE] indicated, .Patient required frequent paracentesis and thoracentesis during the hospital stay .5.75 liters on [DATE]; paracentesis 3 liters on [DATE]; thoracentesis of the right side 1.5 liters on [DATE]; paracentesis of 3.5 on [DATE]; thoracentesis of the right chest of 1.4 liters on [DATE]; and patient will need frequent thoracentesis and paracentesis as an outpatient . The discharge summary also indicated R1 was treated with an antibiotic due to presumed endocarditis. Antibiotics were to continue and were to be administered when R1 had [MEDICAL TREATMENT]. The facility was made aware that R1 required frequent paracentesis through the hospital discharge summary. According to the hospital records R1 had a paracentesis completed 3 times in a period of 8 days. Failure to develop a care plan that addressed all aspects of care for R1 R1's care plan for fluid status was dated [DATE]. The care plan identified the problem as a potential problem related to R1's physician ordered fluid restriction of 1800 cc (cubic centimeters) every 24 hours. The care plan had the following approaches; ~[DATE], .Offer and encourage fluids .Report hard stools .Report poor fluid intake . ~[DATE], .Hydration screener .monitor and document intake and output as per facility policy .Note changes in hydration status and update MD (Medical Doctor) prn (as needed). R1's care plan problem for potential nutritional problems was dated [DATE]. It directed staff to weigh R1 three times a week. Although the care plan addressed fluids and nutrition, the care plan had no directives to staff regarding; 1. Managing and monitoring R1's ascities including setting timely appointments for a paracentesis. Ascities is typically monitored by measuring abdominal girth. Increasing abdominal girth indicates increasing amounts of fluid within the abdominal cavity. The more fluid within the abdominal cavity the greater the pressure on all adjacent organs and vessels. 2. Managing R1's [MEDICATION NAME] catheter used for [MEDICAL TREATMENT] on-going and urgently. R1's care plan did not indicate what type of access R1 had for [MEDICAL TREATMENT]. On [DATE] at 11:45 a.m. Surveyor spoke with the DON (Director of Nursing). Surveyor asked the DON about the access and the DON indicated R1 had a fistula. A fistula is created surgically, typically on an arm for access for [MEDICAL TREATMENT]. On [DATE] at 3:00 p.m. Surveyor spoke with DA-P ([MEDICAL TREATMENT] Administrator) from the facility's [MEDICAL TREATMENT] provider. DA-P confirmed R1 had a [MEDICATION NAME] dual port catheter and explained one port had venous access and the other port had arterial access. DA-P indicated the site of R1's port was not to get wet and R1 required a sponge bath. DA-P indicated a hemostat (a hand held clamp) should be kept at bedside to clamp R1's catheter in case of emergency. R1 was not to get his [MEDICAL TREATMENT] port wet. The facility was also to have a hemostat at bedside. None of this information was located in R1's care plan. On [DATE] at 2:20 p.m. Surveyor spoke with RN-K. Surveyor asked RN-K what she would do if R1's catheter was dislodged or bleeding. RN-K stated she would send the person to the emergency room right away as there was nothing we would be able to do. 3. How and when to communicate with the [MEDICAL TREATMENT] provider. Surveyor requested multiple times to view any written communication sent back and forth from the facility and [MEDICAL TREATMENT] provider. The facility was unable to produce any written communication with the [MEDICAL TREATMENT] clinic. It was critical for both the facility and [MEDICAL TREATMENT] provider to inform each other of any concerns noted both at the facility and during [MEDICAL TREATMENT] in order to ensure continuity of care. On [DATE] at 1:07 p.m. Surveyor spoke with DAA-D ([MEDICAL TREATMENT] Administrative Assistant) from the facility's [MEDICAL TREATMENT] provider. DAA-D indicated it wasn't their practice to have any type of written communication back and forth between their clinic and the facility. On [DATE] at 3:00 p.m. Surveyor spoke with DA-P ([MEDICAL TREATMENT] Administrator) from the facility's [MEDICAL TREATMENT] provider. DA-P stated they do not, as a practice, have any type of written communication which is sent back and forth from them to the facility. DA-P stated they used to use a binder but, too much was overlooked and not getting passed along. DA-P stated she had instructed all staff to call the facility when there was critical information the facility needed to be aware of. Surveyor also asked DA-P what type of access R1 had for [MEDICAL TREATMENT]. On [DATE] at 3:00 p.m. Surveyor spoke with LPN-B and asked how they communicated with [MEDICAL TREATMENT]. LPN-B stated they would call us or we would call them. LPN-B also stated she wished they had better communication. Failure to monitor weights or to act timely to significant changes Surveyor completed a review of R1's weights and noted the following. ~[DATE], 220 # (pounds) ~[DATE], 223.1# ~[DATE], 224.8# ~[DATE], 225.4# R1 had gained 5.4 pounds in 3 days. There was no indication the physician was consulted. There was no indication that a comprehensive assessment was completed including a review of R1's I&O or [MEDICAL CONDITION] including abdominal girth. ~[DATE], 224.4# ~[DATE], 229.8# In 10 days R1 had a weight gain of 9.8 pounds. There was no indication a comprehensive assessment was completed including a review of R1's weights, I&O, and [MEDICAL CONDITION] including abdominal girth. On [DATE] R1 was seen by a physician. The physician progress notes [REDACTED].Significant profound [MEDICAL CONDITION] .abdominal distension .Shortness of breath .Accumulation of ascitic fluid .[MEDICAL CONDITION] in the genitalia . R1 was scheduled for a paracentesis on [DATE]. According to a progress note dated [DATE] 2.6 liters of fluid was removed during the paracentesis. There were no further weights until [DATE] when R1's weight was 230#. On [DATE] R1 was admitted to the hospital. A hospital discharge summary indicated, .Significant findings/Treatment .Patient with influenza A .Fluid overload, [DIAGNOSES REDACTED] (a life threatening condition that consists of rapid deterioration of kidney function) .Decompensated liver [MEDICAL CONDITION] with recurrent ascities .had paracentesis .on [DATE]. Four liters of fluid was removed. The patient felt better .C.diff infection .Recent [MEDICAL CONDITION] (infection in the blood) . R1 returned to the facility on [DATE]. On [DATE] R1 was seen by a physician. The physician ordered a paracentesis. The facility scheduled it for [DATE]. A progress note dated [DATE] indicated 4 liters of fluid was removed. According to R1's weight record, R1 was not weighed from the time of readmission on [DATE] until [DATE]. According to R1's care plan R1 was to be weighed three times a week. On [DATE], R1's weight was 201.4#, which is 28.6# weight loss since the last weight on [DATE]. Weights continue. ~[DATE], 195.6# ~[DATE], 198.0# ~[DATE], 208.0# ~[DATE], 210.2# From [DATE] to [DATE], a period of 8 days, R1 had a weight gain of 14.6 pounds. There was no indication the facility completed a comprehensive assessment. There was no indication the facility consulted R1's physician. The last recorded weight was on [DATE], when R1 weighed 208.2#. Failure to monitor intake and output According to a note on [DATE]: .Hydration screener .monitor and document intake and output as per facility policy .Note changes in hydration status and update MD (Medical Doctor) prn (as needed). It was critical to complete comprehensive assessments, have accurate I&O and weights given R1's tenuous fluid status. This would also be critical information for R1's [MEDICAL TREATMENT] provider to have as well as R1's physician in order to determine appropriate care. Surveyor requested R1's I&O from [DATE] through [DATE]. Surveyor received and reviewed a form titled Look Back Report. The form had intake of water and liquids at meals recorded for each shift. The form did not include any other fluids R1 may have had during each day including fluids during medication administration or supplements. There was no output recorded. On [DATE] at 2:35 p.m. Surveyor spoke with the DON regarding the form titled Look Back Report. The DON indicated the CNAs (Certified Nursing Assistants), per facility practice, document intake on all residents for meals. Surveyor asked the DON why R1 was not put on I&O. The DON indicated as a facility they did not do strict or formal I&O unless they had a doctors order to do so. The DON also stated the previous NHA (Nursing Home Administrator) did not believe in doing I&O. The DON also indicated there was no place for them to document output in their electronic charting. On [DATE] at 8:30 a.m. Surveyor spoke with the DM (Dietary Manager). The DM also indicated anyone with fluid problems such as R1 should have their fluids monitored. The DM also indicated she was aware weights were not being done as they should be. The DM indicated as a facility they were working on the problem. On [DATE] at 11:00 a.m. Surveyor spoke with RN-K regarding the facility's practice for monitoring fluid status. RN-K stated nurses do not put residents on I&O but questioned whether dietary does. RN-K stated she did not monitor I&O and again thought dietary did. Failure to comprehensively assess ongoing changes in condition [MEDICAL TREATMENT] notes, facility nursing notes, and CNA interviews describe changes in R1's condition beginning [DATE]. There is no documented comprehensive assessment of these changes. [MEDICAL TREATMENT] progress notes, which were not housed in R1's clinical record, note the following. ~On [DATE] a progress note indicated R1 was complaining of stomach cramping. The note indicated, .Provider updated . ~On [DATE] a progress note indicated R1 requested his [MEDICAL TREATMENT] be stopped 1 hour and 20 minutes early. The note indicated R1 was, .feeling played out . and the sore on R1 buttock were bothering him. (Refer to F314.) ~On [DATE] a progress note indicated R1 was complaining of not feeling well. The note indicated R1 had a weight gain of 6.6 pounds since the last time R1 had [MEDICAL TREATMENT], 2 days ago. The note also indicated R1 requested [MEDICAL TREATMENT] be stopped 93 minutes early. ~On [DATE] a progress note indicated R1 was complaining of a sore throat and having difficulty eating due to pain on R1's tongue. The progress note indicated, .noted fungal appearance on tongue and a fissure to mid tongue. States has reported this and requested to see the house physician multiple times but has not seen one . The [MEDICAL TREATMENT] provider contacted the facility regarding R1's complaints. (A review of R1's physician orders indicated on [DATE] a physician ordered [MEDICATION NAME]. This is a liquid antibiotic used to treat oral thrush, a fungal infection of the mouth. There was no indication in R1's nursing notes of oral thrush until [DATE] when a nursing note indicated, .Writer request to follow up with MD (Medical Doctor) on patient c/o (complaints of) sore mouth . There no oral assessment ever documented.) ~On [DATE] a progress note indicated R1 had increased lower extremity [MEDICAL CONDITION] and was complaining of shortness of breath. [MEDICAL TREATMENT] was stopped 45 minutes early due to increased back pain and the inability to sit in the [MEDICAL TREATMENT] chair any longer. ~On [DATE] a progress note indicated R1 requested [MEDICAL TREATMENT] be stopped 1 hour and 40 minutes early due to back pain. ~On [DATE] a progress note indicated R1 was complaining of pain in his tail bone. ~On [DATE] a progress note indicated R1's [MEDICAL TREATMENT] was stopped 2 hours early as R1 was complaining of his stomach rolling and cramping. The note indicated R1's abdomen was firm and distended. ~On [DATE] a progress note indicated R1 requested [MEDICAL TREATMENT] be stopped 1 hour and 40 minutes early. The note indicated R1 had .had enough . and indicated the wounds on his buttock made it difficult for him to sit. Surveyor completed a review of R1's nursing notes. All nursing notes were electronic. The nursing notes were noted in multiple different formats including medicare charting, weekly charting, E-interact which was utilized to chart a change in condition when noted, SBAR (Situation, Background, Assessment, Recommendation) which was also used to chart a change in condition, and incident charting. All formats had predefined text. All formats were independent of each other and not linked. There was limited narrative charting extending beyond the predefined text. Surveyor noted the following. ~On [DATE] R1 returned from the hospital. There was no head to toe assessment completed. ~On [DATE] a nursing note indicated R1 was alert and oriented and independent in mobility while in his room. An assessment indicated R1's lungs had slight wheezing, R1 complained of no shortness of breath, and no cough, R1's abdomen was soft and non-tender with no distension, and R1 had [MEDICAL CONDITION] to both lower extremities. The nursing note also indicated R1 had no skin issues. Between [DATE] and [DATE] this was the only comprehensive nursing note Surveyor was able to extract from the facility's documentation. This assessment did not include a pain assessment. ~On [DATE] a nursing note indicated R1 was refusing to wear Ted socks as they were too tight. ~On [DATE] a nursing note indicated, .back from [MEDICAL TREATMENT] .very sleepy and went to bed right away .stating he didn't eat lunch .refuses to have supper stating he was too tired and don't feel hungry. resident was having chest pain ,[DATE] (3 out of 10). Writer asked when it started and resident replied yesterday but had went away afterward. Resident asked for some pain pill writer gave PRN (as needed) [MEDICATION NAME] (a pain medication), an hour after writer went back to follow-up .resident stated he wasn't having chest pain, just want to sleep . R1 was complaining of chest pain. This was a significant change in R1 condition. There was no indication a comprehensive clinical assessment was completed. There was no indication a physician had been contacted. Nursing notes continue. ~On [DATE] a nursing note indicated R1 had no pain and remained independent in mobility. ~On [DATE] a nursing note indicated, .Ace wraps applied instead of Ted's related to resident's refusal recently of being to (sic) tight/uncomfortable . ~On [DATE] a nursing note indicated, .stool .still positive for [MEDICAL CONDITION] .[MEDICATION NAME] (an antibiotic) for 2 more weeks . ~On [DATE] a nursing note indicated R1 continued to have loose stools. The nursing note also indicated, .seems to have some increase in pain/tiredness after post [MEDICAL TREATMENT] . ~On [DATE] a note completed by the DM (Dietary Manager) indicated, .Weight change note .reviewed r/t (relate to) weight loss .has numerous co-morbidities which are progressing .has been receiving antibiotic for some time r/t [MEDICAL CONDITION] .Intakes vary and resident states he is starting to have difficulty (sic) swallowing which was forwarded to nursing for MD update. Even with weight loss resident is shown to have increased [MEDICAL CONDITION] with [MEDICATION NAME] and ted hose being added to his plan of care .MD is aware of residents decline and has suggested palliative care which resident is not ready for at this time .weekly hydration screen and weight 3x weekly . ~On [DATE] a nursing note indicated R1 was complaining of weakness, unsteadiness, and asking for additional assistance with activities of daily living. ~On [DATE] a nursing note indicated, .Weight change .Resident documented as having a significant weight gain .weight is inconsistent r/t .paracentisis (sic) and [MEDICAL TREATMENT] .at times is to (sic) tired to eat . ~On [DATE] a nursing note indicated R1 was requesting more frequent assistance with walking due to feeling week. ~On [DATE] a nursing note indicated R1 was having abdominal pain which R1 rated at 6 on a pain scale of 0 to 10. ~On [DATE] a nursing note indicated R1 was complaining of abdominal cramping and loose stools. The documentation indicated R1 was having fluid balance problems. R1 had complained of chest pain and abdominal pain. R1's ted hose were discontinued as they were too tight. R1 had a significant weight gain. R1 was also requiring increased assistance with activities of daily living. Surveyor completed review of all documentation for R1 since [DATE]. None of the documentation in the weekly notes, medicare notes, interact notes, and SBAR contained a comprehensive clinical head to toe assessment of R1's medical condition since the nursing note of [DATE]. None of the documentation aside from [DATE] addressed the [MEDICAL TREATMENT] provider's concerns as noted in the [MEDICAL TREATMENT] progress notes. CNAs described the resident's condition as follows: On [DATE], CNA-M indicated he worked on the unit R1 resided. CNA-M indicated R1 was having paracentesis, however the fluid would build up fast. CNA-M stated R1 got weaker and weaker and needed more assistance because of it. CNA-M indicated the build up of fluid in R1 abdomen was the worst and really bad. CNA-M stated R1 would indicate the fluid in his abdomen felt tight and really bothered him. CNA-M indicated R1 felt much better after having a paracentesis. CNA-M stated R1 was gaunt and thin everywhere except his belly. CNA-M stated the fluid wrapped around to the back of his hips. CNA-M described R1's condition as looking like the starving children in Africa. CNA-M stated R1 complained of a lot of tightness and pressure which bothered R1. On [DATE] at 9:50 a.m. Surveyor spoke with CNA-U. CNA-U indicated she worked on the unit where R1 resided. CNA-U indicated approximately 1 week before R1's death, R1 was having a hard time breathing and wanted to sit up. CNA-U stated R1 could not get comfortable. CNA-U indicated R1 was requiring increased assistance with care. CNA-U indicated R1 had a large, swollen, and protruding abdomen. There is no comprehensive assessment of these conditions beyond the assessment on [DATE]. Failure to schedule paracentisis On [DATE] at 10:45 a.m. Surveyor spoke with FM-I (Family Member). FM-I indicated on [DATE] she requested the facility schedule a paracentesis for R1. FM-I indicated R1 expressed he was starting to feel full in his abdomen and needed a paracentesis. FM-I also indicated on [DATE] she requested the facility have R1's physician assess R1 as R1 was not feeling well, having a tough week and was scared. FM-I indicated she was in the facility on [DATE] for a meeting with RN-J to discuss R1's discharge. FM-I stated when she observed R1, he was blown up like a beach ball and the skin on his abdomen was taut like a violin string. FM-I stated when she spoke to the facility they had not yet scheduled R1 to have a paracentesis. FM-I indicated R1's physician had also not seen or assessed R1 and she could not understand why because a physician or NP (Nurse Practitioner) was in the facility very frequently. FM-I stated she spoke with RN-J regarding her frustration with the facility not following through to get an appointment scheduled. FM-I indicated RN-J called and scheduled an appointment. On [DATE] at 12:20 p.m. Surveyor spoke with RN-J. RN-J indicated she met with R1 and FM-I on [DATE] to discuss discharge planning. RN-J indicated during their meeting FM-I indicated R1 was in need of a paracentesis and the facility had not scheduled it. RN-J considered this serious as the facility was not addressing R1's needs. RN-J stated R1 was uncomfortable and felt a lot of pressure in his abdomen. RN-J stated R1's abdomen was tight like a drum indicating R1 had gone too long without a paracentesis. RN-J stated she called and made the appointment for R1's paracentesis. On [DATE], 2 weeks after FM-I requested an appointment, R1 had a paracentesis. A progress note dated [DATE] indicated a total of 7 liters of fluid was removed from R1's abdominal cavity. 7 liters is 7000 cc's and equivalent to 2 gallons of fluid. Failure to assess a change in condition on [DATE] On [DATE] at 10:45 a.m. Surveyor spoke with FM-I. FM-I indicated on [DATE] when R1 returned from [MEDICAL TREATMENT] she informed the facility of a change in R1's condition. FM-I stated she told staff something was wrong with R1. FM-1 stated R1 was gyrating, and seriously shaking. FM-I stated R1 had never had that type of response to [MEDICAL TREATMENT]. FM-I also stated she covered R1 with blankets because his body was cold. FM-I stated she reported this to staff and requested they check on him frequently. FM-I stated she knew R1 very well and knew there was something really wrong. FM-I stated she fully expected when she left for the day to get a phone call from the facility that R1 had been transferred to the hospital. On [DATE] at 3:00 p.m. Surveyor spoke with LPN-B. Surveyor asked LPN-B if it was normal for R1 to return from [MEDICAL TREATMENT] with shaking chills. LPN-B stated no. There was no documentation indicating the facility completed an assessment following R1's return from [MEDICAL TREATMENT]. There were no vital signs taken after R1 returned to the facility from [MEDICAL TREATMENT] aside from an oxygen saturation reading. The shaking as FM-I described is indicative of a fever. R1's medical condition required prompt assessment and intervention and possible evaluation by a physician. There were no further nursing notes describing R1's condition until [DATE]. Nursing notes continue. ~On [DATE] a nursing note indicated, .Writer entered resident's room at about 0820 (8:20 a.m.) to obtain a blood sugar and vitals for the Medicare charting. 15 minutes prior, resident was seen sitting in his w/C (wheel chair), but at this time resident was lying on bed. Writer attempted to rouse him, but he was unresponsive .lowered resident to floor and started CPR (Cardio-Pulmonary Resuscitation) .Resident was not revived . On [DATE] at 7:25 a.m. Surveyor spoke with CNA-H. CNA-H he had worked full time on the unit where R1 resided. CNA-H indicated he was on duty the day R1 expired. CNA-H stated R1 looked exhausted, and his legs were filled with water. CNA-H stated that morning R1 had requested assistance into a lounge chair. CNA-H stated R1 was so weak he used a wheel chair to get R1 from the bed into the lounge chair. CNA-H stated it was really hard for R1 to transfer and CNA-H did most of the work. CNA-H stated R1 couldn't eat. CNA-H stated after R1 had been in the recliner for about one half hour he was exhausted and wanted to go back into bed. CNA-H stated he needed to use the wheel chair again. CNA-H stated R1 got light headed during the transfer. CNA-H stated when he assisted R1 into bed he was lying crooked but didn't have the strength to straighten himself. CNA-H stated R1 stated he just wanted to sleep. CNA-H stated another resident was calling for help so he left the room. CNA-H stated after assisting the resident to the bathroom he exited the resident's room and saw the nurses running from R1's room requesting assistance. CNA-H stated they entered R1's room right away when he noted R1 was pale and not breathing. CNA-H indicated they placed R1 onto the floor and started CPR. On [DATE] at 2:35 p.m. Surveyor spoke with the DON. The DON indicated care plans were initiated by the MDS nurse on admission. The DON stated updates and changes to the care plan were made by herself, the nurses on the floor, and other disciplines. The DON stated she was responsible to review care plans to ensure accuracy. Surveyor asked the DON why R1's care plan did not identify what type of access R1 had for [MEDICAL TREATMENT] or directives to staff in the event of an emergency. The DON was unsure but stated is should have been. Surveyor asked the DON about assessments of R1 regarding [MEDICAL TREATMENT]. The DON stated staff should be taking R1's vital signs before and after [MEDICAL TREATMENT]. The DON stated staff should be monitoring for abnormal vital signs, and adverse reactions to [MEDICAL TREATMENT] including dizziness, nausea, and fatigue. The DON stated if a resident on [MEDICAL TREATMENT] was experiencing fatigue, or any other abnormal finding the physician should be informed. The DON stated staff should be monitoring R1's lung sounds, and amount of fluid in R1's feet, hands, and abdomen. Surveyor asked the DON why staff was not monitoring R1's abdominal girth. The DON stated there was no physician order to do so. The DON stated she was aware when R1 had a paracentesis R1's abdomen appeared smaller. As time went by R1's abdomen again became large. Surveyor also spoke with the DON regarding comprehensive assessments when residents have changes in condition. The DON stated she was aware the facility's charting was lacking because of the format they used. The DON indicated she had been working with the nurses and had requested the nurses use more narrative charting. Surveyor asked the DON why there were very limited comprehensive assessment completed for R1. The DON indicated she was not sure but indicated it may be because there was so much duplicate charting. The DON stated she looked at the progress notes daily, but the progress notes did not include all the information found in all the other charting formats. The DON also indicated the floor nurses should be pulling all information together and doing narrative charting to tell each resident's story. On [DATE] at 10:25 a.m. Surveyor spoke with the MD (Medical Director). The MD indicated he felt R1 died of an acute cardiac event. The MD indicated this was common in residents with the [DIAGNOSES REDACTED]. The MD indicated he would send the resident to the emergency room . The MD also indicated increasing ascities was not directly but indirectly related to a cardiac event. The MD stated increased fluid in the abdominal cavity caused increased pressure on all organs and vessels including the lungs and put stress on the heart. The MD also stated any residents with shaking chills should be clinically evaluated as it is a sign of infection. The MD indicated depending on the clinical assessment, an evaluation in the emergency may be warranted. The MD indicated he had spoken with facility staff regarding R1 and facility staff indicated R1 had no changes in condition. Example 2 According to the Department of Health and Human Services Centers For Medicare & Medicaid Services: [MEDICAL TREATMENT] Critical Element Pathway, The LTC (long term care) facility is responsible for the delivery of care and services to residents before transferring to the [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) facility after the resident has received [MEDICAL TREATMENT] and is assessed as stable for transfer back to the to the LTC or LTC facility team. R5 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R5's Minimum Data Set (MDS) assessment, dated [DATE] and [DATE] indicated a significant decline in condition in which the facility did not identify as a significant change in condition. Refer to F274. R5 has severe cognitive impairment, extensive assistance from 2 staff for all cares. Receiving [MEDICAL TREATMENT] three times a week and has been on antibiotics for infected [MEDICAL TREATMENT] port. [MEDICAL TREATMENT]/Respiratory Review of R5 medical record: Surveyor reviewed the communication notes between the [MEDICAL TREATMENT] and the facility from [DATE] to [DATE]. 1.On [DATE], 1400 No behaviors today but pt. seems weak, lethargic. Lungs are wheezy, confused as usual. (Wheezing is a high-pitched [MEDICATION NAME] sound made whil(TRUNCATED)

Based on observations, interview and record review, the facility did not ensure 2 of 5 (R1, R4) sampled residents with an actual pressure injury received care and services to promote healing and prevent reoccurrence. R4 was admitted with a a pressure injury. The wound care clinic documented the pressure injury was almost healed and recommended the facility continue with the same treatment. Documentation indicates staff did not follow treatment orders. 9 days later R4's right buttock pressure injury was open measuring 3.0 x 0.1 centimeters. R4 also had a new pressure injury to the left buttock. On 6/13/17, Surveyor observed 4 open areas to the left buttocks. R1 was admitted to the facility with intact skin. After admission R1 developed a stage II pressure injury. The facility did not identify R1's pressure injury in a timely manner nor put off-loading measures into place once the pressure injury was identified. This is evidenced by: Example 1 R4 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. R4's Minimum Data Set (MDS) assessment, dated 4/13/17, indicated: ~Brief Interview Mental Status score is 12. A score 8-12 is considered moderately impaired. ~Requires total assist of 2 staff for bed mobility, and toilet use. ~Use of a mechanical lift for transfers. ~Unable to ambulate. ~1 Stage 3 pressure injury measuring 2.0 cm x 0.5 cm x 0.0 cm (centimeters). ~History of 1 Stage 3 healed pressure injury. R4's Braden Scale Assessment, completed 4/4/17, showed a score of 15, which indicated high risk for pressure ulcer development. On 5/16/17, a wound care note measurements documented Length x Width x Depth and in Centimeters: #1 Right Buttock measures: 1.0 cm x 0.3 cm x 0.1 cm. Stage 3 improving. No description of periwound. #2 Coccyx measures: 1.0 cm x 0.2 cm x 0.1 cm. Stage 3 improving. No description of periwound. Documentation in the medical record included the following: ~5/23/17, the facility wound care nurse documented both pressure injuries as healed. ~5/24/17, R4 was seen by the wound care clinic who documented the wound is almost healed and to continue the same treatment. The treatment was to wash wounds with prontosan solution, pat dry, apply Iodosorb gel (An antibacterial and absorbent agent that works by absorbing fluid and bacteria from the surface of the wound, which helps it to heal), plain [MEDICATION NAME] and secure with [MEDICATION NAME] border foam. To be changed daily and as needed. Despite the wound clinic documentation, the TAR (Treatment Administration Record), for 5/24/17 through 5/31/17 indicates the pressure ulcers were healed and to be monitored on each shift. There is no documentation indicating the pressure injuries were being monitored. Wound care to the right buttock was documented as not being completed in the TAR. ~6/2/17, Nursing documents 2 open areas: Right upper buttocks measures 3.0 cm x 0.1 cm x 0. On 5/24/17, this area was documented by the wound clinic as almost healed. The measurements are indicative of a decline and recurrence of the pressure injury to the right buttock. The entry now identified a new pressure injury to the left buttock which measures 2.0 cm x 0.1 cm x 0. A [MEDICATION NAME] (semipermeable adhesive dressing) was applied over the areas. There is no evidence the physician or the wound clinic were notified of the recurrent and new pressure injuries. The use of a [MEDICATION NAME] was not the treatment ordered by the wound care clinic. In addition, in an interview with the DON at 12:15 p.m. on 6/14/17, the DON told Surveyor the facility does not use [MEDICATION NAME] dressings. The DON stated she was referring to a duoderm in the 6/2/17 note. ~6/6/17, the facility wound care nurse measurements: #1 Right buttock: 1.0 cm x 0.2 cm x 0 Stage 2. #2 Right buttock: 0.2 cm x 0.3 cm x 0. Stage 2. Both measurements indicate Right buttock and the left buttock is not addressed. There was no description of periwound. ~6/7/17, R4 was seen in the wound care clinic. Orders for the right buttock were to wash with Protonsan solution, pat dry, apply Iodosorb Gel, plain [MEDICATION NAME] & secure with [MEDICATION NAME] border Foam. Change daily and as needed. DO NOT USE DUODERM. On 6/13/17 at 9:50 a.m., Surveyor observed CNA (Certified Nurse Aide)-M and CNA-N transfer R4 from the recliner to the bed. R4 was yelling out in pain, My butt hurts. CNA-M and CNA-N proceeded to complete peri and Foley catheter care while R4 was saying, Oh my butt hurts. CNA-N stated she did observe a dressing on the buttock area when she got R4 up. Surveyor did not observe a dressing during cares. Surveyor observed 4 open areas approximately 0.5 cm on the left buttock and 1 larger one on the right buttock approximately 1.0 cm x 0.5 cm elongated. The wound care documentation does not indicate R4 has 4 pressure injuries to the left buttock. On 6/14/17 at 12:15 p.m., Surveyor interviewed the DON who stated that she is new in her position and is also the wound care nurse. She is not certified, received training from the previous DON and has [AGE] years experience as a nurse. R4 is on her case load. On 6/4/17 at 12:15 p.m., Surveyor spoke with the DON, who stated nursing will call the Physician and get an order for [REDACTED]. Surveyor informed the DON of R4 complaining of buttock pain and what does that mean. The DON stated that new pain is an indicator that the wound is worse and felt that R4 had a decline in wound. The DON indicated R4 is noncompliant with repositioning and makes her needs known. Surveyor was unable to locate any documentation of changes made to increase R4's willingness for repostitioning. Example 2: R1 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. diff. R1's admission MDS (Minimum Data Set) dated 2/3/17 indicated R1; ~Had a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 was cognitively intact; ~Was independent in all aspects of care including transfers, walking, bathing, eating, and using the bathroom; and ~Had no wounds and was not at risk for developing pressure injuries . R1's care plan for skin was initially dated 1/29/17 and revised on 4/5/17. The care plan indicated on 4/4/17 R1 developed a stage II pressure injury on the left buttock. The care plan had the following approaches; ~1/29/17, .meds (medications)/vitamins as ordered .Keep skin clean and dry . ~4/5/17, .Tx (treatment) in place for Stage 2 to L (left) buttocks . There were no other interventions noted including those to direct staff on how to manage R1's pressure injury. Surveyor completed a review of R1's nursing notes and noted the following. ~3/29/17, .Late entry for 3/28; resident has superficial abrasion on R (right) buttock, requested .Duoderm . Surveyor completed a review of R1's wound documentation and noted the following. ~On 4/4/17 R1 was noted with a stage II pressure injury on the left buttock measuring 2.0 cm x 2.0 cm (2.0 centimeters by 2.0 centimeters). There were no new interventions put into place to promote the healing of the pressure injury aside from a treatment order. ~On 4/11/17 wound notes indicated R1 wound had the same measurements as those noted on 4/4/17. R1's pressure injury had not improved. There were no changes made to R1's current plan of care. There were no new interventions put into place to promote the healing of R1's pressure injury. Surveyor completed a review of [MEDICAL TREATMENT] progress notes and noted the following. ~On 3/21/17 a progress note indicated R1 did not complete [MEDICAL TREATMENT] and left 1 hours and 20 minutes early. The progress note indicated R1 was complaining that sores on his buttock were bothering him. ~On 4/15/17 a progress note indicated R1 did not complete [MEDICAL TREATMENT] and left 1 hours and 40 minutes early. The progress note indicated R1 wounds made it difficult for R1 to sit. Per [MEDICAL TREATMENT], R1 had wounds already on 3/21/17. The facility was not aware. There were no measures put into place to promote the healing of R1's wounds until a treatment was ordered of 4/4/17. On 6/6/17 at 4:14 p.m. Surveyor spoke with LPN-B (Licensed Practical Nurse). LPN-B indicated R1 had a wound on his buttock which she thought R1 was admitted with. LPN-B stated R1 only lays in one position when in bed. On 6/13/17 at 2:20 p.m. Surveyor spoke with RN-K. RN-K indicated she worked full time on the unit where R1 resided. RN-K stated she was not sure if [MEDICAL TREATMENT] was contacted regarding R1's pressure injury. RN-K indicated she could not recall if there was any type of cushion sent to [MEDICAL TREATMENT] for R1 to sit on during the [MEDICAL TREATMENT] run. On 6/7/17 at 2:35 p.m. Surveyor spoke with the DON (Director of Nursing). Surveyor asked the DON what other measure were not put into place to promote the healing of R1's pressure injury. The DON indicated there were none but should have been.

Based on observation, interview, and record review, the facility did not provide care and services to restore and/or maintain as much normal bladder function as possible for 5 of 8 sampled residents reviewed for bladder incontinence. Resident #5 had a documented decline in her bladder continence and did not have a bladder program in place. Even though the facility initiated data collection of Resident #5's bladder habits, the data was incomplete. The facility did not assess Resident #5 to determine the cause of the incontinence, and did not use the data that was present to develop an individualized toileting program to help Resident #5 restore/maintain as much normal bladder function as possible. Resident #7 has a new onset of incontinence. The facility did not comprehensively assess Resident #7's urinary incontinence and devise a plan to help her restore bladder function. In addition, Resident #7 was not assisted to the bathroom for 3 hours and 45 minutes. This is contrary to facility's "usual procedure" of checking on and taking the residents to the bathroom every 2 hours. Resident #3 is independent with toileting, but has occasional incontinence. The facility did not comprehensively assess Resident #3 to determine the cause of her incontinence and did not devise an individualized plan of care to help Resident #3 restore as much bladder function as possible. Data collected on several dates on Resident #1's bladder habits found that she was able to maintain some continence. There was no evidence that Resident #1 was offered or assisted to the toilet at times when she was dry. The facility did not use the data collected to develop an individualized plan to assist Resident #1 in restoring bladder function. In addition, the data collection was not complete. Resident #9 had demonstrated the ability to maintain some continence. There was no evidence that Resident #9 was offered or assisted to the toilet at times when she was dry. The facility did not use the data collected to develop an individualized plan to assist Resident #9 in restoring bladder function. In addition, the data collection was not complete. This is evidenced by: According to the University of Iowa Gerontological Nursing Research Center publication titled, "Urinary Incontinence in Adults, Clinical Practice Guidelines," a key factor is a complete history of a resident's health and incontinence to include: ~Onset and duration of urinary incontinence; ~Frequency and amount; ~Precipitants (coughing, sneezing, laughing, exercise); ~Timing related to fluid intake and medications; ~Previous treatments; ~Other health problems; ~Medications; and ~3 day "bladder diary." This history is critical in determining the type of incontinence and in establishing a resident's natural bladder pattern. The facility's own policies and procedures are derived from these standards and have been reviewed by the facility's corporate clinical officers as recently as 6/12/13. The facility's procedures however, do not address the key assessment of doing a PVR (Post Void Residual) test to rule out overflow incontinence and no physical examination to rule out stress incontinence. In addition, the facility's policies do not include review of key factors such as cognitive ability, environmental barriers, functional abilities, and the psychosocial effects of urinary incontinence. Once all of these factors are explored, the facility staff need to devise an individualized plan to assist each resident. This plan can consist of an individualized prompted toileting plan and/or eliminating or fixing any of the above risk factors. The facility has in place procedure to "calculate" the ability of a resident to be successful in a prompted toileting plan. The ability is a mathematical equation derived by dividing the total number of successful toilets with toileting attempts. This interpretation of the bladder diary would rely heavily on the accuracy of the every hour data on the first 2 days of the assessment and the every 2-hour data on the third day. Of note is that none of the residents in the citation had this calculation of ability done. Once the toileting plan is devised, it needs to be communicated to the direct care staff, periodically reviewed for effectiveness, and changed if needed. On 2/6/14 at approximately 11:15 a.m., Surveyor # interviewed RN-A (Registered Nurse). RN-A is also responsible for the MDS (Minimum Data Set) assessments at the facility. RN-A stated the previous DON (Director of Nursing) did all the the urinary incontinence toileting programs. Example #1: Resident #5 was admitted on [DATE]. On 8/11/13, the facility began a 3-day data collection of Resident #5's bladder habits. 8/11/13 - No data was recorded on 10 hours. Resident #5 was continent the other 14 hours. 8/12/13 - No data recorded on 7 hours. Resident #5 was continent 14 times, and incontinent 3 times. 8/13/13 - No data was recorded on 8 hours (entire day shift). Resident #5 was continent 14 times, and incontinent 2 times. The assessment on 8/15/13 states, "Continent...Resident incontinent of urine at times producing small amounts...Reassess if change in status." The Admission MDS (Minimum Data Set) assessment, dated 8/17/13, indicated Resident #5 requires extensive assist of 1 person for toilet use. Resident #5 did not have a toileting program and was occasionally incontinent. Resident #5's care plan includes: ~8/10/13 Problem:-3 Bowel and Bladder." 8/10/13 Strengths: "Has no skin problems. Continent of bowel, Continent of bladder, Takes meds, Accepts dietary interventions. 8/10/13 Related to Diagnosis: [REDACTED]." ~Goal: "Will maintain current bladder function...Will have no UTI." ~Approaches/Staff: "...8/10/13 Nurse Aide--Wear inc (incontinence) pads....8/10/13 Nurse Aide--Assist to toilet..." The Quarterly MDS assessment dated [DATE] indicates Resident #5 continues to require extensive assistance of 1 person for toilet use. Resident #5 was not on a toileting program but was now frequently incontinent (a decline from the 8/17/13 assessment). The facility began a 3-day data collection of Resident #5's bladder habits on 11/14/13. 11/14/13 - No data was recorded on 1 hour. Resident #5 was continent 12 times and incontinent 11 times. 11/15/13 - No data recorded on 4 hours. Resident #5 was continent 15 times, and incontinent 5 times. 11/16/13 - No data was recorded on 17 hours (entire day shift and afternoon shift). Resident #5 was continent 8 times. The assessment Summary of Findings states, "Needs assist to the toilet...Assist to toilet." There was no assessment, and no identifiable cause for the decline in urinary incontinence. There was no changes made to the plan of care to restore as much normal bladder function as possible. During the survey process, Surveyor # observed Resident #5 as being incontinent and was checked and changed. On 2/4/14 at 12:46 p.m., Surveyor # spoke with CNA-R who stated, "Resident #5 used to tell us when she had to be toileted." CNA-R checked Resident #5's brief which was dry. Example #2: Resident #7 has been admitted to the facility for a week and a half. Her [DIAGNOSES REDACTED]. According to her care plan, Resident #7 is dependent of the assistance of a mechanical lift and 2 staff members to transfer from her wheelchair to her bed and back. She needs the physical assistance of one staff member with her personal hygiene and dressing. She depends on staff to propel her wheelchair about. Resident #7's care plan states she is always incontinent and wears incontinent pads. There are no instructions in the comprehensive plan of care or in the aide care instruction sheet of when and how staff are to assist her to toilet. On 2/6/14 at 7:30 a.m., Surveyor # observed Resident #7 in the main dinning area, seated in her wheelchair awaiting breakfast. Over the next 3 hours and 45 minutes, Surveyor # and # observed Resident #7. Resident #7 was observed to receive her meal and she was assisted with eating by CNA-E (Certified Nursing Assistant) until 8:20 a.m. and then assisted by COTA-B (Certified Occupational Therapy Assistant). At 8:35 a.m., Resident #7 told the COTA that she was done with her meal and COTA-B took her back up to the second floor. COTA-B offered to help her to the TV and Resident #7 accepted. At 9:10 a.m., Surveyor # took over the observation. From 9:10 a.m. to 9:31 a.m., Surveyor # observed Resident #7 seated in her wheelchair in front of the TV and no staff approached her. At 9:31 a.m., Surveyor # took over the observation. At 9:43 a.m., HS-F (Housekeeping Staff) escorted Resident #7 to an "activity." Resident #7 was taken down to the attached living center to an activity of humorous stories, jokes, poems, and reminiscence with 11 other residents and staff. Resident #7 did not actively participate but she appeared to be listening at times. Resident #7 did keep her head down and eyes closed for a majority of the time. At 11:00 a.m., MR-G (Medical Records) took Resident #7 back to second floor and positioned her wheelchair in front of the Lawrence Welk program on TV. At 11:15 a.m., CNA-E told Resident #7 that she was going to assist Resident #7 to the bathroom. CNA-P assisted. Resident #7 was transferred into bed. CNA-E stated Resident #7 was "dry earlier and she didn't go so she might be wet." Her incontinence brief was wet per CNA-E and she was given the bed pan. When asked by Surveyor # about Resident #7's toileting needs, CNA-E stated Resident #7's toileting schedule was "like the rest, every couple of hours, when you ask her if she wants to go she sometimes want to go, but it's ever couple of hours." CNA-E also indicated Resident #7's urinary continence was "a hit or miss" and that Resident #7 did not like it when staff used the bed pan. When asked about using the toilet in the bathroom, CNA-E stated that because Resident #7 needed a mechanical lift, it would not fit in the bathroom. CNA-E stated there might have been a commode in the room at one time but she didn't know for sure. Surveyor # reviewed the nursing assessments for Resident #7 in the chart. The 3-day diary was incomplete with gaps in information, for example there is no information during the night shift of the first day of the data. After just one day a nurse wrote an assessment that simply stated Resident #7 is always incontinent and no toileting program was attempted. The night shift the second night does not have individual times but says the resident doesn't use the call light, and was found to be "wet at 3 a.m. and changed at that time." The third day of the assessment only records the day shift. The "Summary of Finding" on the evening shift of 2/2/14 states: "Continent with periods of incontinence, needs assist to the toilet. The plan is to complete the incontinence assessment and assist Resident #7 to the toilet. The assessment states Resident #7 does not have stress incontinence, urge incontinence or overflow incontinence." The note goes on to say that Resident #7 has "functional incontinence, and is continent with periods of incontinence, needs one person to help her, and has only had this incontinence for less that 2 weeks." There was no evidence of a physical assessment or PVR (Post Void Residual) being completed to determine if there were potentially reversible medical causes of incontinence. There was no assessment to explore this new condition and no plan to help Resident #7 restore as much normal bladder function as possible. Example #3: Resident #3 has been a resident of the facility for just over one month. She was admitted for short term rehabilitation for strengthening following acute heart failure. The MDS assessments of 1/10/14 and 1/17/14 indicate she is occasionally incontinent of urine however, no trial toileting programing was outlined for her. The facility had a 3-day bladder diary which indicated that periodically during the day shift Resident #3 reported that she had to go to the bathroom [ROOM NUMBER] to 4 times in an hour. On 2/6/14 at 11:40 a.m., Surveyor # interviewed CNA-H regarding Resident #3's urinary incontinence. CNA-H stated Resident #3 has a weak bladder and wears a pad for occasional leaking. CNA-H stated all of a sudden Resident #3 has to go and it leaks when she stands up to go walk to the bathroom. CNA-H stated Resident #3 changes her pads herself. Resident #3's husband brings them in and when she runs out the facility supplies her. There was nothing in Resident #3's record that indicates staff have talked to her about her urinary incontinence or physically examined her. There was no exploration and plan to reverse what appears to be probable overflow incontinence, urge incontinence, and stress incontinence. Resident #3 takes a diuretic and has to go frequently. The plan of care states Resident #3 wears incontinence pads and is independent walking to the bathroom but is continent. There was no comprehensive assessment and toileting plan to assist her to restore normal bladder function. Example #4: Resident #1 was admitted to the facility in 2011. Current [DIAGNOSES REDACTED]. Resident #1's MDS (Minimum Data Set) assessments include the following: ~6/26/13, no current toileting program and always incontinent of bladder. ~9/21/13, no trial of toileting program since admission/incontinence noted and always incontinent of bladder. ~12/17/13, no trial or current toileting program and always incontinent of bladder. The 12/17/13 MDS also indicated Resident #1 is sometimes understood and sometimes understands others, has short and long term memory problems, and is dependent on 2 staff for transfers, toileting, and hygiene. Resident #1's current care plan included a problem of "Bowel and Bladder" dated 10/25/13. Approaches include: ~10/18/11, Wears inc (incontinent) pads; and ~12/16/11, Check and change every 2 hours. The care plan also indicated Resident #1 requires the use of a full body mechanical lift for transfers. Surveyor # reviewed Resident #1's bladder assessments throughout the IDT (Interdisciplinary Team) notes and noted the following: Assessment #1 6/21/13 (Day 1) Data collection is complete for the 24 hour period. ~Resident #1 was dry for 19 of the 24 hours. ~Resident #1 was incontinent 5 of the 25 hours. There was no documentation indicated that Resident #1 had been offered or assisted with toilet use in that 24-hour period. 6/22/13 (Day 2) Data collection is incomplete and missing 4 entries in the 24 hour period. ~Resident #1 was dry 12 of the 20 documented hours. ~Resident #1 was incontinent 8 of the 20 documented hours. Resident #1 was documented as being offered/assisted with toilet use on 3 times in the 20 documented hours. 6/23/13 (Day 3) Data collection is incomplete and missing 15 entries in the 24-hour period. ~Resident #1 was dry 7 of the 9 documented hours. ~Resident #1 was incontinent 2 of the 9 documented hours. There is no documentation indicating Resident #1 was offered/assisted with toileting during the 9 documented hours. On 6/25/13, the assessment was completed with the incomplete data. The summary states, "...incontinence related to dementia, unable to determine when resident voids, > (greater than) 3 year...Continue current plan of acre (sic), wears incontinence product, check and change every two hours or as needed..." Even though Resident #1 demonstrated the ability to remain continent for periods of time on all 3 days, the facility continued the check and change program and did not assist Resident #1 in restoring as much normal bladder function as possible. Assessment #2 9/17/13 (Day 1) Data collection is incomplete and missing 5 entries in the 24-hour period. ~Resident #1 was dry 12 out of the 19 documented hours. ~Resident #1 was incontinent 7 out of the 19 documented hours. Resident #1 was offered toileting a total of 7 times and refused 6 offers. The other 13 times, Resident #1 was not offered or assisted with toileting. 9/18/13 (Day 2) Data collection is incomplete and missing 15 entries in the 24-hour period. ~Resident #1 was dry 6 out of 9 documented hours. ~Resident #1 was incontinent 3 out of the 9 documented hours. Resident #1 was offered toileting a total of 8 times out of the 9 documented hours. 9/19/13 (Day 3) Data collection is incomplete and missing 9 entries in the 24-hour period. ~Resident #1 was dry 13 of the 15 documented hours. ~Resident #1 was incontinent 2 of the 15 documented hours. Resident #1 was not offered or assisted with toileting 4 of the 15 documented entries. No assessment was completed after this 3-day data collection period. Even though Resident #1 demonstrated the ability to remain continent for periods of time on all 3 days, the facility continued the check and change program and did not assist Resident #1 in restoring as much normal bladder function as possible. Assessment #3 10/21/13 (Day 1) Data collection is incomplete and missing 5 entries in the 24-hour period. ~Resident #1 was dry 12 of the 19 documented hours. ~Resident #1 was incontinent 7 of the 15 documented hours. Each entry indicated Resident #1 was offered and/or assisted to use the toilet. 10/22/13 (Day 2) Data collection is incomplete and missing 8 entries in the 24 hour period. ~Resident #1 was dry 12 of the 16 documented hours. ~Resident #1 was incontinent 4 of the 16 documented hours. Each entry indicated Resident #1 was offered and/or assisted to use the toilet. 10/23/13 (Day 3) Data collection is incomplete and missing 9 entries in the 24 hour period. ~Resident #1 was dry 12 of the 15 documented hours. ~Resident #1 was incontinent 3 of the 15 documented hours. Each entry indicated Resident #1 was offered and/or assisted to use the toilet. The incontinent assessment, dated 10/25/13, was completed despite incomplete data. The Summary of Findings in its entirety was, "Long term incontinence." Even though Resident #1 demonstrated the ability to remain continent for periods of time on all 3 days, the facility continued the check and change program and did not assist Resident #1 in restoring as much normal bladder function as possible. Assessment #4 12/12/13 (Day 1) Data collection is incomplete and missing 1 entry in the 24-hour period. ~Resident #1 was dry 16 of the 23 documented hours. ~Resident #1 was incontinent 7 of the 23 documented hours. Each entry indicated Resident #1 was offered assistance to use the toilet 16 times out of the 23 documented hours. 12/13/13 (Day 2) Data collection is incomplete and missing 4 entries in the 24-hour period. ~Resident #1 was dry 11 of the 20 documented hours. ~Resident #1 was incontinent 9 of the 20 documented hours. 8 of the 20 documented entries indicated Resident #1 was not offered or assisted with toileting. 12/14/13 (Day 3) Data collection is incomplete and missing 13 entries in the 24-hour period. ~Resident #1 was dry 5 of the 9 documented hours. ~Resident #1 was incontinent 4 of the 9 documented hours. Each entry indicated Resident #1 was offered assistance to use the toilet 7 times out of the 9 documented hours. The Summary of Findings on 12/26/13 states, "Total incontinence...Sx (symptoms) of functional incontinence, Sx of total incontinence, Sx of stress incontinence, Other: continue current care plan." Even though Resident #1 demonstrated the ability to remain continent for periods of time on all 3 days, the facility continued the check and change program and did not assist Resident #1 in restoring as much normal bladder function as possible. Example #5: Resident #9 was admitted to the facility in 2008. Resident #9's [DIAGNOSES REDACTED]. Review of the 3 most current MDS assessments dated 5/8/13 (quarterly), 8/3/13 (annual), and 11/1/13 (quarterly) all indicate Resident #9 requires extensive assistance of 2 for toilet use, does not have a current toileting program, has no history of a toileting program, and is always incontinent of bladder. Resident #9's care plan includes the following approaches: ~8/18/12, check and change every two hours with repositioning during night shift; ~8/18/12, bedpan PM/AM shifts at least every 4 hours and with cares. Review of Resident #9's bladder records reveal the following: Assessment #1 7/31/13 (Day 1) - No data collected for 8 of the 24 hours. ~Resident #9 was dry 11 of the 16 documented hours. (Resident #9 was dry between 10:00 p.m. and 3:00 a.m. and not toileted). ~Resident #9 was incontinent 5 of the 16 documented hours. According to the entries, Resident #9 was not assisted to use the toilet during this time period. 8/1/13 (Day 2) - No data collected 14 (8:00 a.m. through 9:00 p.m.) of the 24 hours. ~Resident #9 was dry 6 of the 10 documented hours. ~Resident #9 was incontinent 4 of the 10 documented hours. According to the entries, Resident #9 refused toileting with all interactions. 8/2/13 (Day 3) - No data collected 11 of the 24 hours ~Resident #9 was dry 8 of the 13 documented hours. (Resident #9 was dry between 12:00 a.m. and 4:00 a.m.) ~Resident #9 was incontinent 5 of the 13 documented hours. According to the entries, Resident #9 was assisted with toileting 2 times, refused 4, and no information on toilet use was documented the remaining 7 times. The Summary of Findings documented on 8/7/13 states, "Continue current plan of care such as: wearing incontinent pads, check changing every two hours with repositioning during NOC (night) shift and toilet bedpan am/pm shifts at least every four hours and cares." Staff documented less than half the data required to complete a thorough assessment of Resident #9's bladder habits and to develop an individualized plan of care. There is no evidence to support that the current plan is adequate to assist Resident #9 in restoring as much normal bladder function as possible. Resident #9 demonstrated the ability to remain dry for the majority of the night, which does not warrant every 2 hour toileting. Resident #9 had more incontinence during the day, which would indicate a need for more than every 4 hour toileting. Assessment #2: 10/30/13 (Day 1) - No data collected for 4 of the 24 hours. ~Resident #9 was dry 11 of the 20 documented hours (Resident #9 was dry 6 times during the night.) ~Resident #9 was incontinent 9 of the 20 documented hours (Resident #9 was incontinent 7 times during the day and afternoon shifts.) According to the entries, Resident #9 was not assisted to use the toilet during this time period. 10/31/13 (Day 2) - No data collected 12 of the 24 hours. ~Resident #9 was dry 7 of the 12 documented hours. (Resident #9 was dry 6 times during the night.) ~Resident #9 was incontinent 5 of the 12 documented hours. According to the entries, Resident #9 was not toileted during the 12 interactions with 4 refusals. 11/1/13 (Day 3) - No data collected 12 of the 24 hours. ~Resident #9 was dry 9 of the 12 documented hours. (Resident #9 remained dry 5 times during the night.) ~Resident #9 was incontinent 3 of the 12 documented hours. According to the entries, Resident #9 was not toileted during the 12 interactions, with 5 refusals. The Summary of Findings dated 11/3/13 states, "Total incontinence...toilet every 2 hours during the night, q (every) 4 hours during the day." The data collected does not demonstrate that this toileting plan is consistent with Resident #9's bladder patterns and does not assist Resident #9 in restoring as much normal bladder function as possible. On 2/6/14 at 11:05 a.m., Surveyor # spoke with the DON (Director of Nursing) and COD-V (Corporate Operations Director) regarding the facility's Bowel and Bladder Collection Assessment policy and procedure, with a current review date of 6/12/13. Surveyor # pointed out 3.1.B which states, "Day 1-Assess wet/dry status every 1 hour. If wet, change clothing or incontinence product" and asked why the resident would not be toileted on Day 1. COD-V indicated it is "assumed" that staff offer the toilet on Day 1 of the assessment. COD-V stated staff should be offering the toilet with every check. Documentation does not indicate this is occurring.

Based on observation, interview, and record review, the facility did not provide the necessary treatment to promote the healing of pressure ulcers for 2 of 6 sampled residents reviewed for pressure ulcers. Resident #4's Stage II pressure ulcers were not treated as ordered by the resident's physician. For 6 days the area was inappropriately covered with gauze and no treatment was provided. However, nurses continued to document that the physician prescribed order was completed. Once the dressing was removed, the pressure ulcers were noted to have deteriorated. RN-K did not wash hands in between glove changes during a dressing change. This is evidenced by: Example #1: Resident #4 was admitted to the facility in January 2014 for short term rehabilitation for acute and chronic [MEDICAL CONDITION]. Resident #4 was originally admitted with a Stage II to her bottom from a fall at home. According to her plan of care when she was admitted , Resident #4 was assessed as high risk for impaired skin due to her being "thin and frail, having [MEDICAL CONDITION], and using a steroid medication." In addition, Resident #4 has poor nutrition and weakness. Review of her nursing assessments and plan of care found that during her brief time at the facility she has required hospitalization twice. Of note is that Resident #4 had refused pressure reducing mattresses and cushions in the past but did agree to a gel pad in her recliner. The plan of care posted in her room states, "Peri-wash, wipes, and Sensicare #3 to buttocks/coccyx AM (morning) & PM (evening)." The last time she returned to the facility from the hospital on [DATE] for [MEDICAL CONDITION], she was found to have 4 new open areas on her bottom. The admission assessments and documentation of these wounds were found as a "late entry" on 2/4/14 for wound measurement: Left Buttocks: Length/CM (centimeter): 0.5, Width/CM 0.5, Depth/CM 0.0. The wound margins were regular and defined, the wound bed was pink, pearly, and with no drainage. Left Sacrum: Length/CM: 1.2, Width/CM 0.8, Depth: 0.2. The wound margins were regular and defined, the wound bed was beefy red with maceration present in the skin surrounding the wound, and with no drainage. Coccyx: Length/CM 0.7, Width/CM 0.7, Depth/CM 0.02. The wound margins were regular and defined, the wound bed was beefy red and moist, and there was scant bloody drainage. Right superior (upper) buttocks: Length/CM 2.0, Width/CM 2.0, Depth, 0.02. The wound margins were regular and defined, the wound bed was beefy red and moist, with no drainage. The notation states that Resident #4's physician was updated and the treatment was to cleanse the areas and apply the Sensicare #3. Of note is that Surveyor # reviewed the corporation's wound care treatment guidelines. The guidelines state when a Stage II wound is present a [MEDICATION NAME] dressing is to be used to protect the area. It also directs staff to use a barrier cream for "skin affected by incontinence." Resident #4 is continent of her bladder and bowels. On 2/4/14 at 2:10 p.m., Surveyor # observed COTA-B (Certified Occupational Therapy Assistant) assist Resident #4 with washing up and dressing. Both the surveyor and the COTA noted that on the resident's coccyx and apex of her gluteal crease was a 4 cm by 4 cm gauze sponge taped to her skin. The dressing was dated 1/29/14, 6 days prior to the observation. Surveyor # reviewed the treatment record and found that since that day the nursing staff had documented that they had applied the Sensicare to the open areas twice a day. With a dressing in place since 1/29/14, it would not be possible for the nursing staff to have completed the treatment. On 2/5/14 at approximately 8:00 a.m., Surveyor # observed CNA-C assist Resident #4 with her clothing and personal hygiene. Both the surveyor and CNA-C observed a 4 cm by 1.5 cm foam dressing taped just below the resident's coccyx. The dressing had dried blood on it. CNA-C stated she needed to tell the nurse about this. There was no order for a foam dressing. On 2/5/14 at 9:30 a.m., Surveyor # observed RN-D (Registered Nurse) take off the foam dressing and apply the Sensicare #3 cream. RN-D stated she was not made aware of the open area or the foam dressing in the shift to shift report nor was there anything in the charting about it. RN-D called RN-A who was the WCC (Wound Care Certified) nurse at the facility and asked if she would assess the wound and was told RN-A would not be looking at the area today. RN-D stated she would apply the cream as it was ordered on the treatment sheet. On 2/6/14 at approximately 11:15 a.m., Surveyor # interviewed RN-A. RN-A expressed frustration over the fact that a non-ordered dressing was on for 6 days and floor staff were not applying the cream as ordered. RN-A stated she did assess the wound and showed the surveyor a hand written note of her measurements of the wound. RN-A stated the wounds were not better from the week before and in fact some had worsened. There are discrepancies as to the locations of the 4 wounds from the previous week. RN-A stated the wounds certainly would not get better if the nursing staff were not following her recommendations and doctor's orders. The most recent measurements were: Sacrum: Length 0.8 Width 0.8, Depth 0.0. (Deteriorated) Left Upper Buttocks: Length 1.2, Width 5.6, Depth 0.01. (Deteriorated) Right Upper Buttocks: 0.7, 0.5, 0.0. (Deteriorated) Right Lower Buttocks: Length 2.2, Width 1.0, Depth 0.0. There was no description of the wound characteristics in RN-A's notes and the areas in RN-A's note do not match those in the 2/4/14 wound documentation. There was no documentation of the coccyx in the 2/6/14 note and the right lower buttocks was not previously documented. Example #2 On 2/5/14 at 1:22 p.m., Surveyor # observed RN-K completing Resident #5's dressing change. RN-K removed Resident #5's soiled dressing from the Stage III pressure ulcer on the right ankle, removed her gloves and donned another pair of gloves without sanitizing/washing hands inbetween the glove changes. RN-K proceeded to cleanse the wound, removed her gloves and donned another pair of gloves without sanitizing/washing of hands inbetween glove changes. With the same soiled hands that she removed the soiled dressing, RN-K cut a piece of [MEDICATION NAME] nonadhesive dressing to fit the size of the wound, opened the cap of Prontosan Gel and applied the gel directly onto the fitted dressing, then applied to the wound. RN-K then covered the area with a secondary dressing. RN-K then put the Prontosan Gel cap back on. Removed her gloves and washed hands. RN-K removed foam from Resident #5's left great toe, removed gloves and cut a piece of foam dressing to size (thus contaminating the dressing). RN-K donned gloves without washing/sanitizing hands, and applied the dressing to the toe. RN-K removed her gloves, and without washing hands, put the scissors in her uniform pocket, placed unused supplies in the bucket and left the room.

Based on observations, interviews, and record reviews, the facility did not provide necessary care and services to ensure 1 of 10 sampled residents reached their highest practicable level of well-being. Resident #1 has a [DIAGNOSES REDACTED]. These almost daily behaviors have been since approximately May 2013. Despite the extent and duration of the behaviors, the facility did not complete a comprehensive assessment of Resident #1's behaviors in order to identify an underlying cause of the behaviors so that a care plan could be developed with individualized approaches to prevent the behaviors from occurring or to effectively respond to Resident #1's display of distress. This is evidenced by: Resident #1 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 1/16/14, a [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessments, dated 6/23/13 and 9/21/13, indicate Resident #1 displayed physical, verbal, and other behaviors, as well as refused cares 4 to 6 times a week, but less than daily. The 12/17/13 MDS indicated Resident #1 had no behaviors, which according to nurse's notes is inaccurate. (Refer to F278.) Resident #1's care plan included a problem of "Thought Process," dated 10/20/11, related to her [DIAGNOSES REDACTED]. Approaches dated 4/4/13 state the following: "Targeted behavior: excitable, repeating self, calling out, name calling, swears...hits pinches, slaps, grabs...uncooperative, refusing meds/cares...explain procedures, 1:1...provide calm/quiet environment, Reapproach within 15 minutes, Change position, Offer food, Offer fluid. Anticipate needs. 1:1/enc. (encourage) conversation/support..." Although the care plan describes Resident #1's BPSDs, there are no approaches developed for staff to use in order to prevent Resident #1 from having distressing behaviors. The facility documents behaviors displayed each shift. There is no quantifiable data to show how often the behavior occurred, onset, duration, and intensity, precipitating factors, and/or environmental factors. Surveyor # reviewed Resident #1's IDT (Interdisciplinary Team) notes and noted the following entries for "Shift Behavior Documentation:" May 2013: ~15 instances of "Calling out." ~3 instances of refusing medications. ~10 instances of Resident #1 "Constantly repeating self." ~25 instances of physical aggression (combinations of pinches, slaps, hits, kicks, grabs, and/or spits). ~9 instances of Resident #1 talking to self/talking to someone not there. ~2 instances of being "uncooperative with routine." Descriptions include, "Behavior subsided without physical contact," "Hits during...physical contact," and "Resolved when ADLs (activities of daily living) completed." June 2013: ~10 instances of calling out/swearing. ~4 instances of refusing meds/vitals. ~13 instances of repeating self. ~32 instances of physical aggression. ~15 instances of resident talking to self/someone not there. A Behavior Committee note, dated 6/11/13 states, "...Resident #1 does display behaviors of hitting, kicking, pinching, and grabbing. She does call out and swears. Resident #1 also repeats herself and may refuse meds/cares at times. At times she does talk to someone not present and talks in the third person. Resident #1 is taking [MEDICATION NAME] Sprinkles for behavioral agitation. Behavior Committee will continue to assist and assess when able." July 2013: ~10 instances of calling out. ~2 instances of refusing medications. ~12 instances of repeating self. ~33 instances of physical aggression. ~13 instances of talking to self/someone not there. ~2 instances of being uncooperative with routine. Descriptions include, "Resolved upon completion of cares," and "slaps, swears during cares/physical intervention." August 2013: ~10 instances of calling out. ~3 instances of refusing medications. ~13 instances of repeating self. ~25 instances of physical aggression. ~9 instances of talking to self/someone not there. Descriptions include, "Resolved upon completion of cares," and "slaps, swears during cares/physical intervention." On 8/22/13, Resident #1's physician discontinued [MEDICATION NAME] Sprinkles 125 milligrams at HS (hour of sleep). September 2013: ~5 instances of calling out. ~1 instances of refusing medications. ~8 instances of repeating self. ~25 instances of physical aggression. ~11 instances of talking to self/someone not there. ~2 instances of being "Excitable." ~5 instances of being uncooperative with routine. ~5 instances of swearing. In approximately 72% of the instances, Resident #1 did not respond to care planned interventions. The other 28% indicate Resident #1 did respond and behaviors ceased when staff reapproached at a later time, or when cares were completed. On 9/11/13, a behavior assessment was completed. The assessment indicated Resident #1 did not exhibit verbally or physically abusive behaviors in the last week, and did not refuse medications in the last week. On 9/15/13, a second behavior assessment was completed. Again, the assessment indicated Resident #1 had no physical, verbal, or socially inappropriate behaviors even though physical aggression, swearing, and calling out, were documented in the week prior to this assessment. From 9/1/13 through 9/14/13, Resident #1 had daily episodes of calling out, hitting, kicking, spitting, and/or swearing. The 9/11/13 and 9/15/13 assessments are inaccurate. On 9/17/13, 9/19/13, 9/21/13, 9/22/13, and 9/26/13 behavior assessments were completed. These assessments identified that Resident #1 had verbal and physical aggression, hallucinations, socially inappropriate behaviors, agitation/anxiety, and refusing medications. The Summary of Findings states, "Targeted behaviors, list: Hitting, Spitting, Grabbing, Pinching, Name Calling, Slapping, Speaking to someone who is not there, Seeing someone that is not there, Refusing medications and cares...Not easily altered...Plan: Intervene per care plan..." Although the care planned interventions were not effective 72% of the time, there were no changes made to Resident #1's approaches to individualize her care and reduce BPSDs. October 2013: ~9 instances of calling out. ~2 instances of refusing medications. ~14 instances of repeating self. ~43 instances of physical aggression. ~21 instances of talking to self/someone not there. ~2 instances of being "Excitable." ~3 instances of being uncooperative with routine. ~12 instances of swearing. On 10/28/13 and 10/30/13, staff documented no behaviors for Resident #1. In approximately 78% of the instances, Resident #1 did not respond to care planned interventions. The other 22% indicate Resident #1 did respond and behaviors ceased when staff reapproached at a later time, or when cares were completed. Behavior assessments on 10/1/13, 10/3/13, 10/9/13, 10/15/13, 10/22/13 indicated Resident #1 displays verbal and physical aggression 1 to 3 times per week (documentation shows daily), no socially inappropriate behaviors, and refuses medications/cares 1 to 3 times per week. Plan is, "Intervene per care plan..." Although the care planned interventions were not effective 78% of the time, there were no changes made to Resident #1's approaches to individualize her care and reduce BPSDs. A Behavior Committee Note, dated 10/12/13 states, "...She is not on [MEDICAL CONDITION] medications. Resident #1 does display behaviors of hitting, pinching, slapping, and grabbing. She can become excitable, repeat herself and does call out, swears, and name calls. Resident #1 also can become agitated, uncooperative, and refuses meds/cares at times. Also at times she does talk to someone not present and talks in the third person. Interventions are in place. Behavior Committee will continue to assist and assess when able." Although the Behavior Committee reviewed the types of behaviors Resident #1 was experiencing, there was no review of the effectiveness of current interventions. There were no changes to the data collection process in order to identify trends/root causes of behaviors so that individualized approaches could be developed to prevent the behaviors or to effectively manage behaviors. November 2013: ~4 instances of calling out. ~1 instance of refusing medications. ~11 instances of repeating self. ~23 instances of physical aggression. ~6 instances of talking to self/someone not there. ~1 instance of being "Excitable." ~2 instances of being uncooperative with routine. ~2 instances of swearing. Behavior documentation indicated Resident #1 displayed no behaviors on 10 days. Interventions were effective 52% of the time for the month of November. Most common effective interventions were reapproach later, completion of cares/intervention. These interventions were completed on their own or in concert with other interventions. There were no behavior assessments completed during this month. December 2013: ~1 instance of calling out. ~1 instance of refusing medications. ~11 instances of repeating self. ~17 instances of physical aggression. ~6 instances of talking to self/someone not there. ~1 instance of being uncooperative with routine. ~3 instances of swearing. Behavior documentation indicated Resident #1 displayed no behaviors on 11 days. On 12/31/13, a behavior assessment was completed which indicated Resident #1 had no verbally or physically abusive behaviors, no socially inappropriate behaviors, and there was no change in Resident #1's behaviors. Plan was to "provide meds as ordered, labs as ordered, update physician as needed." Surveyor # 's review of the documentation shows that Resident #1 had several instances of repeating self, talking to someone not there, hitting, kicking, pinching, spitting and/or swearing in the week prior to the assessment. Based on the documentation for the last 2 months, there appears to be a decrease in the shifts where behaviors were documented which may be indicative of a change in Resident #1 and her behaviors. Interventions combined with reapproach later, or completion of care/intervention were effective approximately 46% of the time. January 2014: ~3 instances of calling out. ~2 instances of refusing medications. ~4 instances of repeating self. ~23 instances of physical aggression. ~17 instances of talking to self/someone not there. ~1 instance of being uncooperative with routine. ~6 instances of swearing. Behavior documentation indicates Resident #1 displayed no behaviors on 11 days. However, the number of shifts where behaviors had occurred increased over those documented in December 2013. Interventions were effective 27% of the time, while 73% of the interventions were not effective. Lack of effectiveness increased in January 2014 over those documented in December 2013. A Behavior Committee note on 1/20/14 states, "...resident does display behaviors. Last month she had about 75 documented behaviors. Recommendation: Continue to follow care plans and MD orders." The documentation of Resident #1's behaviors is done 1 time per shift. The actual number, duration, and intensity of the behaviors is unknown. The Behavior Committee did not explore reasons why/how Resident #1 had 32 behavior-free days in the last 3 months as a means of identifying effective interventions to prevent/manage behaviors. The committee also did not assess the decline in intervention effectiveness or presumed increase in behaviors. On 2/5/14 beginning at 4:45 a.m., Surveyor # made several observations of Resident #1 in bed sleeping On 2/5/14 at 6:40 a.m., Surveyor # spoke with CNA-E (Certified Nursing Assistant) and asked what sort of behaviors Resident #1 displays. CNA-E stated Resident #1 would kick, hit, slap, yell, swear during any cares. CNA-E stated it was her opinion that Resident #1's behaviors had been getting worse. On 2/5/14 at 7:15 a.m., Surveyor # observed CNA-S assist Resident #1 with morning cares. The over-the-bed light was on upon entry. CNA-S stated Resident #1 was sleeping soundly. CNA-S made several attempts to wake Resident #1 by calling her name, rubbing her arm and shoulder. CNA-S stated, "I guess she doesn't want to wake up." CNA-S then went to the bathroom and wet a washcloth. CNA-S then proceeded to wipe matter from Resident #1's eyes. Resident #1 stirred and swatted at CNA-S. CNA-S stated, "I know your eyes are sore" and continued to wipe Resident #1's eyes. CNA-S stated she had been told it is easier to provide cares to Resident #1 "from the bottom up." CNA-S then uncovered Resident #1's feet and removed the heel lift boots. She changed Resident #1's socks and put slippers on her feet. Throughout the process, Resident #1 held onto the blanket with her eyes closed. CNA-S stated Resident #1 will sometimes sleep very soundly and today is one of those days. CNA-S went again into the bathroom and wet washcloths. CNA-S returned to Resident #1, who was still lying with eyes closed, clutching the blanket, and breathing deeply. CNA-S stated, "She is really sleeping." CNA-S then told Resident #1 that she was going to wash Resident #1 up. CNA-S completed perineal cleansing at 7:32 a.m. CNA-S stated she was going to get help and give Resident #1 time to wake up. At 7:45 a.m., CNA-S returned with CNA-E. CNA-E and CNA-S were talking as they prepared to complete Resident #1's cares. Resident #1 was still lying in bed with her eyes closed and breathing deeply as one does when sleeping soundly. Despite the appearance that Resident #1 was sleeping soundly, staff did not allow Resident #1 to sleep and wake on her own. CNA-E began to wake Resident #1 by calling her name, saying good morning, and telling Resident #1 what they were going to do. CNA-S pulled the blankets off of Resident #1. Resident #1 immediately crossed her arms over her chest and clutched the gown she was wearing. CNA-E told Resident #1 that CNA-E was going to take Resident #1's gown off. Resident #1 continued to hold the gown against her chest as CNA-E pulled the gown off of Resident #1. Resident #1 fully woke at this point and began to yell, strike out, and kick at CNA-E. CNA-E was hit in the mouth during the incident. CNA-E did not step away from Resident #1 to allow her time to calm. CNA-E continued to talk to Resident #1 while attempting to keep Resident #1 from striking out. Resident #1 then spit at CNA-E. During this time, CNA-S was in the bathroom filling the wash basin with warm water and shower gel/body wash and wash cloths. The body wash was observed to be the kind that can be bought in a store and was not a "no rinse" formula. Upon her return to the bed side, CNA-S began washing Resident #1's chest, arms, and underarms with the soapy washcloths. Resident #1 continued to strike out, kick, yell, and swear at the staff. Staff did not rinse the soap residue off of Resident #1's skin before drying with a towel. At this time, CNA-S commented that Resident #1 had a lot of scratches on her arms and legs. As the cares continued, Resident #1's yelling became louder, she swore more often, and tried to strike out/kick the staff. CNA-E and CNA-S did not stop cares, instead they tried to hold Resident #1's hands to prevent her from striking out. Neither staff suggested allowing Resident #1 time to calm before continuing with cares. CNA-E held Resident #1's arms up so CNA-S could apply deodorant. CNA-E then rolled Resident #1 onto her side to allow CNA-E to wash her back. CNA-E again washed her back with the soapy water in the basin and did not rinse the soap residue off before drying with a towel. CNA-S then lotioned Resident #1's back. CNA-S and CNA-E dressed Resident #1 as she struck out, kicked, yelled, swore, and spit at the staff. At no time did either staff suggest to leave and reapproach Resident #1 later to complete cares. CNA-S and CNA-E then retrieved the mechanical lift to transfer Resident #1. Again, Resident #1 continued to strike out, kick, yell, swear, and grab at staff. This continued until Resident #1 was seated in her wheelchair. Once seated in her wheelchair, Resident #1 began to quiet, and did not strike out at staff. CNA-S brushed Resident #1's hair while Resident #1 held her hand and said, "I love you." Resident #1 continued to talk to herself and did pat/slap CNA-S during this interaction. CNA-E brought Resident #1 her teeth, which she refused to have put in. Surveyor # asked CNA-E if what was observed was common for Resident #1. CNA-E indicated it was. When asked what kind of interventions have been tried to prevent/manage the behaviors, CNA-E stated, "We've tried everything and nothing seems to work." Surveyor # asked CNA-E why, if Resident #1 was sleeping so soundly when staff come in, do they wake her up and get her out of bed. CNA-E stated, "She (Resident #1) is a feeder. They want the feeders out in the dining room so they can be fed and supervised." On 2/5/14 at 9:40 a.m., CNA-E approached Surveyor # and stated, "Resident #1 refused breakfast, but I got her teeth in." On 2/5/14, Surveyor # spoke with RN-A (Registered Nurse). RN-A stated when Resident #1 is in "sleep mode" she can sleep very soundly. Surveyor # asked RN-A about Resident #1's behaviors. RN-A stated Resident #1 is loud and swears during cares. Surveyor # asked what approaches staff should use when the behaviors occur. RN-A stated staff should clearly explain what they are doing, have another staff person assist, and reapproach later. On 2/6/14 at 7:10 a.m., Surveyor # went to Resident #1's room. Resident #1 was already dressed and up in her wheelchair. Surveyor # could hear Resident #1 talking to herself. On 2/6/14 at 10:15 a.m., Surveyor # spoke with SW-Q and SW-T. Both indicated they were part of the Behavior Committee. Surveyor # asked about Resident #1. SW-Q indicated the Behavior Committee had just met that morning to discuss Resident #1. SW-Q stated Resident #1's behaviors are "sporadic" with no routine. SW-Q stated staff should follow approaches of talking through cares, 1:1, toileting, foods, fluids, and reapproaching within 15 minutes. Surveyor # asked SW-Q and SW-T if there had been an assessment to determine the root cause of Resident #1's behaviors. SW-T responded that staff are now going to try music and discuss hospice with Family-U, Resident #1's spouse. Surveyor # asked SW-Q and SW-T what their expectation was when a resident is sleeping soundly and does not appear to want to get up. SW-Q stated she would expect staff to attempt to wake the resident, but if they did not want to get up, staff should leave them sleep. Surveyor # reviewed Resident #1's care plan, updated on 2/6/14. Approaches dated 2/6/14 include: "...talking through cares, provide calm/quiet environment, reapproach within 15 minutes...anticipate needs as needed...1:1/enc. (encourage) conversation/support." The facility added 1 new intervention of "talking through cares." There is no evidence of an assessment being completed to determine if this is a reasonable approach to prevent the BPSDs. All other approaches remain from 4/4/13. On 2/6/14, Surveyor # spoke with COD-V (Corporate Operations Director). COD-V stated she had reviewed Resident #1's behavior documentation and can find no patterns. "Behaviors don't coincide with cares or meals." Since behavior documentation is only completed 1 time per shift, it would be nearly impossible to define a pattern of Resident #1's behaviors. On 2/6/14 at 2:40 p.m., Surveyor # spoke with Family-U about Resident #1's care at the facility. Family-U stated he visits daily and knows Resident #1 can be difficult, "but she can't help that." Surveyor # asked Family-U what works best for Resident #1 when she is having a difficult time. Family-U stated if they leave her alone for awhile, she will calm down.

Based on observation, interview, and record review, the facility did not ensure that 1 of 4 sampled residents reviewed for pressure ulcers received the necessary care and treatment to promote healing and prevent new pressure sores from developing. Resident #6 had a history of [REDACTED]. According to the facility's documentation dated 4/29/13, Resident #6 had a stage I pressure ulcers on both the coccyx and right buttock. Observations on 5/6/13 revealed that Resident #6 had a stage III pressure ulcer to the left sacrum after no repositioning for 5 hours and 30 minutes. The pressure ulcer, when noted on 5/7/13, had progressed to an unstagable pressure ulcer. The facility did not identify the pressure ulcer, implement approaches to treat the pressure ulcer based on current standards of practice, nor document the pressure ulcer according to current standards of practice. Additionally, there were no changes made to Resident #6's care plan to prevent the reoccurrence of pressure ulcers. This is evidenced by: The Clinical Practice Guideline "Pressure Ulcer in Adults: Prediction and Prevention" indicates, ~ "...Individuals in bed assessed to be a risk for developing pressure ulcers should be repositioned at least every 2 hours...A written schedule for systematically turning and repositioning the individual should be used..." ~ "...Uninterrupted sitting by at-risk individuals in chairs or wheelchairs should be avoided...the individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed..." According to the National Pressure Ulcer Advisory Panel (NPUAP) skin care and treatment of [REDACTED]. ~ Development and implementation of individualized programs of skin care; ~ Built-in mechanisms to evaluate programs to ensure they are effective; ~ Proper positioning, transfer, and turning techniques to minimize skin injury due to friction and sheer; ~ Reposition chair bound residents every hour utilizing a written repositioning schedule; and ~ Accurately document skin risk assessment, prevention strategies as well as resident response. In the EPUAP and NPUAP Clinical Practice Guidelines for Prevention and treatment of [REDACTED]. Continue to turn and reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual's response. According to RESNA (Rehabilitation Engineering & Assistive Technology Society of North America) Position on the Application of Tilt, Recline, and Elevating Leg Rests for Wheel chairs, a lift from a seated position requires at least 2 minutes in order for tissue to return to off-loading levels. Resident #6 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 4/9/13. It indicated Resident #6: ~Had both long and short-term memory problems; ~Required total assistance of 1 to 2 staff persons for bed mobility, surface to surface transfers, bathing, dressing, grooming, using the toilet, and eating; ~Did not walk; ~Was always incontinent of both bowel and bladder; ~Had range of motion limitations to both arm and both legs; ~Was at risk for the development of pressure ulcers; and ~Had 1 stage II pressure ulcer. Resident #6's most current skin CAA (Care Area Assessment) summary was dated 1/9/13. It indicated Resident #6 had no current pressure ulcers but a history of pressure ulcers. The CAA indicated Resident #6 was at high risk for the development of pressure ulcers due to her co-morbidities. The CAA indicated staff were to continue to monitor for the development of pressure ulcers and develop and/or revise Resident #6's care plan as needed. Resident #6's skin care plan, dated 5/20/12, had the following approaches: ~ 7/11/12, a low loss air mattress; ~ 7/19/12, to float heels; ~ 4/3/13, to turn and reposition every 2 hours, a dietary supplement; and, ~ 4/14/13, a pressure reduction cushion in the chair. Resident #6's most current skin risk assessment was dated 3/28/13. It indicated Resident #6 was at high risk for the development of a pressure ulcer. Surveyor # completed a review of Resident #6's nursing notes from 11/16/12 to 3/4/13. Surveyor # noted multiple nursing notes indicating Resident #6 had reddened skin to both the right and left buttock as well as the coccyx. The nursing notes indicated the facility was going to continue the same plan of care. A nursing note dated 3/4/13, indicated Resident #6 had a stage II pressure ulcer on the right buttocks which measured 6.6 cm (centimeters) by 6.0 cm. On 3/20/13, the pressure ulcer was noted as healed. There were no interventions added to the care plan to prevent redevelopment of a pressure ulcer. A nursing note dated 4/3/13, indicated Resident #6 had a new stage II pressure ulcer on the right buttock which measured 0.3 cm by 0.2 cm with a depth of 0.1 cm. The nursing note indicated Resident #6 should be turned every 2 hours and laid down after meals. The nursing note also indicated a specialty mattress was obtained. There was no indication the mattress approach differed from that of 7/11/12. The intervention to lie down after meals was not added to Resident #6's plan of care. On 4/15/13, the pressure ulcer was noted as healed. There were no new interventions added to the care plan to prevent the redevelopment of a pressure ulcer. A nursing note dated 4/23/13, indicated Resident #6 had a stage I pressure ulcer on the right buttock measuring 0.1 cm by 0.1 cm and a stage II pressure ulcer on the coccyx measuring 1.5 cm by 0.4 cm with a depth of 0.2 cm. The pressure ulcer on the coccyx was noted as a new pressure ulcer as well as a historical pressure ulcer. The interventions were again to turn every 2 hours and lie down after meals. The intervention to lie down after meals was again not added to Resident #6's plan of care. On 4/29/13, the stage I pressure ulcer on the right buttock was noted as healed. On 5/1/13, a nursing note indicated both the right buttock and coccyx ulcers were a stage I pressure ulcer. From 5/1/13 to 5/6/13, there were no nursing notes identifying that Resident #6 had a pressure ulcer. On 5/6/13 beginning at 7:35 a.m., Surveyor # , with the assistance of Surveyors # , and # completed a continuous observation of Resident #6. The following was noted: ~ At 7:35 a.m., Resident #6 was observed seated in the day room by the nursing station in a specialty wheelchair. ~ At 8:50 a.m., Resident #6 was escorted by CNA-I (Certified Nursing Assistant) to the main dining room on the first floor. ~ At 9:35 a.m., Resident #6 was escorted back to her room by the Activity Director. ~ At 9:41 a.m., Resident #6 was escorted to the Podiatrist by Podiatry Staff-J and Podiatry Staff-K. Resident #6 remained seated in her wheelchair and was not repositioned. ~ At 9:52 a.m., Podiatry Staff-K escorted Resident #6 back to her room. ~ At 10:10 a.m., the Activity Director escorted Resident #6 to an activity in the main dining room. ~ At 11:15 a.m., Activity Aid-P escorted Resident #6 to the 3rd floor hallway. ~ At 11:20 a.m., the Housekeeping and Laundry Director escorted Resident #6 from the 3rd floor to the second floor day room. ~ At 11:25 a.m., CNA-L escorted Resident #6 to her room at the direction of LPN-N (Licensed Practical Nurse). LPN-N entered Resident #6's room and applied an antibiotic ointment to the back of Resident #6's neck. LPN-N then exited Resident #6's room. ~ At 11:38 a.m., CNA-I entered Resident #6's room, combed her hair and then escorted Resident #6 to the dining room on the second floor. ~ At 12:32 p.m., CNA-I escorted Resident #6 to her room. ~ At 1:00 p.m., CNA-L and CNA-M entered Resident #6's room and indicated they were going to lay her down. ~ At 1:05 p.m., Resident #6 was laid down in her bed by CNA-L and CNA-M. Resident #6 was observed to sit in her wheelchair for a period of 5 hours and 30 minutes. During this time, no staff approached Resident #6 to offer or attempt repositioning. On 5/6/13 at 1:05 p.m., Surveyor # observed CNA-L and CNA-M assist Resident #6 with incontinence care. Both CNAs assisted Resident #6 to turn onto her side. Surveyor # noted stool on the Hoyer sling as well as on the back of Resident #6's tee-shirt and shirt. CNA-L and CNA-M then removed Resident #6's pants and brief. The brief was noted to be soiled with a large amount of stool. Surveyor # observed Resident #6's complete buttock area to be excoriated in a butterfly shape. The left ischium was purple red. Surveyor # also noted a [MEDICATION NAME] dressing on Resident #6's left sacrum. CNA-M summoned the nurse and indicated the dressing was loose and needed to be replaced. Surveyor # asked CNA-M about Resident #6's repositioning schedule. CNA-M indicated Resident #6 should be repositioned every 2 hours. On 5/6/13 at 1:14 p.m., LPN-N entered Resident #6's room. LPN-N removed the dressing on Resident #6's left sacrum, and cleansed the area. LPN-N indicated the area measured approximately 1-1/2 inch by 1-1/2 inch. Surveyor # observed the wound base was covered with approximately 75% yellow slough. The wound base beyond the margins of the slough were beefy red. The center of the slough contained 3 pea-sized areas of dark reddish-brown discoloration. This indicated Resident #6 had a stage III pressure ulcer with 3 small areas of questionable viable skin. According to the last entry related to the wound, the area was a stage I. LPN-N obtained and applied a 6 inch by 6 inch [MEDICATION NAME] dressing. On 5/6/13 at 1:30 p.m., Surveyor # spoke with LPN-N about Resident #6's pressure ulcer. LPN-N indicated the pressure ulcer was a stage II pressure ulcer. LPN-N indicated the excoriation to both the right and left buttock were new and questioned the cause. LPN-N also indicated the pressure ulcer on the left sacrum looked better. Surveyor # asked LPN-N about the facility's Wound Management Program. LPN-N indicated the floor nurses and/or the DON (Director of Nursing) were completing weekly wound rounds since their wound nurse resigned approximately 2 weeks ago. LPN-N indicated all wound documentation should be done weekly and charted into their computerized charting system. Surveyor # asked LPN-N about Resident #6's repositioning schedule and toileting schedule. LPN-N indicated Resident #6 should be repositioned and checked for incontinence every 2 hours. On 5/6/13 at 5:35 p.m., Surveyor # spoke with the DON about the facility's Wound Management Program. The DON indicated she was completing weekly wound rounds since their certified wound nurse resigned. The DON indicated she was not well versed in wound management, and the facility's practices in wound management were old. The DON indicated the facility was in the process of filling the position of a certified wound nurse. Surveyor # spoke with the DON regarding the continuous observation as noted on 5/6/13 as well as the noted pressure ulcer. The DON stated the last she knew, Resident #6's skin was healed. The DON also indicated Resident #6 should be turned and/or repositioned every 2 hours. Surveyor # completed a review of nursing notes received on 5/7/13, "5/6/13, 19:02 (7:02 p.m.)...Stage 2...Left buttocks...Length/CM: 1 (Length per centimeter 1.0) Width/CM: 0.6...sprfcl (superficial)..." This was the first time the pressure ulcer on Resident #6's left sacrum had been charted. On 5/7/13 at 8:10 a.m., Surveyor # spoke with the DON. The DON indicated she had observed Resident #6's pressure ulcer and she felt it wasn't very large. The DON also indicated she changed Resident #6's care plan to include every 1 hour side-to-side positioning and up for meals only. The DON indicated the physician was also notified. Surveyor # requested that both Surveyor # and the DON observe Resident #6's pressure ulcer. On 5/7/13 at 10:35 a.m., Surveyor # and the DON, with the assistance of CNA-L, observed Resident #6's pressure ulcer. The DON measured the pressure ulcer at 3.0 cm by 2.0 cm. Surveyor # noted the wound bed was almost completely covered with yellow slough. Within the yellow slough at the 11:00 o'clock position was a 0.5 cm area of brownish-red discoloration. This was indicative of an unstagable pressure ulcer, with a 0.5 cm area of questionable viable skin. On 5/9/13, Surveyor # received additional information from the facility. The information indicated Resident #6's pressure ulcer had been identified by staff on 5/4/13. However, there was no documentation provided which included a thorough assessment including size, stage and characteristics of the pressure ulcer.

Based on observations, interviews, and record reviews, the facility did not provide and obtain pain medications in a timely manner to meet the needs for 1 of 4 sampled residents reviewed for pain control. Multiple observations and interviews were conducted with Resident #4. Resident #4 was noted to be agitated and restless in her chair. Resident #4 reported that she had not received her [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication also used to treat neuropathic pain) because there was none in the facility. Licensed nursing staff was aware [MEDICATION NAME] was not available and did not take any steps in obtaining the medication for Resident #4. Resident #4 reported being in extreme pain and rated the pain a "10+" where 10 is the most excruciating pain the person can imagine. In addition, pain assessments were not comprehensive and did not contain all pertinent information. This is evidenced by: The facility policy and procedure for Pain Assessments stated the criteria for initiating a pain assessment are under the following circumstances: ~ Upon admission, re-admission, quarterly and significant changes in condition; ~ Resident is receiving scheduled pain medications; ~ Resident complains of pain or complains of pain daily not relieved by as needed medications; ~ Resident receives more than one dose of an as needed medication daily greater than 15 days in a month; and ~ Pain is not relieved by non-medication interventions. Resident #4 was admitted to the facility on [DATE] for Venous Stasis Ulcer Stabilization. Resident #4's medical [DIAGNOSES REDACTED]. Resident #4 is alert and oriented. On the Admission Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 15/15 for the Brief Interview of Mental Status (BIMS), which indicates the resident is cognitively intact. On this MDS, Resident #4 was scored as having occasional pain rated 6/10 on a scale of 0-10, with 0 being no pain and 10 being the most severe. Pain control medications ordered on admission included: ~ [MEDICATION NAME] Patch, 25 micrograms/hour, change every three days; ~ [MEDICATION NAME] 800 milligrams for Peripheral [MEDICAL CONDITION]; ~ [MEDICATION NAME] 50 milligrams every six hours as needed for pain; and ~ [MEDICATION NAME] 650 milligrams three times daily. The facility completed a pain assessment dated [DATE]. According to this assessment, Resident #4's pain is mild and on a daily basis to the right shoulder, left leg, and right leg. The pain at its best was rated as 2/10 and at its worst was rated 9/10. The pain assessment states the type of pain is a dull ache related to [MEDICAL CONDITION] Joint Disease. The assessment states the pain is controlled with the current medications. Note: Nurses document that pain was evaluated during medication passes on the Medication Administration Records, however, this is not considered a comprehensive pain assessment, as it only evaluates whether an individual has pain at the time the nurse is administering medications. According a pain assessment completed on 4/7/13, Resident #4 stated she began having pain on 4/5/13 to the right side of her face, eyebrow, cheek, and side of the throat. The resident indicated the pain is constant and worsens with movement. The nurse's notes indicated that on 4/9/13, Resident #4 developed rashy areas to her right forehead and eyelids, which spread to the back of her head at the hairline. This rash also appeared on her right earlobe and down the lateral side of her neck. The resident verbalized pain. An ophthalmologist consult was ordered for 4/10/13 and the resident was diagnosed with [REDACTED]. (Shingles are an acute eruption of vesicles and inflammation that tend to appear along a peripheral nerve pathway, and can cause excruciating pain long after the rash has healed.) [MEDICATION NAME] ointment to the eye was ordered, as well as Valtrax as the [MEDICAL CONDITION] treatment and to continue the [MEDICATION NAME] for pain control. From 4/9/13 through 4/13/13, the resident continued to have pain, and on 4/13 rated the pain as an 8/10. The rash appeared on the resident's scalp. On 4/16/13, there was an entry in the Interdisciplinary Notes (IDT) that an order was received from Resident #4's physician to hold the [MEDICATION NAME] until it arrives from the Pharmacy. On 4/16/13 [MEDICATION NAME] was initiated. From 4/13/13 to 4/23/13, there was no assessment noted in the IDT notes regarding the Shingles. The majority of the documentation for pain indicated Resident #4 had pain less than daily, but no comprehensive assessment of the pain level was noted. There was also no comprehensive assessment regarding the Shingles rash. On 4/18/13, the physician ordered Beady 25 milligrams every 8 hours for the itching relating to the resolution of the Shingles. On 4/23/13, a pain assessment was completed, however it was not comprehensive. The assessment was documented as Resident #4 having mild pain daily to the face and scalp. There was no description of the pain or intensity, no factors that increase or relieve the pain. There were also no non-pharmacological interventions noted that were effective for pain relief. Also on 4/23/13, Nortiptyline was ordered at 10 milligrams every bedtime for pain associated with Shingles. The [MEDICATION NAME] was discontinued. On 4/25/13, the nurse practitioner ordered [MEDICATION NAME] 5% patch to Resident #4's forehead and lower jaw for pain related to Shingles. [MEDICATION NAME] was also increased to 20 milligrams every bedtime. [MEDICATION NAME] eye drops were ordered to the right eye three times daily and every four hours as needed, and [MEDICATION NAME] eye gel every 8:00 p.m. to the right eye. Resident #4 was still receiving the [MEDICATION NAME] eye ointment. Even with all these medication changes related to pain, there was no updated comprehensive pain assessment completed for Resident #4 related to the Shingles. There also is no entry on whether the Shingles rash has resolved. On 4/29/13, a pain assessment was completed but was documented as a "Pertinent Note." In this documentation, the nurse indicated the various medication changes, and the resident's pain rating between 3-10/10, and that her pain is variable. On 4/29/13, the physician increased the [MEDICATION NAME] to 30 milligrams every bedtime and ordered [MEDICATION NAME] 5 milligrams every six hours for pain as needed. [MEDICATION NAME]es were also increased to two patches, one 25 microgram patch and one 12.5 microgram patch every three days. Staff were to also continue with the [MEDICATION NAME] 5% patches. Although this is indicative of ongoing pain issues for Resident #4, there was no comprehensive pain assessment completed indicating whether these medication changes were effective for Resident #4. On 5/1/13, a pain assessment was completed. According to this assessment, Resident #4 had mild pain to the right shoulder, left leg, right leg, and right side of face and eye. The resident rated the pain at a 9/10 as the worst it gets and a 2/10 for the best it gets. The resident described the pain as stabbing, sharp, and achy. On 5/2/13, Resident #4 was seen by a Neurologist. [MEDICATION NAME] 25 milligrams, one tablet twice daily for 10 days, then increase to two tablets twice daily was ordered. On 5/5/13, Resident #4 was interviewed by Surveyor # at 10:10 a.m. The Surveyor noted Resident #4 in her wheelchair in her room. She was constantly shifting her position and alternating between holding the right cheek in her right palm and holding her left cheek in her left palm, moving her head, ear to palm, with each movement. Resident #4 stated she was in severe pain related to having Shingles recently and the facility did not have her pain medication in the building. At 10:35 a.m., Surveyor # was able to locate RN-A, the nurse assigned to Resident #4. The Surveyor explained Resident #4's pain, and was told by RN-A that she could not give Resident #4 her [MEDICATION NAME] as the pharmacy did not supply enough. She stated she offered other as needed medications but the resident refused them. On 5/5/13, during the Resident Group Interview, Resident #4 was noted to be extremely agitated and constantly fidgeting in her wheelchair and changing or shifting her body right and left during the meeting. Surveyor # and # asked her what was causing her discomfort. Resident #4 explained about not receiving her pain medication this morning and there was no supply available in the facility from the Shopko Pharmacy from Appleton. Resident #4 told the group she was recently treated for [REDACTED]. She stated the Shopko Pharmacy in Appleton supplies the facility with the medications, and did not supply enough for her to receive this morning's dose at 8:00 a.m. On 5/5/13 at 3:00 p.m., Surveyor # entered Resident #4's room to interview her further on various topics, including her pain control. Resident #4 reiterated what she said earlier at 10:10 a.m., and in the Resident Group Interview regarding her medication not being in the facility from the pharmacy. Resident #4 stated the nurse (RN-A) was aware but did not offer other alternatives to pain control, other than [MEDICATION NAME] and the [MEDICATION NAME]. Resident #4 stated it has happened once before while she was here in which medications were not in the building when they were scheduled for her to receive them. She further stated, "I don't like to take the [MEDICATION NAME] during the day because it makes me so sleepy. I only take it at night. The [MEDICATION NAME] doesn't help at all, it does nothing for me. The only thing that has helped so far, is the [MEDICATION NAME]." She stated, "Oh gosh, right now the pain is a 10+ (0-10 scale), sometimes it's 20/10. I'm happy if it's 2/10. I can function normally at that level. I am never without pain, it's always there, but at a level 2, I can tolerate it and do something to take my mind off of it." Resident #4 also stated she enjoys some activity participation, as it occupies the time, but "...when I have a lot of pain, it prevents me from going to activities, it hurts so much, it's unbearable at times. So, I stay in my room because I just can't get comfortable." On 5/5/13 at 3:55 p.m., Surveyor # reapproached RN-A and asked again about Resident #4's pain control. RN-A stated the medication was now in the building, "...but if I give her one now, they won't have enough for tomorrow. I offered her the [MEDICATION NAME] and [MEDICATION NAME], but she didn't want them, only wants the [MEDICATION NAME]." On 5/6/13, Surveyor # reviewed the IDT documentation from 5/5/13. There was no entry made that Resident #4 did not receive the [MEDICATION NAME] or the reason. There was no documentation regarding the severe pain Resident #4 had been in throughout the day, and there was no documentation of other approaches attempted to relieve Resident #4's pain, such as ice packs, distraction, etc. Surveyor # reviewed Resident #4's Medication Administration Record. RN-A coded Resident #4 was having no pain all day. On 5/6/13, a Medication Omission Error was documented in the IDT notes regarding the omission of 5/5/13. The reason documented for the omission was the facility did not receive the medication from the pharmacy. The pharmacy was contacted and the medication arrived for the afternoon shift dose. On 5/6/13 at 4:50 p.m., Surveyor # approached the DON (Director of Nursing) regarding the medication omission. The DON stated RN-A approached her later in her shift, around 1:30 p.m. or 2:00 p.m. to inform her the medication was not in the building. The DON stated she herself called the Shopko Pharmacy in Appleton and demanded the medication be sent over right away. The DON stated education was going to be completed with RN-A for not calling the pharmacy earlier and allowing Resident #4 to have pain all shifts. The DON stated the reason for the omission is that the pharmacy only sent the facility one-half of the prescription ordered, causing the facility to have short supply. She stated the medication came in around 4:00 p.m. yesterday.

Based on observations, interviews and record reviews, the facility did not ensure that 1 of 13 sampled residents reviewed for pain received appropriate assessment and treatment of [REDACTED]. Resident #8 has a pain assessment completed on 4/29/12. The assessment identified Resident #8 is able to answer questions related to pain, identified pain as a 10 at its worst and pain is exacerbated with movement. Resident #8's care plan does not identify assessment of pain and administration of pain medication prior to activities that require movement, does not evaluate effectiveness of pain medication and does not include non-pharmacological interventions. Resident #15 was not provided interventions for pain management in situations where pain could be anticipated. Resident #15 was admitted with a pubic ramus fracture and is toe touch weightbearing with walker and assistance. The pain assessment indicates that pain is exacerbated by movement: transferring, however the pain assessment was not consistent prior to transfers to the bathroom, wheelchair and prior to therapy. Resident #15 care plan does not identify measurable goals using the pain scale, does not identify what type of activities that require movement; prior therapy, transfers. This is evidenced by: The facility provided Surveyor # and Surveyor # with a copy of the policy and procedure for "Pain Assessment." According to the procedure, a pain assessment is to be initiated when: ~A resident is receiving a pain medication ~A resident complains of pain or complains of pain daily not relieved by a PRN (as needed) medication ~A resident receives more than one dose of PRN medication daily greater than 15 days per month ~The pain is not relieved by non-medication interventions. The "Pain Assessment" by the RN or Designee should include: ~Complete pain assessment by clicking on all pertinent data ~Summarize findings and develop a plan ~Compare assessment information with the pain management guidelines tool, determine if/or what intervention is going to be implemented for relief of pain, discuss with resident and/or significant other and physician as appropriate. ~Initiate pain scale 0-10 ~Identify goal and interventions in the comfort care plan ~Place pain scale for cognitively intact resident on Medication Administration Record, [REDACTED]. ~Director of Nurses/designee to review all completed pain assessments ~Effectiveness of PRN pain medication is monitored in medication administration record Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's hospital discharge instructions for her left elbow fracture indicate: ~Take pain medication as prescribed ~Keep elbow at or above your heart when resting ~Apply ice packs 4 times a day for 20 minutes, each time Resident #8's hospital discharge instructions for her pelvic fracture indicate: ~A break in the pelvis can be a very serious injury, it is important to follow treatment and therapy instructions as a broken pelvis can cause chronic pain and limited function without proper care. Resident #8's Pain assessment dated [DATE] includes the following: ~Indicators of pain, vocal c/o (complaint of) pain, facial expression ~Pain Severity, pain is mild, pain is moderate, and pain is severe ~Pain location, left upper extremity, pelvis ~Exacerbated by, repositioning ~Relieved by, PRN medication ~Answers questions, yes ~Caregiver opinion used, no ~Pain scale at present, 5 ~Pain scale worst, 10 ~Resident pain scale goal, 0-5 ~Pain symptoms, Achy, dull, with movement, verbal complaining, and facial grimacing ~DX related to pain, arthritis, pelvic fx (fracture) and left elbow fx ~Receives scheduled pain medication, yes ~Receives prm pain medication, yes ~Summary of findings, experiencing mild pain, experiencing moderate pain, experiencing severe pain, pain daily, on scheduled pain meds, pain controlled Resident #8's care plan includes a problem dated 4/29/12 of "Comfort." Approaches include: Nurse's pain scale TID (three times a day), give prn med if needed, meds ordered: [MEDICATION NAME] 25 mcg. Nurse Aide: use pillow for comfort, assist with ADL's (activities of daily living), encourage rest periods Resident #8's CNA (Certified Nursing Assistant) Communication Sheet indicludes, Comfort: use pillow for comfort, assist with ADL's (Activities of Daily Living), encourage rest periods Resident #8's TAR (Treatment Administration Record) shows no documentation of non-pharmacological approaches including discharge instructions to apply ice packs 4 times a day for 20 minutes each time. Resident #8's MAR (Medication Administration Record) for April, 2012 indicates the following: ~Pain Scale Q (every) shift: 4/28/12: P.M. =5 4/29/12: Noc=6, A.M.=0, P.M.=5 4/30/12: Noc=6, A.M.=0, P.M.=6 ~[MEDICATION NAME] 25 mcg topical Q, 72 hours, last changed 4/30/12 ~APAP ([MEDICATION NAME]) 325, 2 tabs Q 4hours prn (as needed) for pain/fever 4/28/12 at 9:45 p.m. Pain prior to med documented as a 6, after med, a 2. 4/29/12 the time is not legible. No pain rating was documented. ~[MEDICATION NAME]-APAP 5/325 mg every 3 hours as needed 4/29/12 at 1:30 a.m. Pain prior to med was a 6, after med 0. 4/29/12 at 8:30 p.m. Pain prior to med was a 5, after med 1. 4/30/12 at 1:00 a.m. Pain prior to med was a 6, after med 3. 4/30/12 at 12:40 p.m. Pain prior to med was 5, after med 0. 4/30/12 at 2:45 p.m. Prior to med was 6, after med 0. 4/30/12 at 11:30 p.m. Prior to med was 2, after med 0. On 4/30/12 at 2:51 p.m., Surveyor # observed Resident #8 seated on the commode in her room. RN-E was in the room and stated "I have your pain pill here but I'll wait to give it to you until your comfortable in the chair." RN-E told Surveyor that Resident #8 could have [MEDICATION NAME] 5mg/325 every 6 hours. CNA-CC (Certified Nursing Assistant) was also in the room and approached Resident #8 and stated "I know your in a little bit of pain and your uncomfortable on the commode." CNA-CC and RN-E brought Resident #8 to a standing position, CNA-CC provided pericare and transferred Resident #8 into the recliner chair in her room. Even though Resident #8's pain assessment indicated that movement exaccerbated Resident #8's pain, facility staff administed her pain medication after her transfer to the commode and then to the recliner chair rather than before the transfers. At 3:06 p.m., RN-C reported the [MEDICATION NAME] is scheduled / can have it every 3 hours." On 5/2/12 Surveyor # requested May 2012 MAR from the NHA nothing had been provided at time of exit. Review of OT (Occupational Therapy) note dated 5/3/12 indicates: Left upper extremity: Patient stated was aching, nursing completeted pain assessment and gave pain medication. Patient last pain medication was at midnight per nursing, patient seen at 8:00 a.m. On 5/1/12 at 9:46 a.m., Surveyor # observed RN-C enter Resident #8's room and state "I come to bring you your pills." RN-C took Resident #8's pulse and then administed the pills. RN-C did not inquire or ask Resident #8 if she had pain. Once outside Resident #8's room, Surveyor # asked RN-C if resident got any pain medication. RN-C stated "She can have it if she wants it. She usually asks for it if she needs it." On 5/1/12 at 10:12 a.m., CNA-J entered room to help Resident #8 to the commode. Resident #8 stated "its (arm) OK as long as I don't move it." CNA-J replied "Do you want a pain pill when we are done here?" CNA-J brought Resident #8 to a standing position and transferred her to the commode. Resident #8 stated "If the arm drops down I scream." Resident groaning and stating "Ow, ow! I'm falling, I'm tipping too far to the bad leg," during the transfer. At 10:18 a.m., RN-C entered Resident #8's room and stated that she just wanted to check to see if she has a [MEDICATION NAME] on. On 5/1/12 at 10:25 a.m. Surveyor # and Surveyor # observe CNA-F transferring Resident #8 from her commode to a reclining chair beside her bed to Resident #8's left side. CNA-F used a gait belt and hemi walker to transfer Resident #8. Resident #8 stood and took 2 steps to her left. Resident #8 moaned, grimaced and stated, "Terrible Pain" when asked how she was doing by CNA-F. CNA-F assisted Resident #8 to a sitting position in the recliner, placed pillows behind Resident #8 back and under her left arm and elevates Resident #8 feet in recliner. Resident #8 indicated, "Oh what a relief it is." At 10:34 a.m., Surveyor # asked Resident #8 about her [MEDICATION NAME]. Resident #8 reported she had the pain patch at home but the patch is not effective here in helping the pain when it "shoots up" during activity. On 5/1/12 at 12:05 p.m. Surveyor # and Surveyor # observed OTR-H (Occupational Therapist) in Resident #8 room. OTR-H asked Resident #8 how she feels. Resident #8 responded, "Don't move, it's pretty good, but sitting on my hip, now my hip is hurting." At 12:10 RN-C entered the room and stated she has Resident #8 medications. RN-C administers medications and exits. OTR-H provides massage to Resident #8 left shoulder. Resident #8 indicated, "Feels good." OTR-H inquired about Resident #8 pain. Resident #8 responded, "Not bad if I don't move it, then I get numb somewhere else." At 12:25 p.m., Resident #8's lunch tray is brought in and RN-C returned and asked Resident #8, "Are you comfortable?" Resident #8 stated, "If I don't move my arm. You told me not to move my arm but it's kind of hard to do." On 5/1/12 at 12:08 p.m., Surveyor # approached RN-C who was preparing to give Resident #8 medication to include a pain pill. RN-C reported "I talked to her about her pain." Surveyor asked RN-C what Resident #8 said about her pain and RN-C reported that the resident said it was a "7." At 12:29 p.m., Surveyor asked RN-C if Resident #8's report of pain at a "7" was at rest or with movement. RN-C reported "7" was at rest as the resident wasn't moving. At 12:32 p.m., RN-C entered Resident #8's room and asked her about her pain. RN-C asked Resident #8 if she was comfortable. Resident #8 reported "I'm OK if I don't move my arm." RN-C stated "You don't look like you are in pain and you shouldn't be moving your arm anyway." On 5/1/12 at 2:00 p.m. Surveyor # and Surveyor # observed a converstaion between RN-E and RN-C. RN-E asked if Resident #8 had any pain. RN-C responded "Not really." RN-C indicated she had asked Resident #8 during medication pass. At 2:03 p.m. RN-E entered Resident #8 room and asks her on a 0-10 scale how she would rate her pain. Resident #8 responded, "None when not moving." At 2:05 PTA-I (Physical Therapy Assistant) entered Resident #8's room. PTA-I asked Resident #8 if she had any pain when, "We got up yesterday." Resident #8 responded, "Yeah some pain, at a 5 with moving." PTA-I asked Resident #8, "Where is the pain?" Resident #8 stated, "My whole left side, arm and leg." RN-E indicated she will see if she can get Resident #8 something for the "break through" pain and exited room. PTA-I brought over a wheelchair and hemi walker. PTA-I assisted Resident #8 to a standing position. Resident #8 stood on both legs took 2 steps. Resident #8 groaned, grimaced, and stated, "Not too bad unless I move." PTA-I assisted Resident #8 to sit in her wheelchair. RN-E entered and stated she has Tylenol for Resident #8's "Break through" pain. Resident #8 stated "It hurts when I put weight on my left leg." PTA-I took Resident #8 to the therapy room. Resident #8 completed knee and leg lift exercises from her wheelchair. PTA-I indicated Resident #8, "Won't be walking today." At 2:30 p.m. PTA-I, OTR-H (Rehabliitation Director), Resident #8 discuss observations of transfer and pain. OTR-H indicates she will call Resident #8 orthopedic physician to seek clarification about her transfer and weight bearing status. On 5/1/12 at 4:30 p.m. OTR-H informed Surveyor # and Surveyor # that she had called Resident #8 orthopedic physician to clarify weight beating status. OTR-H indicated Resident #8 should continue weight bearing as tolerated. OTR-H also stated the orthopedic physician indicated it (fracture) will hurt with transfer. On 5/2/12 at 10:20 a.m. Surveyor # and # observed CNA-F assist Resident #8 with monrning cares. Resident #8 was seated on a commode at bedside. Surveyor # asked Resident #8 to rate her pain on a 0-10 scale with no movement. Resident #8 responded, "Zero." Surveyor # asked Resident #8 to rate her pain on a scale from 0-10 with movement. Resident #8 responded "10" on her left side. CNA-F stated, "Big time." CNA-F completed personal cares and assisted Resident #8 to the reclining chair. On 5/3/12 at 7:55 a.m. the NHA informed Surveyors # and Surveyors # that Resident #8 has a care plan for pain that has been in place since her admission. On 5/1/12 at 10:40 a.m. Surveyor # and Surveyor # interview the DON (Director of Nursing) regarding assessment and care planning process with admission. The DON indicated the admitting nurse completes the assessments that include pain among others. The DON further explained the admitting nurse completes a note related to ENT (ear, nose and throat), skin, respiratory, GI (Gastro-intestinal) and breast. The DON further explained the admitting nurse develops a temporary care plan and CNA Communication (door card). Surveyor # asked the DON how unit staff is aware of Therapy times for residents. The DON indicated Therapy times are at the nurses stations. Example #2 This is evidenced by: Resident #15 was admitted to the facility on [DATE] following a fall at home which she was diagnosed with [REDACTED]. On 5/2/12 at 9:02 a.m., Surveyor # was observing Resident #15 during the medication pass task. Resident #15 requested a pain pill. Resident #15 was sitting in her wheelchair. LPN-BB (Licensed Practical Nurse) asked Resident #15 what she rated her pain. Resident #15 said a 5. LPN-BB then asked if she wanted Tylenol or the stronger pill [MEDICATION NAME]. Resident #15 stated that the Tylenol doesn't do anything and that she wanted the [MEDICATION NAME]. LPN-BB gave [MEDICATION NAME] 50 mg at 9:20 a.m. On 5/2/12 at 9:23 a.m., Surveyor # observed Physical Therapy taking Resident #15 down to therapy for treatment. Surveyor # asked Resident #15 at 9:35 a.m., if she was having any pain in which Resident #15 stated, "I'm really not having any pain until I do a lot of moving which it will come soon." According the Nursing Drug Handbook, [MEDICATION NAME] is given for moderate to moderately severe pain. Oral pill form onset is unknown but the peak time is in 2 hrs. Duration is unknown. Record review indicates that a pain assessment was completed on 4/24/12. The assessment indicates that pain is exacerbated by movement and is relieved by as needed [MEDICATION NAME]. The pain scale worst is a 6 and a pain scale goal is 2. Summary of findings was pain less than daily, pain controlled. The MAR for May 2012 indicates that the nurses check Resident #15 pain scale every shift, but does not indicate the time of the assessment and does not indicate if resident rates the pain with movement since this exacerbates the pain. The record indicates no pain on 5/1/12 and a "5" on 5/2/12 on the day shift, otherwise there is no pain. The medication record indicates that Resident #15 has had [MEDICATION NAME] on 5/1/12 at 6:10 p.m. (none prior to therapy or transfers that day) and on 5/2/12 at 9:20 a.m. when the resident asked for the pain pill. Review of Resident #15 physician orders [REDACTED]. For mobility resident is to have touch toe weight bearing. Review of Care Plan dated 4/25/12 indicates: "Problem-8 Comfort...Approaches Nurses-Pain scale with med admin Give prn if needed. Update physician as needed. Nurse Aide-enc (encourage) rest periods, encourage act of choice, Pressure relief chair, Assist w (with) ADL's (Activities of Daily Living) prn., and Use pillow for comfort." The care plan does not include an approach for assessment of the pain with movement and administration of her prn pain medication prior to activities that require movement. On 5/3/12 at 9:05 a.m., Surveyor # interviewed Resident #15 who stated that as long as she sits like this (still in her wheelchair) she has no pain but as soon as I move it is real bad. When asked what she would rate her pain then she stated a 7. Resident #15 stated,"They used to give me 2 or 3 a day and with my morning pills. Today I haven't gotten my morning pills yet." Resident #15 stated that when the CNAs transfer her, the pain really hurts but it is slowly getting better. "The nurses try to give me a pain pill before therapy but it doesn't always happen. Nursing does not ask me what my pain level is when I am moving mostly when I am just sitting in my chair. Therapy will ask me about my pain and sometimes I take a pain pill when I get back from therapy."

Based on observations, interviews, and record reviews, the facility did not provide appropriate assessment and treatment of [REDACTED]. Resident #3 had a [DIAGNOSES REDACTED]. On 5/7/11 and 5/8/11, Resident #3 complained of abdominal pain rated at 8 out of 10 (10 being the worst pain ever). There is no evidence that the facility assessed Resident #3's pain or obtained an order for [REDACTED]. This is evidenced by: Resident #3 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #3 was cognitively intact, required the assistance of 1 to 2 staff for toileting, and had a Foley catheter. Physician orders [REDACTED]. An additional order dated 3/28/11 included: Tylenol PM, 1 at bedtime as needed (per resident request). Physician orders [REDACTED]. every 4 hrs as needed; [MEDICATION NAME] tablet, 325 mg, 2 tablets (650 mg) by mouth every 4 hrs as needed for pain; and, [MEDICATION NAME] tablet 500 mg, give 1-2 tablets by mouth every 6 hrs as needed for pain. These were discontinued per physician's orders [REDACTED]. Resident #3's care plan includes a problem of "Comfort." The approaches include: "Pain scale TID (three times a day) every shift, if rates pain greater than goal of 1 offer PRN (as needed) pain medication....Update physician as needed..." A nurse's note dated 4/23/11 states, "...has no scheduled pain meds, has used 5 doses of Tylenol pm to aide him in sleep..." Review of Resident #3's pain assessments finds that staff did not complete a comprehensive pain assessment. A nurse's note on 5/6/11 states, "...Dark yellow, thick mucous found in urine...Abdominal Pain: None...Abdominal Distension: no..." A nurse's note on 5/7/11 states, "13:31 (1:31 p.m.)...Mucous in urine: yes...Abdominal Pain: none...Abdominal distension: no..." According to the MAR, Resident #3 had received PRN Tylenol twice before this note was written at 7:00 a.m. (rated at an 8), and 9:30 a.m. (rated at an 8). A second note on 5/7/11 states, "...23:32 (11:32 p.m.) Abdominal Pain: RLQ (Right Lower Quadrant) LLQ (Left Lower Quadrant)...Abdominal Distension: no. There is no assessment of the lower quadrant pain. An assessment would include the type of pain, the intensity, aggravating factors, or factors that relieve the pain. The assessment would also include a pain rating. According to the MAR, Resident #3 had received an additional PRN Tylenol at 3:00 p.m. (rated at a 6) and a scheduled Tylenol at 9:30 p.m. A nurse's note on 5/8/11 states, "...09:48 (9:48 a.m.) Mucous in urine: Yes...Abdominal Pain: RLQ, LLQ..." According to the MAR, Resident #3 received PRN Tylenol at 2:00 a.m. (rated at an 8) and 7:00 a.m. (rated at an 8). There is no evidence that the facility completed a comprehensive pain assessment despite Resident #3's continued pain rated at an 8. ~5/8/11, "...13:02 (1:02 p.m.)...was informed by family that they wanted resident sent emergently 911..." Resident #3 was sent to the hospital and found to have an obstruction in his catheter preventing the urine from draining and causing the bladder to distend and cause pain. Resident #3 was also diagnosed with [REDACTED]. On 12/14/11 at 1:25 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated staff should have monitored Resident #3's urinary output and assessed for his pain and the potential source of the pain.

Based on observations, interviews, and record reviews, the facility did not consistently provide 2 of 12 sampled residents reviewed for incontinence and/or catheter use with the necessary care and services. On admission to the facility, Resident #3 had physician orders [REDACTED]. There was no documentation by the facility of the times nor volume of Resident #3's intermittent catheterizations. Despite no documentation of outputs, the facility obtained an order for [REDACTED]. On 5/7/11 and 5/8/11, Resident #3 complained of abdominal pain rated at 8 out of 10 (10 being the worst pain ever). Resident #3's family insisted on transfer to the emergency room . Resident #3 was found to have a distended, full bladder and leakage around the catheter indicating a blockage in the tubing. Resident #3 had a new Foley catheter placed which was noted to drain 1800cc's (cubic centimeters) of urine. Lengthy observations of Resident 11 and staff interviews were conducted and no offers or attempts to toilet or reposition Resident #11were noted from 7:00 a.m. through 1:16 p.m. This is evidenced by: Example #1: According to "Lippincott's Nursing Center.Com" assessment of Foley catheters should include determining whether the Foley catheter is functioning properly. This would include, "...looking to see whether the catheter system is draining effectively by comparing the urine output with the patient's fluid intake. A discrepancy in intake and output volumes may indicate a mechanical problem with the catheter..." Resident #3 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #3 was cognitively intact, required the assistance of 1 to 2 staff for toileting, and had a Foley catheter. Resident #3's care plan does not direct staff to monitor Resident #3's urinary volume until 5/10/11. Surveyor # completed a review of Resident #3's admission records. This indicated Resident #3 had had a Foley catheter while hospitalized . The Foley catheter was discontinued on 3/4/11 prior to Resident #3's admission to the facility. The admission records indicated Resident #3 was to continue intermittent catheterizations four times a day. There was no evidence that the facility documented the times the catheterizations were completed or the urine volume obtained with each catheterization. Surveyor # completed a review of nursing notes and noted the following: ~3/7/11, "...On 3/5/11 resident was complaining of abdominal discomfort, The PM (evening) nurse got an order to put in a Foley...put in a...Foley...got 1700 cc out through out the night..." ~3/14/11, "...on 3/8/11 orders for...DC (discontinue) Foley in one week per residents request and start straight cath every 4 hours and PRN (as needed)..." ~3/27/11, "...on 3/18/11 per resident's family- new orders to insert Foley cath (catheter)..." There is no evidence in the medical record that staff completed the 4 times daily catheterizations, noting precatheterization voiding amounts and postcatheterization residuals to determine if there was a medical need for the indwelling Foley. Surveyor # completed a review of Resident #3's physician orders [REDACTED]." Surveyor # was unable to determine the date of the order. Surveyor # spoke with the Ward Clerk as well as LPN-A (Licensed Practical Nurse). Both indicated the order would have been obtained on or before 4/23/11. Nurse's notes continue: ~4/23/11, "...has no scheduled pain meds, has used 5 doses of Tylenol pm to aide him in sleep..." ~5/6/11, "...Dark yellow, thick mucous found in urine...Abdominal Pain: None...Abdominal Distension: no..." ~5/7/11, "13:31 (1:31 p.m.)...Mucous in urine: yes...Abdominal Pain: none...Abdominal distension: no..." ~5/7/11, "...23:32 (11:32 p.m.) Abdominal Pain: RLQ (Right Lower Quadrant) LLQ (Left Lower Quadrant)...Abdominal Distension: No ~5/8/11, "...09:48 (9:48 a.m.) Mucous in urine: Yes...Abdominal Pain: RLQ, LLQ..." ~5/8/11, "...13:02 (1:02 p.m.)...was informed by family that they wanted resident sent emergently 911..." Resident #3 had acute abdominal pain. According to the May 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This indicates significant pain. There was no physician notification nor any attempts to assess Resident #3's pain. Surveyor # completed a review of the hospital records dated 5/8/11. Under the heading "Chief Complaint" it indicated, "...patient presents with pain in the lower abdomen, right lower quadrant, in the left lower quadrant...symptoms...began...3 days ago, and became worse today...pain was severe today...moderate abdominal tenderness..." Under the heading titled "Assessment" it indicated, "...Complains of pain in groin. Pain currently 8 out of 10 on a pain scale...leakage around catheter insertion site...per radiology bladder is full...emptied 1800 ml (milliliters) urine, Foley clamped..." Surveyor # completed a review of the radiology report. Under the heading "Impression" it indicated, "...There is rather marked distension of the urinary bladder and fat stranding is seen surrounding the bladder..." The physican's final impression states, "[MEDICAL CONDITION] - obstructed Foley catheter, Urinary Tract Infection..." The hospital records also indicated that Resident #3 received [MEDICATION NAME], a pain medication, intravenously for pain control. Resident #3 returned to the facility on [DATE]. Surveyor # completed a review of Resident #3's MARs for March, April and May 2011. There was no evidence of recorded output during the month of 3/11 or 4/11. Careful monitoring of urinary outputs is critical in ensuring that the catheter is draining properly. Monitoring of output was noted to first begin on 5/10/11. On 12/13/11, Surveyor # requested evidence of urinary output for Resident #3 prior to 5/10/11. There was no further information received. On 12/14/11 at 1:25 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated staff should have monitored Resident #3's urinary output. Example #2: Resident #11 was admitted to the facility on [DATE] with an order for [REDACTED]. According to the care plan formulated by the facility for Resident #11 on 10/18/11 for Bowel and Bladder, the resident is incontinent of bowel and bladder function and was to be toileted upon rising, before meals, and during night rounds. The MDS assessment dated [DATE] indicates that Resident #11: ~Is totally dependent on staff for bathing, personal hygiene, and toileting; ~Has both short-term and long-term memory impairments and has severely impaired cognitive skills for daily decision-making; and, ~Is transferred with the use of a mechanical lift. On 12/13/11, Surveyor # observed Resident #11 from 7:00 a.m. to 8:55 a.m. No toileting or repositioning was offered by staff. From 9:05 a.m. to 9:30 a.m., Surveyor # observed Resident #11. No staff approached Resident #11 during this time period. From 9:30 a.m. to 10:05 a.m., Surveyor # observed Resident #11. No staff offered or assisted Resident #11 with toileting or repositioning. From 11:48 a.m. to 12:40 p.m., Surveyor # observed Resident #11 and no staff offered or assisted Resident #11 with toileting or repositioning. From 12:40 p.m. to 1:19 p.m., Surveyor # observed Resident #11 and no staff offered or assisted Resident #11 with toileting or repositioning. ~1:16 p.m., staff entered Resident #11's room and layed her on the bed with the use of a mechanical full-body lift. Surveyor # returned and observed cares being given. Resident #11 was incontinent of a large amount of urine. On 12/14/11 at 8:10 a.m., Surveyor # asked CNA-V (Certified Nursing Assistant) Resident #11's care needs. CNA-V stated Resident #11 is total care and is generally incontinent of bladder and bowel function. CNA-V stated, "...usually when I get her up first or early, then I lay her down after breakfast and before lunch. If I do her later, I lay her down after lunch. Yesterday I just didn't get to her, they were going to take care of her after I left..." CNA-V's shift ended at 1:00 p.m. On 12/14/11 at 11:10 a.m., Surveyor # asked the DON (Director of Nurses) about the facility's expectations for incontinent residents, specifically Resident #11. The DON stated Resident #11 was to be taken to the bathroom upon rising in the morning, before meal service, and during the night rounds. She further stated the expectation was Resident #11 be toileted every two hours.

Based on observation, record review, and interview, the facility staff did not ensure that 1 of 7 sampled residents was given incontinence care in a manner to reduce the incidence of UTIs (Urinary Tract Infections). Resident #48 did not receive incontinence care by CNA-OO (Certified Nursing Assistant) in a manner to reduce her incidence of UTIs. This is evidenced by: Surveyor # reviewed the nursing home's formal policies and procedures of "Perineal Care - Female/Male" and "Catheter Care - Urinary." Item 3.10 instructs staff to: A. Female: 1. Wash and rinse perineal area with soap and water, and/or disposable wipes. 2. Avoid scrubbing back and forth. 3. Wipe from clean to dirty with a single wipe, then turn or discard cloth. The policy on catheter care does not outline the need to do perineal care in a manner to reduce the chance of introducing feces into the urinary meatus. The facility's policies are based on current standards of practice as outlined by "The Lippincott Manual of Nursing Practice," 7th edition and nursing assistant textbooks published by Hegner, Acello, and Caldwell. A review of the previous plan of correction by Surveyor # found that all staff were in-serviced and received a post test. The test for "Infection Control/Handwashing" found: "5. Improper peri care may include: a. No peri care done. b. Wiping back to front on females. c. Failure to provide after incontinence episodes. d. Scrubbing back and forth. e. Failing to wash hands prior to and after peri-care. f. All of the above. (Correct answer)" Resident #48 was last admitted to the nursing home on 11/21/11. Resident #48 has [DIAGNOSES REDACTED]. She had a history of [REDACTED]. She is currently under Hospice care and has an indwelling Foley catheter as treatment for [REDACTED]. She has a history of ESBL (Extended Spectrum Beta Lactimase) in her urine. ESBL is a series of bacteria that are resistant to antibiotics. It lives in contaminated feces and is primarily transmitted via the contaminated hands of health care workers. Resident #48 is completely dependent on the physical assistance of one or two staff members for her transfers and personal hygiene. On 02/16/12 at 10:33 a.m., Surveyor # observed CNA-OO and CNA-PP assist Resident #48 with her perineal care. As Resident #48 is seeking no further tests, the facility staff continue to use contact-type precautions for the ESBL. CNA-OO was noted to cleanse the urinary meatus and around the catheter tubing. However, after doing so, she was then observed to cleanse feces off the resident in a back to front manner. CNA-OO wiped the washcloth 4 times from the anus to the perineum and down approximately 4 inches in between her inner thighs. Each time the cloth was seen to be contaminated with feces and brush up against the catheter tubing. After cares were completed Surveyor # asked CNA-OO of the proper procedures for cleaning feces of a female resident, especially when the resident has a catheter. When reminded of the need to wash front to back, the CNA stated, "Of course! I can't believe I did that!" The proper procedure outlined in the policy was confirmed and reiterated by the DON in an interview at 1:50 p.m.

Based on observations, staff interviews, and record reviews, the facility did not ensure that 6 of 7 sampled residents reviewed for pressure ulcers received necessary and appropriate care and treatment to prevent the development of pressure ulcers and/or to promote the healing of pressure ulcers. Resident #10 was assessed by the facility as being at risk or at very high risk for the development of pressure ulcers. On 3/8/11, the CNA (Certified Nursing Assistant) documented that Resident #10 had redness/discoloration of the left buttocks. Although reported to the licensed nurse that same day, there was no evidence of further follow-up until 3/14/11, when the wound nurse discovered the CNA's entry. At that time, the redness/discoloration had progressed to a Stage II open area on the left buttocks. Resident #10 also had care planned approaches for a J cushion in his wheelchair since 2008, and approaches that he is to sit up straight and have his feet on foot pedals when he is in his wheelchair. On 3/23/11 and 3/24/11, Resident #10 was observed seated in the wheelchair without any cushion, reclined at a 30 degree angle, and without his feet on foot pedals. On 3/24/11, the wound nurse documented 2 new open areas on Resident #10's right buttocks. Resident #1 was admitted to the facility with no pressure ulcers. The facility developed a care plan to provide pressure reducing surfaces and to keep heels off the bed. On 3/11/11, the facility documented a change in Resident #1's skin including redness to the buttocks, and heels getting soft. No changes were made to Resident #1's care once previous interventions were found to be ineffective. On 3/12/11, Resident #1 presented with 2 Stage II pressure ulcers on his buttocks. Although now healed, observations found that staff were not providing the correct pressure-relieving device in the reclining chair. Resident #3 was admitted to the facility with a Stage 1 on the right side of the coccyx. Staff did not measure or assess the wound thoroughly. An initial care plan was not developed to address Resident #3's problem with skin integrity. On 3/15/11, Resident #3 developed a Stage 2 to the left buttock and a care plan was first developed at that time. On 3/22/11, documentation shows that Resident #3 developed a second pressure ulcer to the left buttock. No changes were made to Resident #3's care plan after the second pressure ulcer on the left buttock developed. Resident #9 has had recurrent Stage II pressure ulcers on both buttocks. After healing the pressure ulcers, the facility made no changes to Resident #9's care plan to prevent future pressure ulcers from developing. Resident #9 currently has a Stage II pressure ulcer on both the left and right gluteal fold. The wound nurse recommended that the Hoyer sling, which had been left under Resident #9 while in the chair, be removed. The wound nurse also recommended that an ergo slide be used for all turning and repositioning. Observations revealed that the Hoyer sling was still being left under Resident #9's buttocks while in the wheelchair and that the ergo slide was not being utilized by staff. Additionally, the type of cushion which Resident #9 had in the wheelchair had not been assessed and/or changed in light of Resident #9's multiple Stage II pressure ulcers. When the cushion was assessed by the facility, it was found layered with multiple soaker pads rendering the cushion ineffective. The facility was aware that Resident #7 would elevate her feet on a stool in her room; however, no interventions were put into place to ensure full off load of the heels. Additionally, the facility indicated that Resident #7 should have had special boots to wear to reduce pressure to the heels given Resident #7's recent surgery. This approach, however, was not added to Resident #7's plan of care. Resident #7 developed an unstageable pressure ulcer to the left heel. While the facility had systems in place to monitor the skin of all residents, the pressure ulcer on Resident #7's left heel was not noted until it was unstageable and covered with black eschar. Resident #14 has had multiple recurrent Stage II pressure ulcers over the past year. After each Stage II was healed, the facility did not develop new interventions to avoid future pressure ulcer development. Observations found that Resident #14 has a current Stage II pressure ulcer to the buttocks that was not documented by the facility. This is evidenced by: Example #1: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE], indicates Resident #10: ~Is dependent on staff for all cares including bed mobility and transfers; ~Is transferred with a mechanical lift; ~Has short and long-term memory problems; ~Has moderately impaired cognitive skills for daily decision making; ~Is always incontinent of bowel and bladder; ~Has no pressure ulcers; ~Has pressure relieving device in chair and bed; and, ~Is on a repositioning schedule. Resident #10's Braden Scale Assessments indicate: 5/24/10, "Score 13 (Moderate risk scores 13-14)...Plan: Manage moisture. Manage Friction/Shear ...use ergo slide, use lift pad ... 8/16/10, " Score 12" (Scores of 10-12 indicates a high risk). The Plan remained the same as 5/24/10 despite the change in risk. 11/4/10, "Score 15 (Scores of 15-18 indicate a person is at risk). Plan Manage Moisture. Manage Friction/Shear... 1/27/11, " Score 12...Plan ...Pressure reduction support surfaces ... " Resident #10's care plan includes a problem of "Skin Integrity" which was originally initiated 4/25/08 and most recently reviewed on 11/4/10. Interventions included, "...4/25/08, Pressure relief/chair J cushion on w/c (wheelchair). 9/29/08, CNA Skin inspection: bath day. 1/6/09, avoid shearing skin with repositioning/boosting res (resident) ..." Resident #10's care plan also includes a problem of "Mobility" with an approach of, "4/10/09--Res is to sit up straight, feet on pedals when in w/c (wheelchair)." Review of the CNA Skin Inspections finds documentation that Resident #10 has no skin issues until 3/8/11, when redness or discoloration is documented on the right and left buttocks. Although reported to the nurse, there is no evidence of Licensed Nurse Follow Up documented. The next Skin Inspection entry is 3/9/11 at 11:11 p.m. and states, " sore on bottom of butt and scrotum area ... " The Licensed Nurse Follow Up on 3/10/11 at 3:26 a.m. states, " Open area on right buttocks 1cm x 1 cm (centimeter) [MEDICATION NAME] in place ...re-educated staff on proper peri care ... " Skin Inspection dated 3/14/11 indicates no skin issues. Wound Care notes for 3/14/11 state, "...partial thickness r/t (related to) shearing and moisture ..." According to the documentation, there are 2 open areas on the left buttock: the first is 2.3 cm long x 3.0 cm wide "discolored," the second is 0.6 cm long x 0.3 cm wide x 0.1 cm deep. This demonstrates a decline from 3/10/11, when the licensed nurse documented 1 area that was 1cm x 1cm. The entry goes on to state, "The [MEDICATION NAME] dressing has been effective in decreasing the size of the partial thickness area. Continue current plan of care ..." The care plan for Skin Integrity was first updated on 3/14/11, 4 days after the ulcer was discovered. New approaches include, "Treatment as ordered [MEDICATION NAME]. Ergo slide for repositioning/prevent shearing. Wound care nurse. Assess/measure weekly." The CNA Communication Sheet, with a print date of 3/23/11, indicates a J cushion should be in the wheelchair, that Resident #10 is to sit up straight in the chair with feet on the foot pedals. The CNA Communication Sheet is consistent with approaches added to the care plan 4/25/08 and 4/10/09 respectively. On 3/23/11 at 11:24 a.m., Surveyor # observed Resident #10 seated in his wheelchair reclined to 30 degrees. Surveyor # noted that there was no cushion in the wheelchair under Resident #10. Resident #10 had no pressure relieving device even though there were 2 open areas documented. Resident #10's feet were not touching the foot pedals. This can create additional pressure on an already compromised area. The mechanical lift sling remained under Resident #10. Surveyor # conducted a continuous observation. On 3/23/11 at 1:00 p.m., CNA-F and CNA-G transferred Resident #10 to bed with a mechanical lift. Surveyor # observed skin indentations where the sling straps were left under Resident #10 from the left buttock area extending down the back of his leg to backside of knee. Skin indentation also observed on the back of his right upper leg. Surveyor also observed a 4 x 4 [MEDICATION NAME] intact on his right buttock area. Surveyor # asked CNA-F why Resident #10 had a [MEDICATION NAME], in which she stated, "I'm not really sure ..." Surveyor then asked how long Resident #10 had been up. CNA-F stated that he was changed right before he went to the morning activity at 10:00 a.m. This would be approximately 3 hours of sitting. On 3/24/11 at 7:45 a.m., Surveyor # observed Resident #10 sitting straight up per the CNA Communication Sheet. Surveyor #2989 observed the mechanical lift sling remained under Resident #10. Again, there was no J cushion and Resident #10's feet were not on foot pedals. According to the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention; 2009 "Repositioning for the Prevention of Pressure Ulcers:" ~ 2.1 "Repositioning frequency will be determined by the individual's tissue tolerance, his/her level of activity and mobility, his/her general medication, the overall treatment objectives, and assessments of the individual's skin ~4.2 Place the feet of the individual on a footstool or footrest when the feet do not reach the floor. When the feet do not rest on the floor, the body slides forward out of the chair. Footrest height should be adjusted so as to slightly flex the pelvis forward by positioning the thighs slightly lower than horizontally. ~4.3 Limit the time an individual spends seated in a chair without pressure relief. When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high; therefore, without pressure relief, a pressure ulcer will occur quickly." ~"5. Record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime." On 3/24/11 at 8:00 a.m., Surveyor # interviewed CNA-I. CNA-I stated Resident #10 had gotten a new wheelchair about 5 or 6 months ago because he was leaning more. CNA-I stated that Resident #10 has not had a cushion since getting the new chair. Surveyor # reviewed Resident #10's care plan and stated, "I guess he is to have one." Review of the wound care notes from 3/24/11 find the following: Right buttock #1 Stage II- Pressure Ulcer- 1.5 long x 1.3 wide " [MEDICATION NAME]." Right buttock #2 distal 1cm long x 1 cm wide x 0.2 cm deep. " Summary of Findings: ...There is a distal partial thickness that is new this week. The left buttock skin integrity remains intact. " The pressure ulcers to the right buttock were not previously documented. On 3/24/11, Surveyor # spoke several times with COTA-J (Certified Occupational Therapist Aide) who stated that Resident #10 was screened on 11/3/10 and the facility changed the wheelchair on that date. COTA-J stated that today she gave Resident #10 a foam cushion and she ordered a Roho cushion that would fit the chair. COTA-J stated that therapy will put foot extensions on the wheelchair so Resident #10's feet will be supported. There is no evidence that Resident #10 had a pressure relief cushion in a chair since 11/3/10. According to the weekly skin inspection notes, 4 months later (3/3/11) Resident #10 first had a blister to buttock. At 3/24/11 at 12:45 p.m., COTA-J stated that she recommends removal of all soaker pads and slings while up in wheelchair because any other barriers between the cushion and the resident body will void out the efficacy of the device. This is consistent with guidance from the EPUAP (European Pressure Ulcer Advisory Panel) and NPUAP (National Pressure Ulcer Advisory Panel). On 3/24/11 at 8:05 a.m., Surveyor # interviewed RN-E who stated that according to the COTA-J, Resident #10's J cushion was transferred with the old chair. Surveyor # asked about the delay between Resident #10's pressure ulcer being identified on 3/10/11 and the beginning of treatment on 3/14/11. RN-E stated that she was not notified by nursing that Resident #10 had a pressure ulcer on 3/10/11, and that she found out by reviewing on 3/14/11 in the CNA weekly inspection notes. RN-E was asked who updated the CNA Communication Sheet and Care Plans on 3/22/11. RN-E stated that she did and stated that she should have looked to see if the J-cushion was on the chair. Example #2: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted for therapy. A Braden Scale assessment was completed on 3/4/11 and scored Resident #1 at a 19. However, review of the individual area scores finds that the total should be 18, indicating Resident #1 is at risk for pressure ulcer development. The plan is to protect heels, provide pressure relief mattress and pressure reduction support surfaces. Resident #1's care plan includes a problem of Skin Integrity dated 3/4/11. Approaches include, "Treatment as ordered. Pressure relieving device(s) for bed. Keep heels off bed. CNA Skin Inspection: bath days." Skin Inspection documentation on 3/6/11, indicates there are no skin issues, including redness or discoloration, on this date. The MDS assessment, dated 3/11/11 indicates Resident #1: ~Requires extensive assistance with bed mobility, transfers, and personal hygiene; ~Is at risk for pressure ulcer development; ~Has no current or healed pressure ulcers; ~Has a pressure reducing device for bed and chair; and, ~Is on a repositioning program. The CAAs (Comprehensive Assessment Action) dated 3/11/11, indicates that Resident #1 has no pressure ulcers but has redness on buttocks and heels are soft but blanchable. There was no redness or discoloration documented during the 3/6/11 skin inspection. The plan indicates to provide moisture barrier, protect heels, and pressure reduction support surfaces. Despite the change in Resident #1's skin condition, no changes were made to the care plan. A nurse's note on 3/12/11, indicates that Resident #1 has a 1cm x 3cm Stage II pressure ulcer on the L buttock and a 1cm x 1.4cm open area on the right buttock. There is no evidence that Resident #1's care plan was reviewed and revised when previous interventions were proven ineffective. The 3/13/11 Skin Inspection indicates that there is redness/discoloration, "buttocks, feet, open sores on left and right buttocks." The licensed nurse follow-up states, "Reported areas observed: areas on buttocks have dressing of [MEDICATION NAME] in place, currently being monitored, redness on feet noted, heel not spongy, encouraged resident to use pillow under feet at night and to elevate legs as much as possible ..." The next entry related to Resident #1's ulcers was made by the facility's wound care nurse on 3/15/11 and is as follows: "Resident admitted with stage 2 ulcerations on right buttock and excoriation noted on left buttock. ...Ergo slide added to plan of care for shearing preventions ...Reposition every 2 hours ...Care plan updated." There were no measurements or assessment of either pressure ulcer. There is no evidence that Resident #1 was admitted with any pressure ulcers. Resident #1's Skin Integrity Care Plan was updated on 3/15/11 to include approaches of, "Ergo slide for shearing prevention ...pressure relief/chair: foam, encourage buttock lifts ..." On 3/22/11, Surveyor # observed Resident #1 sitting in a lift chair. RN-E, the facility's wound care nurse, was in the room to assess the ulcer areas. Upon Resident #1's rising, Surveyor # observed that Resident #1 had been sitting on a lap blanket and soaker pad placed over the top of a tan colored inflatable cushion with multiple openings. The cushion was deflated and flat. According to Resident #1's care plan, he is to have a foam cushion to reduce pressure while sitting. RN-E completed the assessment and documented, "Stage 2 resolved. Incontinence Associated [MEDICAL CONDITION]: Yes blanchable pinkness discoloration with purplish blister formation. Right buttock 2cm x 0.8 cm. Left buttock 1.8cm x 0.6cm ...bilateral buttocks have blanchable ruddiness with purplish blisters ..." Of note, Resident #1 had an indwelling urinary catheter at the time of the assessment. On 3/22/11, Surveyor # asked RN-E why Resident #1 had the purple blisters. RN-E stated that she believed it was a perspiration factor and possible shearing. RN-E stated that she thinks the leather lift chair, a brief, soaker pad and the inflatable cushion were all factors. Example #3: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3 is currently receiving [MEDICAL CONDITION]. A nurse's note on 3/11/11 states, "...Pressure ulcer present: Yes on right side of coccyx. # of Stage 1 Present: Number present: 1. Location of each: one on right side of coccyx ...Skin and Ulcer Treatments: Pressure reducing device/bed, Turning/repositioning program, Ulcer care, Application of nonsurgical dressings, Summary of Findings: Has pressure ulcer, Has skin problems ..." The entry does not include measures or a detailed assessment of the wound characteristics. Despite knowledge of the pressure ulcer upon admission, a care plan was not developed to address Resident #3's immediate care needs related to skin integrity. The initial care plan is needed to direct staff on proper interventions of problems to prevent any complications or declines. An entry in the nurse's notes dated 3/15/11 states, "Pressure Ulcer: Stage 2 partial thickness ...Location: left buttock. Size: Length/CM 1, Width/CM: 0.5, Depth/CM: 0.2 ...Wound Bed: Beefy red, Moist ...Summary of Findings: Resident was admitted to the facility with stage 2 on his left buttock ...Will further evaluate effectiveness as had no measurements for comparison ..." According to documentation on 3/11/11, Resident #3 had a Stage 1 on the right side of the coccyx. The 3/15/11 note identifies a newly developed Stage 2. A Skin Committee Note dated 3/15/11 states, "...care plan and interventions reviewed. Ergo slide and low air loss mattress in place. See care plan ..." Resident #3's care plan includes a problem of "Skin Integrity" dated 3/15/11. Approaches include, " ...Pressure relieving device(s) for bed. Loss (sic) air loss. Pressure relieving devices for chair: foam. Encourage him to do buttock lifts. Ergo slide for shearing prevention. Keep heels off bed. Specialty mattress. Position off: left buttock ... " On 3/22/11, an entry in the nurse's notes states, "Pressure ulcer: Stage 2 ...Location: left buttock. Size: Length/CM: 2, Width/CM: 2 discoloration. Size: Length/CM: 1, Width/CM: 0.3, Depth/CM: 0.2. Wound Perimeter: Attached, Maceration present. Wound Bed: Pink, pearly, moist. Tissue Condition: Granulation present ..." This note indicates that Resident #3 now has 2 pressure ulcers. Review of the care plan finds no new interventions after the development of the second pressure ulcer. On 3/23/11, Surveyor # requested a copy of the initial admission care plan for Resident #3. The DON (Director of Nurses) stated that she first started the nursing care plan on 3/14/11. The DON stated that a care plan is to be written right away for a new admission. Example #4: Resident #9 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #9's current MDS (Minimum Data Set) dated 3/3/11, indicates Resident #9: ~Has both short and long-term memory problems; ~Has a severe cognitive impairment; ~Requires total assistance of 1-2 staff persons for bathing, toileting, bed mobility, transfers, and does not walk; ~Has ROM (range of motion) impairments of the upper and lower extremities, which interferes with daily functions and/or places Resident #9 at risk for injury; ~Is always incontinent of bowel and bladder; ~Is at risk of developing pressure ulcers; and, ~Has no pressure ulcers. Of note, during the 7 day look back period, Resident #9 did have a pressure ulcer. The 3/3/11 MDS incorrectly indicated that Resident #9 had no pressure ulcers. Resident #9's care plan includes a problem of "Skin Integrity" originally developed 8/14/07. Approaches include: "8/14/07, ...pressure relieving device(s) for chair...pressure relieving device(s) for bed..." "4/2/08...Wedge cushion to position on side..." "11/28/08...Elbow protectors/Foot cradle..." "3/10/09...reposition hourly; pillow between legs..." "12/2/09...Soft foot boots on bilaterally when in bed..." "8/30/10...caution with pulling buttock to prevent any tissue tear..." "10/5/10...encourage to elevate heels..." Resident #9's CNA (Certified Nursing Assistant) care plan had the approaches as listed above. Additionally, it had an approach which indicated, "...ergo slide for repositioning...may have sling under resident while up in w/c..." A Braden Scale (used to determine a person's risk for developing a pressure ulcer) was completed on 1/3/10 and scored Resident #9 at "11". According to this scale, a score of 10-12 is High Risk. Resident #9's wound notes indicate the following: 1/11/10, "...partial thickness with denuded areas left buttock. Size, denuded Length/CM (per centimeter) 10, Width/CM: 8. Size, upper partial thickness Length/CM: 0.5, Width/CM 0.9...Depth/CM: 0.2. Size, lower partial thickness Length/CM: 1.5, Width/CM 1.2, Depth/CM: 0.2. Location, right buttock. Size, denuded Length/CM: 10, Width/CM: 8...partial htickness (sic). Size, Length/CM: 1, Width/CM: 1.4...Depth/CM: 0.2. Wound perimeter, Attached, [DIAGNOSES REDACTED] present. Wound Bed: Beefy red, Moist...Summary Of Findings: New open area...Resident has had denuded bilateral buttocks most likely r/t (related to) IAD (Incontinence Acquired [MEDICAL CONDITION])... Will continue with the extra protective barrier cream ove (sic) gluteal cleff and gluteal fold for additional protection. Reposition every 1 hr (hours)...Continue current plan of care." 1/26/10, "...coccyx slit...Length/CM: 3, Width/CM: 0.2, Depth/CM: 0.1...new open area..." 1/29/10, "...She has IAD with denuded bilateral buttocks and stage 2 on her buttocks..." 2/2/10, "...Pressure Ulcer: Stage 2 partial thickness with IAD r/t incontinence...Location left and right buttocks...Continue with current plan of care. On 3/8/10, the wound notes indicate that the pressure ulcers were noted to be healed. A Braden Scale was completed on 3/29/10 and scored Resident #9 at "12" or High Risk. A Braden Scale was completed on 6/23/10 and scored Resident #9 at "13" with a score of 13-14 being moderate Risk. Wound notes continue: 7/13/10, "Pressure Ulcer: Stage 1 nonblanchable...Location: right buttock. Size: Length/CM 1, Width/CM: 2.2...Wound perimeter: Intact, denuded....Pressure Ulcer: Stage 2 ...Location: Left buttock. Size: Length/CM 1.5, Width/CM: 3... 7/22/10, "Pressure Ulcer: Stage 2 discoloration with nonblanchable area remaining. Location: left buttock. Size Length/CM 0.7, Width/CM: 2.9. Location: right buttock. Size: Length/CM 0.5, Width/CM: 1. Size: Length/CM 1, Width/CM: 0.2..." 8/3/10, "Pressure Ulcer: Stage 2 resolved...Location: Left buttocks, Right buttocks. No new interventions were added to Resident #9's care plan to address prevention of future pressure ulcers. Wound Care notes continue: 8/11/10, "Pressure Ulcer: Stage 2 partial thickness...Location: left buttock. Size: Length/CM: 0.3, Width/CM: 0.3, Depth/CM: 0.1..." The left buttock had been documented as being resolved on 8/3/10. 8/18/10, "Pressure Ulcer: Stage 2. Location: right buttock. Size: Length/CM: 2, Width/CM: 1.7. Location: left buttock. Size: Length/CM: 1.3, Width/CM: 2.4. Location: gluteal cleff. Size: upper Length/CM: 3, Width/CM: 0.2, Depth/CM: 0.1. Size: lower Length/CM; 3, Width/CM: 0.3, Depth/CM: 0.1...Continue current plan of care..." 8/24/10, "Pressure Ulcer: Stage 2 resolved..." On 8/30/10, Resident #9's Skin Integrity care plan was updated with the approach, "Nurses--caution with pulling buttocks to prevent any tissue tear." No new approaches related to pressure ulcer prevention were added to Resident #9's care plan. A 9/14/10 Braden Scale scored Resident #9 at 13 or Moderate Risk. Wound Care notes continue: 2/14/11, "Pressure Ulcer: Stage 2 partial thickness...Location: right gluteal fold. Size: Length/CM: 1, Width/CM: 1, Depth/CM: 0.1. Location: left gluteal fold. Size: Length/CM: 2, Width/CM: 2.5, Depth/CM: 0.2...Wound perimeter attached, maceration present. Wound Bed: Moist, pink, pearly...Summary of Findings: New pressure ulcer (sic)...Continue current plan of care. 2/15/11, "Skin Committee Meeting Note...Stage 2 ulceration on bilateral gluteal folds noted...Care plan and intervention reviewed. See care plan. Continue with current plan of care." 2/22/11, "Pressure Ulcer: Stage 2 partial thickness epithealized over...Location: right gluteal fold. Size, Length/CM: 1, Width/CM: 7 epithealized. Location: left gluteal fold. Size: Length/CM: 1.5, Width/CM: 2 epithealized...continue with current plan of care." 3/1/11, "The [MEDICATION NAME] dressings on the right and left gluteal fold were changed yesterday and remain intact. Will assess further next week. Recommend to continue with current therapy." There is no documentation of the size or characteristics of the pressure ulcers. 3/7/11, "Pressure Ulcer: Stage 2 partial thickness...Location: right gluteal fold. Size: Length/CM: 0.5, Width/CM: 0.5, Depth/CM: 0.1. Location: left gluteal fold. Size: lateral Length/CM: 1.8, Width/CM: 0.8, Depth/CM: 0.2. Size: Length/CM: 0.3, Width/CM: 0.3, Depth/CM: 0.2. Size: medial Length/CM: 0.8, Width/CM: 1 Depth/CM: 0.2...The right gluteal fold is more superficial. The left gluteal fold has 3 open areas with large amount of maceration. Recommend to keep the Hoyer lift out from under buttock area when up in chair...Continue current plan of care." The recommendation to keep the Hoyer lift out from under Resident #9's buttocks when up in the chair was not added to Resident #9's care plan. On 3/22/11 at 7:20 a.m., Surveyor # observed RN-B (Registered Nurse) complete the dressing changes to Resident #9's pressure ulcers. CNA-L (Certified Nursing Assistant) had requested RN-B to complete a dressing change as the [MEDICATION NAME] on Resident #9's buttocks was wrinkled and not fully adhered to Resident #9's skin. This was also observed by Surveyor # . RN-B began to remove the [MEDICATION NAME] from Resident #9's right and left gluteal folds. During this time Resident #9 cried out many times, "Ow!" RN-B indicated to Surveyor # that the pressure ulcers were looking much better. RN-B indicated that the pressure ulcer had "almost been a Stage 3." Surveyor # observed the pressure ulcers on Resident #9's buttock. Surveyor # noted the left and right ischial areas had an area of discoloration measuring approximately 10cm (centimeters) in diameter. On the right gluteal fold there was a Stage II pressure ulcer measuring approximately 0.5cm in diameter. On the left gluteal fold there was pressure ulcer measuring approximately 1.0cm in diameter CNA-L then cleansed Resident #9's buttock area including the areas where the pressure ulcers were. During this process, Resident #9 cried out, "Ow!" several times and tightened her buttock muscles. RN-B then placed skin prep around the open areas on Resident #9's right and left gluteal folds. During this time Resident #9 cried out, "Ow!" RN-B then placed and held a [MEDICATION NAME] to Resident #9's right and left gluteal folds. During this time, Resident #9 hollered out, "Ow!" RN-B then applied a barrier cream to Resident #9's buttock area at which point Resident #9 again hollered out, "Ow!" During the dressing change and application of a barrier cream, RN-B changed his gloves appropriately, however the handwashing completed with each glove change was approximately 1-2 seconds. (Refer to F441.) The ergo slide was not in use during this observation. On 3/22/11 at 9:35 a.m., Surveyor # observed CNA-G and CNA-L assist Resident #9 into bed via a Hoyer lift. CNA-G and CNA-L then removed Resident #9's pants and adult brief. Surveyor # noted that the adult brief was not wet. This was verified by CNA-L. Surveyor # also noted an indented reddened line on the back of Resident #9's upper thighs measuring approximately 1.5 inches in width. This area matched the binding of the Hoyer pad. An ergo slide was not in place. On 3/22/11 at 2:15 p.m., Surveyor # observed the cushion in Resident #9's wheelchair. The cushion was noted to be a Skil-Care cushion. The cushion was noted to be firm and not soft or pliable. On 3/29/11 at 11:30 a.m., Surveyor # spoke with a representative from Skil-Care. The representative indicated that the cushion in Resident #9's wheelchair was a pressure reduction cushion. The representative indicated however that there are better cushions for treating residents with pressure ulcers which offer greater pressure reduction On 3/24/11 at 11:15 a.m., Surveyor # spoke with COTA-J (Certified Occupation Therapy Assistant). COTA-J indicated that she was involved in the wound team. COTA-J indicated she is the person who screens residents for wheelchair positioning including appropriate wheelchair cushions to prevent sheering. COTA-J indicated that when nursing identifies a concern, they will initiate a screen and she, in turn, will complete the screen. Surveyor # asked COTA-J if she completed a screen for Resident #9 or was involved in looking at wheelchair cushions for Resident #9. COTA-J indicated she had not. On 3/23/11 at 10:55 a.m., Surveyor # spoke with CNA-I and questioned what an ergo slide was. CNA-I indicated that it was a large pad made of a special type of material designed to prevent sheering. CNA-I indicated it was placed under the residents while in bed and used to turn and reposition them. On 3/24/11 at 9:10 a.m., Surveyor # spoke with RN-B about Resident #9's pressure sores. RN-B indicated that he felt they were due to Resident #9's incontinence and intermittent loose stools. On 3/24/11 at 11:30 a.m., Surveyor # spoke with the DON (Director of Nursing) about Resident #9's pressure ulcers. Surveyor # asked the DON what her thoughts were on how and why Resident #9 had developed several Stage II pressure ulcers over the last year. The DON indicated that that was "a loaded question" and gave no further response. Example #5: Resident #7 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. On 10/26/10, Resident #7 had a fall in the facility which resulted in a left [MEDICAL CONDITION]. Resident #7 was subsequently hospitalized for [REDACTED]. The most current MDS was dated 1/13/11, indicates Resident #7: ~Cognition is moderately impaired; ~Requires limited to extens

Based on observation, interviews and record reviews, the facility did not ensure that 3 out of 8 residents reviewed for pain received pain interventions consistent with current standards of practice. Residents #21, #23, and #24 received [MEDICATION NAME] for pain management; however the LN (Licensed Nurse) did not evaluate or document the effectiveness of these interventions. This is evidenced by: On 05/19/11, the DON (Director of Nurses) provided Surveyor # with a copy of the facility policies titled "Pain Assessment" and "Pain Assessments for Cognitively Impaired/Dementia Residents." Noted in both polices was "PURPOSE...To continue managing pain and to identify a need for a change in the resident's treatment plan." Also in both polices was "PROCEDURE...Effectiveness of PRN (as needed) pain medication is monitored in medication administration record (MAR)." Example #1: Resident #21 was admitted to the nursing home on 05/13/11 following bilateral knee replacement surgery. The facility had not developed a care plan to address Resident #21's pain concerns, approaches, or goals. On 05/17/11 at approximately 3:30 p.m., Surveyor # interviewed Resident #21 regarding his nursing home stay. Resident #21 was asked what pain interventions were utilized by the nursing home staff as well as how effective was the nursing home staff at managing his knee pain. Resident #21 reported the nursing home staff administered scheduled and as needed pain medications and that these medications had been increased since his admission. In addition to pain medication, Resident #21 reported that the nursing home staff were using ice packs to manage the pain. Resident #21 stated that overall the nursing home staff was providing good pain relief. Resident #21 was observed on 05/17/11 at 3:30 p.m. and 05/19/11 at 8:25 a.m. by Surveyor # to be resting in bed with both legs elevated and heels floated off of the bed. Resident #21 had no subjective signs of pain during the observations. Surveyor # reviewed the MAR and noted the following dates and times when as needed [MEDICATION NAME] were administered to Resident #21 and there was no follow up assessment to determine the efficacy of the medications: *05/15/11 at 11:00 p.m. Tylenol given; *05/13/11 at 6:30 p.m. [MEDICATION NAME] 5 mgs (milligrams) given; *05/14/11 at 3:10 a.m. [MEDICATION NAME] 10 mgs given; *05/15/11 at 6:30 a.m. and 10:00 a.m. [MEDICATION NAME] 10 mgs given; *05/16/11 at 9:30 p.m. [MEDICATION NAME] 10 mgs given; *05/17/11 at 8:00 p.m. [MEDICATION NAME] 10 mgs given. Review of the nurses notes found multiple entries documentating that Resident #21 had "horrible and excruciating" pain, but none that addressed the effectiveness of the prn pain medication or to correlate with the pain medication times. Example #2: Resident #23 was admitted to the nursing home on 05/09/11 with a [DIAGNOSES REDACTED]. On 05/10/11 the facility developed a care plan titled "Comfort" for Resident #23. Resident #23's pain goal was a 4 on a 0-10 scale. Interventions listed on the care plan were prn medications, offer diversion, use pillow for comfort, encourage rest periods, and update physician as needed. On 05/18/11 at 11:15 a.m., Surveyor # interviewed Resident #23 regarding her nursing home stay. Resident #23 stated her back pain was controlled with as needed Tylenol. Resident #23 stated she was satisfied with her nursing care and pain control. On 05/18/11 at 11:21 a.m., Surveyor # observed Resident #23 transfer from the wheelchair into bed by the rehabilitation aide. Resident #23 had no verbal or facial expressions of pain. Surveyor # reviewed the MAR and noted the following dates and times when as needed [MEDICATION NAME] were administered for Resident #23 and there was no follow up assessment to determine the efficacy of the medications: *05/11/11 at 11:10 p.m. Tylenol given; *05/12/11 at 8:15 p.m. Tylenol given; *05/16/11 at 12:50 a.m. and 6:00 p.m. Tylenol given. Surveyor # reviewed the MAR and noted the following dates and times when as needed [MEDICATION NAME] were administered for Resident #23 and the documentation did not meet the facility policy. The medication effectiveness assessment was completed by the next shift during a routine every shift pain assessment. *05/11/11 at 2:40 a.m. Tylenol given; *05/13/11 at 4:50 a.m. Tylenol given; *05/14/11 at 4:00 a.m. Tylenol given; *05/15/11 at 3:30 a.m. and 1:00 p.m. Tylenol given; *05/17/11 at 3:30 a.m. Tylenol given. Review of the nurses notes noted multiple pain documentation that indicated Resident #23 had "mild to moderate back pain", but none that addressed the effectiveness of the prn pain medication to correlate with the prn medication use. Example #3: Resident #24 was admitted to the nursing home on 10/19/10 following a fall at home. Resident #24 had a foot ulcer which caused her pain. The facility developed a care plan titled "Comfort" for Resident #24. Resident #24's pain goal was 4 on a 0-10 scale. Interventions noted in the care plan were Tylenol as needed, pain scale three times per day and give prn medications if pain greater than goal. On 05/18/11 at 10:35 a.m., Surveyor # interviewed Resident #24 regarding her stay at the nursing home. Resident #24 stated she continued to receive foot ulcer care and that the foot ulcer does cause her some pain. Resident #24 stated that she is satisfied with the nursing care and pain control that is provided to her. During the interview, Surveyor # did not detect any subjective signs of pain. Surveyor # reviewed the MAR and noted the following dates and times when as needed [MEDICATION NAME] were administered to Resident #24 and there was no follow up assessment to determine the efficacy of the medications: *05/08/11 at 9:30 p.m. Tylenol given; *05/11/11 at 2:00 a.m. Tylenol given; *05/12/11 at 2:45 a.m. Tylenol given. Surveyor # requested additional documentation that would address the effectiveness of prn pain medications and no documentation was provided. On 05/19/11 at 11:45 a.m., Surveyor # interviewed the DON regarding the facility expectations for pain management. The DON stated that staff have been educated on the facility pain policy which was to assess the effectiveness of as needed pain medications and record the findings on the MAR. The DON stated that she has already identified 2 LNs (Licensed Nurses) who did not follow the facility pain policies regarding assessments of prn medications as well as documentation. The DON stated both LNs have been reeducated on the facility policies. On 05/19/11 at 11:00 a.m., Surveyor # interviewed LPN-T (Licensed Practical Nurse) regarding pain assessments. LPN-T stated that the LN should assess the effectiveness of pain medications approximately 20 to 30 minutes after administration. LPN-T stated that the LN should document the assessment on the resident's MAR, update the physician if ineffective, and consider other interventions. On 05/19/11 at 11:40 a.m., Surveyor # interviewed RN-N (Registered Nurse) regarding pain assessments. RN-N stated that prn medications are given followed by an assessment of the effectiveness after about 30 minutes. RN-N stated that information should be documented on the MAR. On 05/19/11 at 11:55 a.m., Surveyor # interviewed RN-Y via telephone regarding pain assessments. RN-Y stated she had received further education from the DON on the facility's pain assessment policy. RN-Y stated that both Resident #23 and #24 were reliable residents when reporting pain. On 05/19/11 at 12:10 p.m., Surveyor # interviewed LPN-Z via telephone regarding pain assessments. LPN-Z stated he had received further education from the DON on the facility's pain assessment policy. LPN-Z stated the need to reassess residents following prn medication administration was not a new concept and that he had been trained on the need for reassessment during his nursing education as well as during the facility orientation. LPN-Z stated that assessing the effectiveness of pain medication was a reasonable facility request. LPN-Z stated that Resident #23 and #24 were reliable to provide accurate information regarding pain.

Based upon observations, interviews and record review, the facility did not ensure that 1 of 9 sampled residents reviewed for incontinence and catheter use received appropriate treatment related to their bladder function. Resident #2 had a change in bladder status. Staff did not comprehensively assess Resident #2's bladder status and did not develop a plan to assist Resident #2 in restoring as much bladder function as possible. Due to the incontinence and the facility's failure to manage the incontinence, Resident #2 developed skin breakdown. The facility then placed an indwelling urinary catheter. This is evidenced by: According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. Surveyor # completed a review of the facility's policy titled, "Bowel and Bladder Collection Assessment," revision date of 7/7/2009. "...Complete if the resident has a bowel movement, is incontinent of bowel or bladder, has experienced a change in their continence status, had a Foley catheter removed and quarterly...B. Complete the bladder record for 3 days. Day 1 complete for 24 hours. On day 2 and 3, at least 12-hours each day during waking hours. (Example: 8 a.m. to 8 p.m.). ......F. When bladder diary and prompted voiding trial is complete, analyze the results. Consider: i. Does resident recognize the need to void? ii. When placed on appropriate receptacle, did the resident void? iii. Did the number of wet episodes decrease with prompt void or toileting? iv. Is resident receiving medications that cause increase in need to void at certain times of the day? v. Does resident request to be awaken at night to void? G. On day 4 RN/LPN review assessment, summarize findings and develop a plan. Complete incontinence assessment and incontinence assessment type...." Resident #2 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment dated [DATE], indicates Resident #2: ~Is able to make his own decisions and makes his needs known; ~Is dependent on staff for transfers with the use of a Hoyer lift; ~Requires extensive assistance of one staff for bed mobility, toilet use, and personal hygiene; ~Has impairment on both sides of lower extremities and uses a wheelchair; ~Is continent of bladder and occasionally incontinent of bowel; ~Is at risk for developing pressure ulcers; and, ~Does not have any open areas. Review of the Bladder and Bowel Record from 6/19/10 through 6/21/10 finds that Resident #2 was incontinent only 2 times. The Summary of Findings states, "Continent. Needs assist to the toilet. Assist with urinal and bed pan." Wound Care note dated 11/1/10 states that Resident #2 had denuded areas on both buttocks. The Summary of Findings state, "...gentamyasin ointment and lotimum HCL is effective in maintaining skin integrity." Wound care note dated 11/9/10 states that IAD was resolved. On 11/9/10, Resident #2's Skin Integrity care plan was updated to include an approach of, "Routine cleansing and barrier cream with incontinence care." Wound care note dated 11/23/10 states, "...Increased denuded area with scant excoriation...Location: bilateral buttocks." No measurements were documented. Summary of findings state, "...increased denuded buttocks from IAD of moisture when utilizing urinal. Recommend to continue to cleanse, pat dry, and utilize barrier cream...Continue plan of care." These areas were documented as resolved on 12/7/10. There are no other Wound Care notes until 3/9/11. On 1/24/11, Resident #2's Bladder and Bowel care plan was updated to include the approach, "When using urinal, encourage Resident #2 to raise HOB (head of bed) to prevent spilling." Another Bladder and Bowel Record was initiated on 2/16/11 and was to be completed through 2/18/11. Review of the information finds that data was not collected for 37 hours over the 3 day period. The data that was collected indicates Resident #2 remains continent of bladder with only 1 episode of incontinence. The Summary of Findings indicate Resident #2 is continent of bladder, but also that Resident #2 has "non-functional incontinence." Types of incontinence include stress, functional, overflow, urge, and mixed. Review of the Wound Notes finds the following entries: ~3/9/11, "Incont (Incontinence) Associated [MEDICAL CONDITION] (IAD): Yes partial thickness with reddened area with satellite [MEDICAL CONDITION] noted..." The note indicates an area of IAD on the left buttock that is 0.5 x 0.4 x 0.2, and 4 areas on the right buttock: *0.8 x 0.7 x 0.4 *0.5 x 1 x 0.2 *0.4 x 1 x 0.2 *1 x 0.7 x 0.2 "3/9/11, Skin Committee Meeting Note:...Large amount of reddened rash with satellite [MEDICAL CONDITION]; utilizing [MEDICATION NAME] and [MEDICATION NAME] cream...Continue with current plan of care. "3/14/11, Incont Associated [MEDICAL CONDITION]: yes few small partial thickness areas with redness and satellite [MEDICAL CONDITION]: left buttock. Size: 0.4 x 0.4 x 0.2 (four small areas with excoriation.)..." "3/15/11, Skin Committee Meeting Note:...The IAD has continued to worsen with increased rash, excoriation and some partial thickness slits noted...Discussion with resident that this type of rash is moisture related and even through measure for decreasing moisturization have been taken; condition has worsened. Recommend to place foley cath (catheter) to control incontinence...Continue with current plan of care." Six days after the IAD developed (per the record, Resident #2 had been free of IAD since 12/7/10), a catheter was placed. There is no evidence that the facility explored reversible causes of Resident #2's incontinence. There is no evidence that the facility attempted different interventions or modified his environment to restore as much normal bladder function as possible. On 3/23/11 at 11:00 a.m., Surveyor # interviewed Resident #2. Resident #2 stated that he recently developed a "bedsore." Resident #2 stated he was incontinent at night and would wake up wet. Resident #2 stated the facility related the wetness to the urinal spilling. Surveyor # then asked Resident #2 if the facility provided him with a non-spill urinal. Resident #2 stated that anatomically, he did not believe it would work. Resident #2 stated he no longer has a stream when he voids. He stated that this is new for him and is of recent onset. When Surveyor # asked Resident #2 if he told anyone else, he stated no one had asked him. Surveyor # then asked him if any nurses talked to him about his incontinence and no stream with voiding Resident #2 replied, "No." Resident #2 also stated he did not think his physician was aware. He proceeded to say he now has a Foley Catheter. On 3/22/11 at 8:00 a.m., Surveyor # interviewed the wound Care Nurse RN-E who stated Resident #2 has IAD, and the barrier cream is now working well. RN-E stated the nurses tried a [MEDICATION NAME] dressing and other creams but nothing had worked. RN-E stated the catheter is in for one month and if skin is better, then Resident #2 would be re-evaluated. On 3/22/11 at 8:18 a.m., Surveyor # observed Resident #2's buttock area. Bilateral buttocks had cream spread over the non open faded red areas. Resident #2 stated that the Wound Care Nurse just cleansed the wounds and said they no longer are open and look much better.