Every finding on record at Temple View Transitional Care Center

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified or b) residents were injured due to unsafe areas in the facility. Findings include:The facility's Homelike Environment policy, undated, documented Temple View Transitional Care is committed to providing residents with a safe, clean, comfortable, and homelike environment that promotes dignity, independence, choice, and quality of life. This policy ensures compliance with federal regulations while supporting a person-centered care philosophy. The following areas were observed: a) On 1/5/26 at 8:12 AM, observed a fly strip covered with bugs in the middle of room [ROOM NUMBER]. Observed another fly strip by the window with several bugs on it. On 1/5/26 at 8:14 AM, Resident #8 stated the fly strips had been there since last summer and the maintenance man had placed them there. b) On 1/5/26 at 8:15 AM, observed in room [ROOM NUMBER]'s restroom, a metal bracket sticking out from the wall at eye level. On 1/5/26 at 8:16 AM, Resident #8 stated she did not know what metal bracket I was asking about because she cannot see very well. c) On 1/5/26 at 10:26 AM, observed in room [ROOM NUMBER]'s restroom the vent was covered with a gray fuzzy substance. d) On 1/5/26 at 11:22 AM, observed the vent in the ceiling, on the hallway outside the dining rooms covered with a thick black substance. The vents in the front lobby had a black substance on the vent and on the ceiling surrounding the vent. e) On 1/6/ 26 at 11:35 AM, observed the walls by Hall 100's nurse's station with large areas of the walls with gouges and missing paint in several different areas. The vent above the nurse's station was observed to have a black substance on the vent and on the ceiling around the edge. On 1/6/26 at 1:09 PM, review of the Housekeeping Weekly Cleaning Schedule did not document cleaning of the vents. On 1/6/26 at 11:45 AM, the Maintenance Supervisor stated the walls should have been repaired and the vents needed to be cleaned but he was not sure whose job it was to clean the vents. He also stated the fly strips, and the metal bar should not have been in room [ROOM NUMBER]. On 1/6/26 at 11:54 AM, the DON stated she did not know the fly strips were in room [ROOM NUMBER] and they should not have been there. On 1/7/26 at 11:57 AM, the Administrator stated the vents should have been cleaned by maintenance but had not been cleaned for a year. On 1/6/26 at 12:02 PM, observed in the Medication Prep room on the 100 Hall, the sharps container filled past the full line and the wall mount enclosure was unlocked and the door ajar. On 1/6/26 at 12:45 PM, RN #2 stated the sharps container should have been changed when it was full, and the enclosure locked. On 1/7/26 at 11:08 AM, the DON stated the sharps containers should have been changed when full and the enclosure locked.

Based on observation, review of the State Operations Manual, and staff interviews, the facility failed to treat residents who needed assistance with eating their meals with dignity and respect. This failed practice had the potential to negatively affect resident's self-esteem, decreased enjoyment of meals and mealtime, and may impact resident's food and fluid intake. Findings include:On 1/5/26 at 11:37 AM, RNA #1 was observed standing next to the dining room table, spoon feeding Resident #34 when he was seated at the table eating his lunch.On 1/5/26 at 11:40 AM, RNA #1 stated she always stands so she can move around the room to help other residents if they need it. On 1/5/26 at 11:50 AM, the DON and the Regional Nurse stated staff should not be standing while feeding residents.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Infection Control Prevention and Control Program - Hand Hygiene Policy Updated 1/1/22, documented wash hands with soap and water for the following reasons: a. Before eating or after using the restroom b. When hands are visibly soiled; and c. After contact with a resident with infectious diarrhea including but not limited to infections caused by norovirus and C. difficile. The following was observed for hand hygiene: a) On 1/5/26 at 7:48 AM, observed LPN #1 serve Resident #23 his meal tray in his room. Resident #23 was not offered or encouraged to perform hand hygiene before eating. On 1/5/26 at 7:50 AM, observed LPN #1 serve Resident #8 her meal tray in her room. Resident #8 was not offered or encouraged to perform hand hygiene before eating. On 1/5/26 at 7:51 AM, LPN #1 stated she should have offered the residents hand hygiene with meals. b) On 1/5/26 at 10:47 AM, LPN #1 changed Resident #22's wound vac (a non-surgical treatment using a sealed dressing, foam, and a portable suction pump to remove fluid, reduce swelling, and draw edges together and promote faster healing). The following was observed: LPN #1 washed her hands in the restroom using soap and water. She then donned a gown and gloves. She removed Resident #22's socks, Ace bandage, Kerlix (gauze roll), and old dressing. She then removed her gloves and applied a new pair of gloves. LPN #1 did not wash her hands between glove changes after cleaning Resident #22's wound. She cleaned the wound with normal saline. She then removed her gloves and applied a new pair of gloves. LPN #1 did not wash her hands between gloves changes after cleaning the wound. LPN #1 applied skin prep around the wound bed as a barrier. She then applied Adaptic (a non-adherent wound dressing) over the wound bed. LPN #1 applied black foam over the Adaptic and then covered the suction device with a barrier dressing. LPN #1 removed her gloves and then washed her hands in the restroom with soap and water. On 1/5/26 at 11:03 AM, LPN #1 stated she should have washed her hand between glove changes and thought she had. The following was observed for enhanced barrier precautions: On 1/5/26 at 8:16 AM, observed Enhanced Barrier Precaution signage on Resident #35's door. On 1/5/26 at 8:17 AM, observed CNA #1 and CNA #2 enter Resident #35's room and had transferred her from the wheelchair to the bed. CNA #1 and CNA #2 had not donned proper PPE before transferring Resident #35. On 1/5/26 at 8:23 AM, CNA #2 stated they should have used donned PPE before transferring Resident #35. The following was observed for hall trays: On 1/5/26 at 12:10 PM, observed RN #2 communicating to two other staff present that there was one undelivered tray remaining in the food cart, RN #2 then removed a dirty food cover and meal tray from the food cart. On 1/5/26 at 12:18 PM, RN #2 stated the dirty food cover and meal tray should not have been put in the meal cart when there were undelivered lunch trays in the cart.

Based on review of the State Operations Manual, interview, and record review, it was determined the facility failed to employ a qualified Director of Food and Nutrition Services. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include:On 1/5/26 at 7:40 AM, during the initial tour of the kitchen, the Dietary Supervisor stated he is not a Certified Dietary Manager or qualified Director of Food and Nutrition Services but was enrolled in a Certified Dietary Managers course.On 1/5/26 at 7:41 AM, the Assistant Dietary Supervisor stated she is not Certified Dietary Manager, or Qualified Director of Food and Nutrition services but she took the Certified Dietary Manager course in 2023. She stated she did not attend the required 3-day in person training that was required to complete the course and had to take the course over.On 1/7/26 at 2:10 PM, the Administrator stated the Dietary Supervisor and Assistant Dietary Supervisor are not qualified Directors of Food and Nutrition services but are enrolled in an online Certified Dietary Managers course and should be certified by the end of this year.

Based on observations, record review and staff interviews it was determined the facility failed to ensure medications were properly stored and not expired. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy. Findings include:The following was observed during the medication cart audits. On 1/6/26 at 10:52 AM, the 200 Hall medication cart was audited with RN #1 present. Observed the following: - one bottle of Gas Relief with an expiration date of 7/25 printed on the bottle On 1/6/26 at 10:56 AM, RN #1 stated, the bottle of Gas Relief should have been discarded and had not been. On 1/6/26 at 2:25 PM, the DON stated the expired medications should have been removed from the medication cart and had not been.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were assessed appropriately for adequate indications for the use of opioid pain medications. This was true for 1 of 17 residents (Resident #2) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse consequences or increased risk of death. Findings include:The facility's Unnecessary Drugs policy, dated revision 5/2020, documented a resident's medication regime must be free from unnecessary drugs; in excessive dose, excessive duration, without adequate monitoring, without adequate indications for its use, or in the presence of adverse consequences or any combination of these reasons.Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including right above knee amputation and diabetes.Resident #2's medical record included the following physician orders for pain medication:Acetaminophen Oral Tablet 325 Mg Give 1 tablet by mouth every 4 hours as needed for pain - Pain rated 1-5 - Order date 10/27/25.Percocet Oral Tablet 10-325 Mg (Oxycodone w/Acetaminophen) - Give 1 tablet by mouth every 4 hours as needed for Max of 4 a day for Pain rated 6-10 - Order date of 10/30/25.The following was documented on Resident #2's MAR for administration of Percocet 1 tablet:-11/7/25 at 9:35 PM for pain level of 5- 11/24/25 at 6:47 AM for pain level of 5-11/29/25 at 8:54 PM for pain level of 5-12/15/25 at 8:53 PM for pain level of 5-12/26/25 at 9:19 PM for pain level of 5-12/27/25 at 12:48 PM for pain level of 4-1/2/26 at 8:50 PM for pain level of 5-1/5/26 at 9:03 PM for pain level of 5On 1/7/26 at 10:40 AM, the DON stated the pain medication should have been administered as ordered according to the pain level and had not been.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 1/7/26 at 4:40 PM, during the 200 Hall medication cart audit, observed the narcotic accountability sheet, dated 1/1/26 to 1/7/26, with 1 licensed nurse signature not documented. On 1/7/26 at 4:42 PM, CMA #1 stated two nurses should have signed the narcotic accountability sheet and she had not signed it when she accepted the medication cart today. On 1/7/26 at 4:45 PM, during the 100 Hall medication cart audit, observed the narcotic accountability sheet, dated 1/1/26 to 1/7/26, with 1 licensed nurse signature not documented. On 1/7/26 at 4:47 PM, LPN #2 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 1/7/26 at 5:07 PM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on policy review, record review, observation, and staff interview, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted and how the alternatives failed to meet the resident's assessed needs. This was true for 1 of 17 residents (Resident #41) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment, and/or death. Findings include:The facility's Bed Rail Policy revised August 2017, documented It is the policy of the facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails.The facility should maintain evidence that it has provided sufficient information so that the resident or resident representative could make an informed decision. Information that the facility must provide to the resident, or resident representative include, but are not limited to:What assessed medical needs would be addressed by the use of bed rails;The resident's benefits from the use of bed rails and the likelihood of these benefits;The resident's risks from the use of bed rails and how these risks will be mitigated; andAlternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate.Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypercapnia (a lung condition that can cause confusion and severe shortness of breath), schizoaffective disorder (a serious mental illness), and AFib (an irregular heartbeat where episodes start and stop on their own).On 1/5/26 at 10:21 AM, Resident #41 was observed with bilateral upper side rails on his bed. Resident #41's medical record did not have documentation of the evaluation of the alternatives attempted or documentation of the purpose of the intended use of the side rails.On 1/6/26 at 1:38 PM, the DON stated Resident #41 did not have a side rail assessment completed and should have.

Based on observation, interviews, and record review, the facility failed to ensure resident received oxygen as prescribed by the provider. This was true for 2 of 17 residents (#9 and #30) reviewed for respiratory care. This failure created the potential for respiratory difficulties or impaired breathing. Findings include:Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (disease caused by damage to the airways that limit airflow) and depression. Resident #9's medical record included physician orders for oxygen 1.5 liters per minute via nasal cannula continuously. Order start date of 11/6/25. On 1/5/26 at 11:35 AM, observed Resident #9 sitting in the dining room with oxygen administered at 2L/min via nasal cannula. On 1/6/26 at 11:20 AM, observed Resident #9 sitting in her room with oxygen administered at 2L/min via nasal cannula from bedside oxygen concentrator. The bedside oxygen concentrator was labeled to administer at 2L/min. Resident #9's portable oxygen concentrator on walker was labeled and set to administer at 2L/min. On 1/6/26 at 11:25 AM, RN #2 stated Resident #9's oxygen rate should have been at 1.5L/min via nasal cannula as ordered and had not been. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including orthopedic aftercare, Sjorgren's disease (chronic autoimmune disorder that affects the body's moisture-producing glands) and diabetes. On 1/5/26 at 9:30 AM, 1/6/26 at 11:12 AM, and 1/7/26 at 10:02 AM, observed Resident #30's oxygen humidifier dated 12/28/25. Resident #30's medical record included physician orders for oxygen tubing change weekly and humidifier bottle every night shift every Sunday. Order start date of 12/21/25. On 1/7/26 at 10:52 AM, the DON stated Resident #30's oxygen humidifier should have been changed on Sunday (1/4/26) and had not been.

Based on observations, staff interview, and review of the facility policy, the facility failed to ensure residents were handled safely during transfers. This was true for 2 of 3 residents (Resident #35 and #68) reviewed for transfers. This failure had the potential to cause injury for residents requiring staff assistance with transfers. Findings include:The facility's Safe Resident Handling/Transfers policy, revision date 8/30/21, documented it is the policy of this facility that the residents will be transferred/handled safely. Use of gait belts or lifts may be used for residents as needed to provide safety for caregiver and patient during transfers. 1. Resident #35 was initially admitted to the facility 11/23/22 and readmitted [DATE], with multiple diagnoses including acute posthemorrhagic anemia (rapid blood loss leading to a sudden drop in red blood cells and oxygen delivery) and COPD (a group of lung diseases that block airflow and make it difficult to breath). On 1/5/26 at 8:12 AM, observed CNA #1 and CNA #2 transfer Resident #35 from her wheelchair to her bed. CNA #1 stood behind Resident #35's wheelchair and slid her arms under Resident #35's armpits while CNA #2 placed her arms under Resident #35's legs and they lifted her out of the wheelchair and transferred her to the bed. On 1/5/26 at 8:16 AM, when CNA #2 was asked if this is the way Resident #35 was supposed to be transferred, CNA #2 stated Resident #35 is care planned to be transferred this way. On 1/7/26 at 11:01 AM, the Director of Rehabilitation stated the Bear Hug transfer is used for a resident who can assist with a one-person transfer. A gait belt is placed around the resident's waist, and the staff use it to stand and pivot the resident to transfer. He also stated that grabbing the resident under the arms and legs to transfer was not appropriate. On 1/7/26 at 11:04 AM, the DON stated that the CNAs should not have transferred Resident #35 by grabbing her under the arms and legs. 2. Resident #68 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia, UTI, and CHF (congestive heart failure). On 12/22/25, Resident #68's care plan documented 2 staff participation with transfers. On 12/23/25, a physical therapy evaluation of Resident #68 documented the following: - chair/bed-to-chair transfer - partial/moderate assist (meaning helper lifts, holds, or supports trunk or limbs but provides less than half the effort). On 12/26/25, Resident #68's MDS documents he is dependent with chair/bed-to-chair transfers (meaning resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity). Per facility reported incident, on 12/27/25, Resident #68 was transferred to his bed from his wheelchair by CNA #3. CNA #3 provided a written statement documenting the following: - CNA #2 and CNA #3 entered Resident #68's room to assist with transferring him from his wheelchair to his bed. - On 12/27/25, CNA #3 transferred Resident #68 using a bear hug technique (when 1 caregiver wraps their arms around patient's chest and under armpits, lifting from chair, pivoting resident to sit in another location). - CNA #2 stood behind CNA #3 while he completed the bear hug transfer for Resident #68. - CNA #3 stated he did not remember using a gait belt. On 12/27/25, CNA #2 provided a written statement documenting Resident #68 had a gait belt on, but it was too loose. Resident #68 landed perpendicular on the bed after the bear hug transfer. On 1/8/25 at 2:36 PM, the DON stated CNA #3 used the bear hug technique to transfer Resident #68. She stated CNA #3 was hurrying and should have slowed down and waited for CNA #2 to assist with the transfer.

Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 17 Residents (#2 and #46) reviewed for quality of care. Resident #2 and Resident #46 were at risk for adverse outcomes when physician orders were not written correctly and/or followed as ordered. This failed practice had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include:Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including Left below knee amputation (BKA), Right above knee amputation (AKA) and diabetes.1. Resident #2's physician order documented Wound Vac to left BKA with continuous suction at 125mmHG Q shift. Order date 12.26.25Resident #2's Care Plan documented alterations in musculoskeletal status related to Left BKA and Right AKA. Date initiated 10.28.25On 1/5/26 at 10:30 AM, observed Resident #2 sitting on bed with wound vac attached to right above knee residual limb. On 1/5/26 at 3:00 PM, interviewed DON about Resident #2's physician's order for wound vac to left below knee residual limb. The DON stated she had transcribed the order incorrectly and would correct it in Resident #2's medical record.On 1/6/26 at 8:25 AM, observed Resident #2's wound vac order with revision date 1/5/26 at 3:30 PM, documented Wound Vac to Right BKA with continuous suction at 125mmHG Q shift. The wound vac order remained incorrect based on Resident #2's physical assessment.2. Resident #2's medical record included order for Biotene Dry Mouth/Throat Liquid Mouthwash - Give 1 application by mouth four times a day for dry mouth - Order date 10/27/25.On 1/6/26 at 1:47 PM, observed bottle of Biotene mouthwash at Resident #2's bedside. On 1/6/26 at 2:19 PM, Resident #2's Care plan reviewed and documented Self-administration of medication after nurse prepares. Date initiated 10/28/25.On 1/8/26 at 10:05 AM, the DON stated Resident #2's medical record should have included an order to have the Biotene at the bedside and did not. 3. Resident #46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (disease caused by damage to the airways that limit airflow) and diabetes.Resident #46's physician orders for bowel care management were documented as: -Milk of Magnesia Suspension 400mg/5ml - Give 30 ml by mouth every 12 hours as needed for bowel care - Give on day 3 or day 4 with no bowel movement. Order date 5/30/25.-Prune Juice - Give 8 oz by mouth Q 12 hours prn every 12 hours as needed for bowel care - Give on day 3 or day 4 with no bowel movement. Order date 5/30/25.-Dulcolax Suppository 10 mg Insert 1 suppository rectally every 24 hours as needed for bowel care - Give on day 4 or day 5 with no bowel movement - Order Date 5/30/25.-Fleet Enema 7-19 Gm/118ml Insert 1 application rectally every 24 hours as needed for bowel care - Give on day 4 or day 5 with no bowel movement - Order Date 5/30/25.Resident #46 had a documented bowel movement on 12/28/25 at 9:13 AM and not again until 1/4/26 at 1:25 PM, over 168 hours with no documented bowel movement. No documentation of Resident #46 receiving the physician ordered medications for constipation management.On 1/8/26 at 10:12 AM, the DON stated Resident #46 should have received the ordered medications for bowel management and had not.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 17 residents (#35 and #41) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan. Findings include:The facility's Comprehensive Person-Centered Care Planning policy, revised April 2025, documented the facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan. The following was observed for care plan review: Resident #35 was initially admitted to the facility 11/23/22 and readmitted [DATE], with multiple diagnoses including acute posthemorrhagic anemia (rapid blood loss leading to a sudden drop in red blood cells and oxygen delivery) and COPD (a group of lung diseases that block airflow and make it difficult to breath). Resident #35's Physician order dated 12/19/25, documented apply oxygen via NC at 2 LPM continuous, every shift. Resident #35's care plan did not document her oxygen use. On 1/6/25 at 11:54 AM, the DON stated Resident #35's oxygen had not been care planned and it should have been. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypercapnia (a lung condition that can cause confusion and severe shortness of breath), schizoaffective disorder (a serious mental illness), and AFib (an irregular heartbeat where episodes start and stop on their own). On 1/5/26 at 10:21 AM, Resident #41 was observed with bilateral upper side rails on his bed. Resident #41's care plan did not document the use of side rails. On 1/6/26 at 1:38 PM, the DON stated Resident #41's care plan did not document the use of side rails and should have.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an advanced directive. This was true for 2 of 17 residents (Resident #35 and #41) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include:The facility's Nursing Administration – Advance Directive Documentation policy, revision date December 2019, documented the facility shall include documentation in the resident's health record that, at the time of admission, the residents have been provided with written information regarding the advanced directives and whether the resident has executed such a document. The following resident's records did not contain documentation of an advanced directive or that the resident or the resident's representative was offered assistance to formulate an advanced directive. Resident #35 was initially admitted to the facility 11/23/22 and readmitted [DATE], with multiple diagnoses including acute posthemorrhagic anemia (rapid blood loss leading to a sudden drop in red blood cells and oxygen delivery) and COPD (a group of lung diseases that block airflow and make it difficult to breath). A Social Services assessment, dated 2/20/25, documented Resident #35 had an advanced directive. On 1/7/26 at 9:02 AM, review of Resident #35's medical record documented a Durable Power of Attorney (DPOA). Her DPOA was for financial power not medical power. Resident #35's record did not include an advanced directive or documentation of information about an advanced directive was provided and discussed with her or resident representative. On 1/7/25 at 10:20 AM, the LSW stated Resident #35 did not have an advanced directive or documentation that she was offered to formulate one and should have. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including acute respiratory failure with hypercapnia (a lung condition that can cause confusion and severe shortness of breath), schizoaffective disorder (a serious mental illness), and AFib (an irregular heartbeat where episodes start and stop on their own). On 1/5/26 at 3:12 PM, a review of Resident #41's medical record did not contain documentation of an advance directive or an offer to formulate an advance directive. On 1/7/26 at 10:46 AM, the DON confirmed there was no advance directive in Resident #41's medical record and neither Resident #41 or his guardian was offered to formulate an advance directive.

Based on record review and staff interview, it was determined the facility failed to ensure accurate medical records were maintained for each resident. This was true for 2 of 17 residents (#2 and #4) whose records were reviewed for pain management. This deficient practice resulted in inaccurate documentation and created the potential for harm if inappropriate care and/or treatments were provided to the resident. Findings include: Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including right above knee amputation and diabetes. On 1/7/26 at 10:10 AM, during record review Resident #2's November 2025 medication administration record documented Percocet Oral Tablet 10-325 Mg (Oxycodone w/Acetaminophen) had been administered by CNA #4 on 11/1/25 at 8:34 PM, 11/7/25 at 4:33 PM, and 11/29/25 at 1:10 PM. On 1/7/26 at 10:30 AM, review of the Active Employee List had CNA #4 listed as a registered nurse and an initial hire date of 7/9/13 with a termination date of 12/21/23 and a rehire date of 6/27/25. On 1/7/26 at 11:14 AM, the DON stated CNA #4 was currently working as a registered nurse and the facility had been unable to change her credentials in the electronic medical record system. Resident #4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including above the knee amputation, multiple sclerosis (a disease where the immune system attacks the protective sheath around nerve fibers in the brain, spinal cord, and optic nerves), and chronic pain syndrome. Resident #4's physician's order dated 10/8/25, documented Fentanyl Patch 72 Hour 75 mcg/hr (micrograms per hour). Apply 1 patch transdermally one time a day every 3 day(s) for pain. Resident #4's December 2025 MAR documented the administration and site of the Fentanyl Patch 72 Hour 75 mcg/hr as follows: 12/10/25 11:53 AM - Shoulder - rear (right) 12/13/25 1:19 PM - Shoulder - rear (left)12/16/25 11:55 AM - Shoulder - front (right)12/19/25 11:51 AM - Shoulder - rear (left)12/22/25 10:22 AM - Shoulder - rear (right)12/25/25 10:58 AM - Shoulder - rear (left)12/28/25 11:45 AM - Shoulder - front (right)12/31/25 12:31 PM - Shoulder - front (left) Resident #4's physician order dated 10/3/25, includes instructions to document site of Fentanyl 75 mcg patch Q shift. Resident #4's December 2025 MAR documented the site of the Fentanyl 75 mcg patch as follows: 12/10/25 – left shoulder (day shift) 12/10/25 – left shoulder (NOC shift) 12/11/25 – left shoulder (day shift) 12/11/25 – left shoulder (NOC shift) 12/12/25 – left shoulder (day shift) 12/12/25 – right shoulder (NOC shift) 12/13/25 - right shoulder (day shift) 12/13/25 - right shoulder (NOC shift) 12/14/25 - left shoulder (day shift) 12/14/25 - left shoulder (NOC shift) 12/15/25 - left shoulder (day shift) 12/15/25 - left shoulder (NOC shift) 12/19/25 - right shoulder (day shift) 12/19/25 - right shoulder (NOC shift) 12/20/25 - right shoulder (day shift) 12/20/25 - left shoulder (day shift) 12/20/25 - left shoulder (NOC shift) 12/25/25 – right shoulder (day shift) 12/25/25 – right shoulder (NOC Shift) 12/26/25 – right shoulder (day shift) 12/26/25 – right shoulder (NOC Shift) 12/27/25 – right shoulder (day shift) 12/27/25 – right shoulder (NOC Shift) 12/28/25 – left shoulder (day shift) 12/28/25 – left shoulder (NOC Shift) 12/29/25 – left shoulder (day shift) 12/29/25 – left shoulder (NOC Shift) 12/30/25 – left shoulder (day shift) 12/30/25 – right shoulder (NOC Shift) 12/31/25 – right shoulder (day shift) 12/31/25 – left shoulder (NOC Shift) On 1/8/26, A review of Resident #4's MAR identified a discrepancy in the documented administration and site compared to the documentation of the Q shift site observation of the Fentanyl 75 mcg patch. On 01/8/26 at 9:30 AM, the DON stated the nurses should have been documenting on the MAR the correct site of the Fentanyl 75 mcg patch and had not.

Based on observation and interview, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 1 of 1 resident (Resident #101) observed for dignity. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth. Findings include: Resident #101 was admitted on [DATE], with multiple diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves) and overactive bladder. On 4/22/25 at 9:30 AM, Resident #101 was observed in her wheelchair in the hallway with her urinary drainage bag without a privacy cover. On 4/22/25 at 2:06 PM, the DON was interviewed and stated the urinary drainage bag should have been covered and was not.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include: The State Operation Manual, Appendix PP revised on 8/8/24, documented S483.35(g) Nurse Staffing Information. S483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. On 10/24/24 at 1:30 PM, observed the Daily Staffing sheets for April 2024 through October 2024, noting 46 days were not completed accurately with the scheduled total hours and the actual hours worked by RNs, LPNs, and CNAs. The following dates were missing the required data: - April 10 and 11, 2024 - May 15, 16, 18. 19, 21 through 30, 2024 - June 1 through 30, 2024 On 10/24/24 at 2:30 PM, the DON stated those dates listed were not completed and probably had been posted incomplete or were not posted at all. On 10/24/24 at 4:30 PM, the Administrator and ADON stated the Daily Staffing sheets had not been completed on those dates list above.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure the food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA (Food Drug Administration) Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. The facility's Kitchen Resource: Food Safety for Your Loved One policy/procedure, non-dated, documented Food or beverages that have past the manufacturer's expiration dated should be thrown away. Food and beverages items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away three days after the date marked. Food in unmarked or unlabeled containers should be marked with the current date the food item was stored. The facility's Handling Cold foods for Trayline policy, non-dated, documented under At the time of service: Cold food items will be taken from the refrigerator one tray at a time to be used at the meal service (unless a reach-in refrigerator is available). Milk will be iced to chill it for use at meal service. During the initial kitchen inspection conducted on 10/21/24 at 7:53 AM, the following was observed: Single serve milk and yogurt containers were placed on the counter without any ice tray to keep them cold. In the reach-in refrigerator: - one bag of shredded cheese, opened to the air, had not been sealed correctly - one tray of poured juice cups had not been dated - 5-pound sour cream container had not been labeled with opened date In the walk-in refrigerator: - one whipped cream container with use by date of 10/9/24 - two containers of Pesto with use by date of 10/17/2023 On 10/21/24 at 8:42 AM, the Food Service Manager stated the Dietary Aide should not have left the milk and yogurt on the counter without an ice tray to keep it cold. On 10/21/24 at 8:45 AM, the Food Service Manager stated the unlabeled and outdated food items in the refrigerators and freezer should have been removed and disposed of. On 10/22/24 at 10:22 AM, observed in the snack refrigerator/freezers, the following items: Hall two refrigerator: - 4 containers of non-dated cottage cheese - small milkshake bottles not dated - small bag of non-dated, opened, shredded cheese labeled with resident's name - opened cheese spread dated 9/30 - non-dated wrapped sandwich labeled with resident's name - non-dated plate of pizza - non-dated plate with brownies - non-dated opened food item wrapped in foil Hall one refrigerator: - non-dated open rice bowl with meat labeled with resident's name - opened non-dated potato salad container - opened non-dated macaroni salad container 10/22/24 at 11:05 AM, the Food Service Manager stated all the food in the refrigerators should have been labeled with a resident name and dated when opened.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 65 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) cross contamination due to equipment not being cleaned between use b) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or c) residents were injured due to unsafe areas in the facility. Findings include: The facility's Housekeeping policy, revision date May 2007, documented the facility would provide a clean, comfortable, homelike, and sanitary living area. The following areas were observed: a) On 10/22/24 at 8:35 AM, observed the sit-to-stand (a device used to rise from a seated position to a standing position without using hands for assistance) base sides had a white dried substance, while the center of the base and in the crevasses had visible dirt and other debris on it . On 10/22/24 at 11:49 AM, Resident #49s feeding pump stand was observed with a dry, cream colored substance on the base. On 10/22/24 at 12:33 PM, the Housekeeping Supervisor stated the equipment in the rooms are cleaned 2-3 times a week. She also stated, when the housekeepers clean a resident's room they clean the bathroom, the oxygen concentrators top to bottom, and the feeding pump stands are cleaned top to bottom, including the base. On 10/22/24 at 12:39 PM, observed Resident #49's feeding pump pole with the Housekeeping Supervisor and she stated that pole got missed, it should have been cleaned. On 10/23/24 at 12:18 PM, the DON stated the Hoyer lifts, sit-to-stands, and vital sign machines should be cleaned after each use. The equipment in the room is cleaned by housekeeping and she was not aware of how often the housekeepers clean the equipment in the room. On 10/24/24 at 8:37 AM, the Maintenance Manager stated the sit-to-stand device should have been cleaned before being put in the storage room. b) On 10/21/24 at 9:35 AM, observed in room [ROOM NUMBER], food particles and large stains in the carpet. On 10/22/24 at 10:31 AM, room [ROOM NUMBER]-A's floor was observed with chunks of food substance and black, dry, smearing on the floor. On 10/22/24 at 2:11 PM, observed in room [ROOM NUMBER], the wall and wallpaper had large scrapes and scratches. On 10/22/24 at 3:23 PM, the privacy curtain in room [ROOM NUMBER] was observed with a dry, brown substance. On 10/24/24 at 10:00 AM, observed food particles smashed into the carpet in room [ROOM NUMBER] similar to what was observed on 10/21/24. On 10/24/24 at 10:09 AM, the housekeeping supervisor stated room [ROOM NUMBER] should have been vacuumed. c) On 10/21/24 at 8:00 AM, observed in room [ROOM NUMBER]'s bathroom, a piece of flooring was missing and there was a quarter inch gap between the flooring and the toilet base. On 10/21/24 at 10:10 AM, observed the window in room [ROOM NUMBER] with an approximate 8 inch crack. On 10/21/24 at 3:59 PM, observed loose plastic door protectors on the following rooms: room [ROOM NUMBER], 114, 208, 221, and the janitor closet on hall 100. On 10/23/24 at 8:04 AM, the Administrator stated the loose plastic door covering could cause a skin tear and it should have been repaired. On 10/24/24 at 10:18 AM, the Maintenance Supervisor stated the plastic door covering being loose could cause hazards and it does not look very good. On 10/24/24/ at 2:01 PM, the Maintenance Supervisor stated he did see where the missing door cover could be an issue and they should be fixed. 50983 51121

Based on observation and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals and follow proper handling of medications. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The following was observed: 1. On 10/21/24 at 8:00 AM, observed food tray delivery and set up on Resident #19's overbed table. CNA #1 did not encourage him to perform hand hygiene before eating. On 10/21/24 at 8:03 AM, observed food tray delivery and set up on Resident #42's overbed table. NA #1 did not encourage him to perform hand hygiene before eating. On 10/21/24 at 8:09 AM, CNA #1 stated she should have provided hand hygiene to the residents. On 10/21/24 at 8:12 AM, NA #1 stated she should have asked if the residents wanted their hands cleaned before eating their meals. On 10/24/24 at 10:21 AM, the IP stated the staff should have offered hand hygiene before meals. 2. On 10/22/24 at 12:09 PM, RN #1 was observed dispensing medication into the medication bottle cap and poured out three tablets when she only needed two tablets. RN #1 held the third tablet in the medication bottle cap touching it with her ungloved finger and dispensed the two tablets into a medication cup and put the tablet she touched with her ungloved hand, back into the medication bottle. On 10/22/24 at 12:11 PM, RN #1 stated, she should not have touched the tablet with her bare hand. On 10/23/24 at 7:49 AM, LPN #1 was observed dispensing medication for Resident #53. She popped an Oxycodone tablet out of the package into her bare hand and then placed it in Resident #53's medication cup. LPN #1 then administered the medication to Resident #53. On 10/23/24 at 8:00 AM, LPN #1 stated she did not realize she had popped the pill directly into her hand. She also stated should not have touched the pill.

Based on observation and interview, the facility failed to ensure dignity of residents when staff enter their rooms without knocking and waiting for acknowledgement to enter. This was true for 2 out of 2 resident rooms observed during the morning meal tray delivery. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth. Findings include: On 10/21/24 at 8:04 AM, observed CNA #2 had not knocked or waited for resident acknowledgement prior to entering room [ROOM NUMBER] when delivering the breakfast meal. On 10/21/24 at 8:05 AM, CNA #2 stated she normally does knock but the door was open, so I did not knock on the resident's door. On 10/21/24 at 8:06 AM, observed NA #2 had not knocked or waited for resident acknowledgement prior to entering room [ROOM NUMBER] when delivering the breakfast meal. On 10/21/24 at 8:07 AM, NA #2 stated she should have knocked before entering the resident's room. On 10/25/24 at 11:20 AM, the ADON stated staff need to knock prior to entering a resident's room, even if you see the resident in their bed.

Based on observation, review of facility infection surveillance documents, review of nursing schedules, staff interview, and policy review, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to prevent and contain COVID-19 infections. The facility's failure to implement and maintain infection control measures to prevent transmission of COVID-19 placed all staff and the 47 residents in the facility who tested negative for COVID-19, in immediate jeopardy of serious harm, impairment, or death related to COVID-19 infection. Findings include: The CDC website, accessed on 10/26/20, included a section titled Responding to Coronavirus in Nursing Homes, which documented facilities were to assign dedicated HCP to work only on the COVID-19 positive unit. The website also included Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which documented dedicated means that HCP are assigned to care only for COVID-19 positive patients during their shift. On 10/21/20 at 10:00 AM, the DNS stated the facility currently had one resident, one staff member, and one nursing student who tested positive for COVID-19. The DNS stated they had plenty of staff and were not in a staffing crisis. 1. The facility had three halls, the Front Hall (rooms 200-212, 214, 216, and 218), the Back Hall (rooms 213, 215, 217, 219, and 220-231), and the COVID-19 positive unit (rooms 124-133). The COVID-19 positive unit had a plastic barrier that covered floor to ceiling and wall to wall which separated it from other halls. Resident #1 was the only resident residing in the COVID-19 positive unit at that time. Staffing schedules, dated 10/18/20 to 10/24/20, included shift assignments for nursing staff which included RNs, LPNs, and CNAs. The staffing schedules documented the Back Hall had a licensed nurse assigned to it from 6:00 AM to 10:30 PM and the Front Hall had a licensed nurse assigned from 6:00 AM to 6:30 PM. The staffing schedules documented one CNA was assigned for the day shift, 6:00 AM to 6:00 PM, and one CNA for the night shift, 6:00 PM to 6:00 AM, for the COVID-19 positive unit. The schedules did not include assignment of a licensed nurse dedicated to the COVID-19 positive unit. Residents who tested negative for COVID-19 resided on the Back Hall and Front Hall. On 10/21/20 at 11:10 AM, LPN #1 stated she was assigned as the licensed nurse for the COVID-19 positive unit and the Back Hall. On 10/21/20 at 3:30 PM, RN #1 drew up [MEDICATION NAME] (antibiotic) 1-gram injection to administer to Resident #1. RN #1 drew up the injection at the nurse's cart located on a COVID-19 negative hall in the facility. RN #1 entered the anteroom (a small room that is entered before a larger room) at the entrance of the COVID-19 positive unit. Resident #1 was standing on the other side of the plastic barrier inside the COVID-19 positive unit. RN #1 zipped open the plastic barrier to Resident #1's waist and injected the antibiotic into Resident #1's exposed right hip. On 10/21/20 at 3:40 PM, RN #1 stated she was unable to cross the plastic barrier into the COVID-19 positive unit to administer the injection to Resident #1 and then work back on the negative unit. RN #1 stated this was the best solution the facility thought of to administer the injection to Resident #1 and not enter the COVID-19 positive unit. RN #1 stated CNAs were unable to administer injections to residents. On 10/21/20 at 11:35 AM, the DNS stated Resident #1 was moved to the COVID-19 positive unit on 10/5/20. The DNS stated one CNA or an NA (Nursing Assistant) were scheduled to work a 12-hour day shift and a 12-hour night shift and they rotated every 3 days or nights. The DNS stated the licensed nurse was assigned to the Back Hall and the COVID-19 positive unit but did not cross the barrier into the COVID-19 positive unit. The DNS stated the licensed nurse dispensed the medications for Resident #1 and the CNA that was assigned to the COVID-19 positive unit administered the medications to Resident #1, while the licensed nurse watched via Zoom. The facility failed to ensure a licensed nurse was assigned to the COVID-19 unit only during each shift. 2. On 10/21/20 at 10:00 AM, the DNS stated the county's positivity rate was high and the residents' and staff were tested twice a week for COVID-19. The facility's Laboratory Services - Testing Requirements for COVID-19 policy, revised 9/15/20, documented Routine staff testing based on their county positivity rates from the prior week. The policy documented, If COVID-19 is confirmed for a staff member, the facility followed CDC guidelines for Criteria to Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV2 Infection. The CDC website, accessed on 10/29/20, on Criteria for Return to Work for Healthcare Personnel (HCP) with [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Infection, updated 8/10/20, stated the following: HCP with mild to moderate illness who are not severely immunocompromised: * At least 10 days have passed since symptoms first appeared and * At least 24 hours have passed since last fever without the use of fever-reducing medications and * Symptoms (e.g., cough, shortness of breath) have improved HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. HCP with severe to critical illness or who are severely immunocompromised: * At least 10 days and up to 20 days have passed since symptoms first appeared * At least 24 hours have passed since last fever without the use of fever-reducing medications and * Symptoms (e.g., cough, shortness of breath) have improved * Consider consultation with infection control experts The facility's policy and CDC guidelines were not followed. The facility's COVID-19 test results and staff timecards documented staff worked with confirmed positive test results as follows: * CNA #3 tested positive on 9/27/20 at 12:13 AM and worked on 9/26/20 from 9:54 PM to 6:11 AM on 9/27/20. CNA #3 continued to work the shift after testing positive for COVID-19 at 12:13 AM. CNA also worked on 9/28/20 from 6:06 AM to 2:16 PM and 9/29/20 from 5:57 AM to 6:30 AM. On 10/22/20 at 1:15 PM, the DNS stated CNA #3 tested positive on 9/27/20 at 2:05 AM and worked on 9/26/20 from 9:54 PM to 6:11 AM on 9/27/20 and on 9/28/20 from 6:06 AM to 2:16 PM. The DNS stated the screening log on 9/29/20 documented CNA #3 had symptoms and the facility performed the rapid test that showed she was positive for COVID-19 and was directed to the local laboratory to confirm the test results for CNA #3's positive results. The DNS stated she missed the email notification and the faxed results from the laboratory for CNA #3's COVID-19 test results on 9/27/20. * CNA #2 tested positive on 10/13/20 at 9:15 PM and 10/17/20 at 9:13 PM and had worked 10/18/20 from 6:00 AM to 2:00 PM. On 10/21/20 at 4:30 PM, the DNS stated CNA #2 tested positive on 10/17/20. The DNS reviewed CNA #2's timecard and stated CNA #2 worked on the negative unit from 6:00 AM to 2:00 PM on 10/18/20. The DNS stated she received the notification via email on her smartphone from the laboratory on 10/17/20 at 9:13 PM but did not open the email to review until late evening of 10/18/20. The DNS stated she should have reviewed her email when she received the notification from the laboratory on 10/17/20 that CNA #2 tested positive for COVID-19 and CNA #2 should not have worked the day shift on 10/18/20. The DNS stated she erroneously documented in her tracking log CNA #2's COVID-19 test results on 10/13/20 were negative and she stated the test results clearly documented CNA #2 tested positive for COVID-19 on 10/13/20. On 10/21/20 at 4:35 PM, the DNS stated three staff members tested positive for COVID-19 at the end of September and currently a staff member and a nursing student tested positive. The DNS stated CNA #3 had symptoms of COVID-19 on 9/29/20 and was sent to the local laboratory to get tested for COVID-19. The facility failed to ensure nursing staff did not work with both COVID-19 positive and COVID-19 negative residents during the same shift and to ensure staff were assigned to work the COVID-19 positive unit who tested positive did not provide cares for residents and worked with staff who were on the COVID-19 negative unit. These deficient practices placed staff and residents who had tested negative of COVID-19, at imminent risk of COVID-19 infection and subsequent serious harm, impairment, or death related to the infection. On 10/21/20 at 6:33 PM, the DNS and the Regional Resource Nurse were verbally informed of the Immediate Jeopardy (IJ) determination at F880 and written notification was emailed to the facility on [DATE] at 11:38 AM. On 10/22/20 at 2:37 PM, the facility provided a plan to remove the immediacy. The facility alleged the immediacy was removed on 10/22/20 at 12:25 PM. The removal plan was accepted on 10/22/20 at 4:47 PM. The facility's IJ removal plan included: * Licensed nurses scheduled to work the on the COVID-19 positive unit 24 hours a day. * Staff COVID-19 laboratory results were notified via email to the DNS, phone call of positive test results to the Administrator and the DNS, and results faxed to the facility for the Front Hall Charge nurse to review faxes 6 times per a 12 hour shift and document check and immediate notification to the Administrator and DNS. Surveyors completed onsite verification on the removal of the IJ and confirmed the IJ was removed as of 10/22/20 at 7:46 PM. On 10/23/20 at 9:30 AM, the Administrator, DNS, and the Regional Resource Nurse were verbally informed the immediacy was removed based on onsite verification the IJ removal plan was implemented. 3. The facility's policy PPE for COVID, revised 7/16/20, directed staff to tie all ties on the gown when donning a gown. The facility's policy Emerging Infectious Disease (EID): Coronavirus Disease 2019 dated 3/9/20, documented staff must receive training and demonstrate understanding of when to use PPE, what PPE is needed, and how to properly don (put on), use, and doff (remove) PPE in a manner to avoid self-contamination. A COVID-19 Personal Protective Equipment Donning/Doffing User Check, dated 6/6/20, documented the competency steps for donning a gown included tying all ties of the gown, and ask for assistance if needed. The competency steps for doffing the gown included untying the ties and pulling the gown off from the shoulders by carefully pulling it down and away from the body. The facility's policy and CDC guidance were not followed. Examples include: a. On 10/21/20 at 11:27 AM, room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had a stop sign on the door that said contact precautions were in place and to check with the nurse before entering the room. There were also signs posted on the door that gave instructions for proper donning (putting on) and doffing (removing) PPE. RN #3 said the two residents in room [ROOM NUMBER] were on isolation precautions because they were possibly exposed to COVID-19 by staff at the facility. RN #3 said staff wore a face shield and mask at all times, and they put on a new gown before entering the room and put on gloves after entering the room. On 10/21/20 at 12:15 PM, CNA #4 entered room [ROOM NUMBER]. She was wearing a face shield, mask, and gown. The upper ties on the gown were tied near the neck, and the lower ties near the lower back were not tied, leaving her back partially exposed. Approximately one minute later, CNA #4 opened the door, removed her gown, and exited the room. CNA #4 said she should tie both the upper and lower ties on her gown, and she did not. b. On 10/21/20 at 12:23 PM, RN #3 was observed entering room [ROOM NUMBER]. She was wearing a face shield, mask, and gown. The upper ties on the gown were tied near the neck, and the lower ties near the lower back were not tied, leaving her back partially exposed. Approximately three minutes later, RN #3 exited the room and she was not wearing a gown, but she was still wearing a face shield and mask. RN #3 said all the ties on the gown should be tied, and she did not notice the lower ties on her gown were not tied when she entered the room. On 10/21/20 at 12:34 PM, the DNS said all ties should be tied on the isolation gown. 4. The facility's undated policy for hand hygiene documented All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. The policy directed staff us use an alcohol-based hand rub containing at least 62% alcohol or soap and water after removing gloves. This policy was not followed. On 10/21/20 at 12:00 PM, CNA #4 entered room [ROOM NUMBER] with another female CNA. The two CNAs repositioned Resident #2 and removed his incontinence brief, and CNA #4 cleaned Resident #2's perineal/groin area. CNA #4 then removed her gloves and disposed of them. CNA #4 did not perform hand hygiene, and then she obtained a new pair of gloves and put them on. The two CNAs put a new incontinence brief on Resident #2, repositioned him in bed, and finished preparing him for lunch to arrive. CNA #4 then removed her gloves and performed hand hygiene. On 10/21/20 at 12:11 PM, CNA #4 said she should perform hand hygiene in between providing resident care, when her hands were dirty, after touching her face, and after removing gloves. CNA #4 said she did not perform hand hygiene after she removed her gloves immediately following personal care to Resident #2, and she should have performed hand hygiene. On 10/21/20 at 12:34 PM, the DNS said staff should perform hand hygiene before entering and after leaving a resident's room, and in between glove changes. The DNS said staff should perform hand hygiene after providing personal care to a resident and after removing their gloves.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure consistent professional nursing standards of practice for medication administration were followed and resident assessments were completed by a licensed nurse in the COVID-19 positive unit. The facility's failure placed 1 of 1 resident (Resident #1) in the COVID-19 positive unit at imminent risk of serious harm, impairment, or death related to the high risk for receiving the wrong medications and changes of the resident's condition not being identified and addressed due to lack of a nursing assessments and monitoring. Findings include: The Potter & Perry Fundamentals of Nursing, Eighth Edition, textbook, under Professional Standards in Nursing Practice states under the section Legal Guidelines for Recording, nurses should only chart for themselves, are accountable for information they enter into a patient's chart, and nurses were never to chart for someone else. The Nurse.com website, dated 12/16/15, and accessed on 10/26/20, documented, One of the first general principles in medication administration that a nurse must adhere to is to personally prepare any medications properly ordered for a patient and to personally administer those medications. Although there may be instances in which more than one healthcare provider may be required to administer a single medication, such as in a code, it is not generally acceptable practice to prepare any type of medication for another person to administer. Nor is it acceptable practice to administer a medication that another has prepared. The reasons for this strict rule are numerous. First and foremost, because preparation and administration are fraught with potential for error, relying on another nurse to prepare a medication that you administer is dangerous at best. According to the Agency for Healthcare Research and Quality article, Medication Administration Errors, updated on 9/7/19, errors in medication administration can occur through failures in any of the five rights: right patient, right medication, right time, right dose, and right route. The article states such errors may be the result at the individual-level but may also result from system-level failures such as understaffing and poor process. On 10/21/20 at 10:00 AM, the DNS stated the facility had one resident that tested positive for COVID-19 and was moved to the COVID-19 positive unit. 1. Resident #1 tested positive for COVID-19 on 10/5/20 and was moved to the COVID-19 positive unit. On 10/21/20 at 11:10 AM, LPN #1 stated she was assigned as the licensed nurse for the COVID-19 positive unit and the COVID-19 negative unit located on the Back Hall. LPN #1 stated she was not allowed to cross the COVID-19 positive unit barrier and come back to the COVID-19 negative unit. LPN #1 stated she dispensed the medications and CNA #1, who was assigned to the COVID-19 positive unit, administered the medications to Resident #1 while she watched via Zoom on an IPad. LPN #1 was observed dispensing three oral medications into a medicine cup. The medications were [MEDICATION NAME] (Antibiotic) 250 mg, [MEDICATION NAME] (pain management) 600 mg, and [MEDICATION NAME] (anxiety) 0.1 mg. LPN #1 was observed with an IPad and connected via Zoom with CNA #1 in the COVID-19 positive unit. LPN #1 placed the medicine cup with the three medications on the bedside table that was located in the anteroom of the COVID-19 positive unit. LPN #1 stated to CNA #1 via Zoom that the medications for Resident #1 were located on the bedside table in the anteroom. CNA #1 was observed via Zoom entering the anteroom (a small room that is entered before a larger room) and picking up the medicine cup for Resident #1. CNA #1 was observed via Zoom holding the medicine cup and walking into Resident #1's room and handing the medicine cup to Resident #1. Resident #1 was observed via Zoom sticking out her tongue and stating all gone. LPN #1 stated CNA #1 administered the medications to Resident #1 while she was watching via Zoom. LPN #1 stated she documented on the EMR that she administered the medications to Resident #1. LPN #1 stated she was unaware that it was a concern that CNA #1 administered the medications to Resident #1 while she observed via Zoom. On 10/21/20 at 11:35 AM, the DNS stated Resident #1 was moved to the COVID-19 positive unit on 10/5/20. The DNS stated three CNAs and one NA were assigned to the COVID-19 positive unit. The DNS stated one CNA or the NA were scheduled to work a 12-hour day shift and a 12-hour night shift and they rotated every 3 days or nights. The DNS stated the licensed nurse was assigned to the Back Hall negative unit and the COVID-19 positive unit, but did not cross the barrier into the COVID-19 positive unit. The DNS stated the licensed nurse dispensed the medications for Resident #1 and the CNA that was assigned to the COVID-19 positive unit administered the medications to Resident #1, while the licensed nurse watched via Zoom on the IPad. The DNS stated she was unaware that it was a concern that a licensed nurse dispensed the medications for Resident #1 and had a CNA administer the medications to Resident #1 while watching via Zoom. 2. The Nursing 2020 website, accessed 10/26/20, documented a section on Assessing Patients Effectively. It documented the basic four techniques were as follows: 1. Inspection - Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Assess for color, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system. 2. Palpation - Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. Because your hands are your tools, keep your fingernails short and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last. 3. Percussion - Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient's body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas. 4. Auscultation - Auscultation involves listening for various lung, heart, and bowel sounds with a stethoscope. On 10/21/20 at 11:25 AM, LPN #1 stated she assessed Resident #1's pain level by asking her via Zoom and then documented Resident #1's pain level on the EMR. On 10/21/20 at 11:35 AM, the DNS stated the licensed nurses who were assigned to the COVID-19 positive unit assessed Resident #1's lung sounds by listening on the IPad or her smartphone using the EKO App (Digital Stethoscope technology). The DNS logged onto her smartphone using the EKO App and brought up Resident #1's name and showed lines that were up and down like an EKG reading. The DNS stated the CNA assigned to the COVID-19 positive unit recorded Resident #1's lung sounds on the EKO App for the licensed nurse to listen and assess her lung sounds. The DNS was unable to have the sound work for the lung sounds to be heard. On 10/21/20 at 11:55 AM, LPN #1 stated Resident #1 had developed a fever and shortness of breath related to COVID-19. LPN #1 stated Resident #1 was started on antibiotics for an upper respiratory infection. LPN #1 stated she listened to Resident #1's lung sounds on the EKO App. LPN #1 stated the CNA placed a stethoscope on Resident #1's chest and the device recorded Resident #1's lung sounds through the EKO App and was able to listen on the EKO App through the IPad. On 10/21/20 at 2:30 PM, the DNS stated the facility did not have a policy for licensed nurses to use Zoom or the EKO App for assessments for COVID-19 positive residents. The DNS stated they used CDC guidance for telehealth. The CDC guidance for Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic, dated 6/10/20, and accessed on 10/26/20, documented Telehealth Modalities: Several telehealth modalities allow Healthcare Providers (HCP) and patients to connect using technology to deliver health care: Synchronous: This includes real-time telephone or live audio-video interaction typically with a patient using a smartphone, tablet, or computer. In some cases, peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) can be used by another HCP (e.g., nurse, medical assistant) physically with the patient, while the consulting medical provider conducts a remote evaluation. The CDC guidance did not include documentation a CNA could perform nursing assessments by using the EKO App that recorded lung sounds for the licensed nurse to listen and monitor at a later time. The CDC guidance did not include a licensed nurse could perform nursing assessments and monitoring via Zoom. On 10/21/20 at 3:40 PM, RN #1 stated she assessed Resident #1's lung sounds by downloading the EKO App on the IPad and the CNA recorded the lung sounds and she listened to the recorded lung sounds later in her shift. RN #1 was unable to have the EKO App have the sound work to hear Resident #1's lung sounds. RN #1 stated she listened to Resident #1's lung sounds and documented her nursing assessment in Resident #1's nurse's progress notes. Resident #1's October 2020 MAR, from 10/5/20 to 10/20/20, documented the following for Resident #1: * Monitor for COVID-19 signs/symptoms three times a day. 15 out of 33 documentation opportunities were blank. * Monitor Pain level twice a day. 5 out of 32 documentation opportunities were blank. * Monitor Episodes of Depression three times a day. 16 out of 32 documentation opportunities were blank. * Monitor Anti-Depressant Side Effects three times a day. 16 out of 32 documentation opportunities were blank. On 10/21/20 at 5:00 PM, the DNS reviewed Resident #1's October 2020 MAR. The DNS stated when the MAR indicated [REDACTED]. The DNS stated the licensed nurses' did not complete a hands on head-to-toe assessment for Resident #1. The DNS stated the CNAs and NA assigned to the COVID-19 positive unit completed the vital signs and notified the licensed nurse to document in the MAR. The DNS stated the assessments and monitoring for Resident #1 were completed via Zoom and by the CNAs/NA. The CNAs or NA who administered medications and performed nursing assessments were out of there scope of nursing practices. These negative facility practices placed Resident #1 on the COVID-19 positive unit at imminent risk for receiving the wrong medications and for changes in her condition to go undetected resulting in serious harm, impairment, or death. On 10/21/20 at 6:33 PM, the DNS and the Regional Resource Nurse were verbally informed of the Immediate Jeopardy (IJ) determination at F684 and written notification was emailed to the facility on [DATE] at 11:38 AM. On 10/22/20 at 2:37 PM, the facility provided a plan to remove the immediacy. The facility alleged the immediacy was removed on 10/22/20 at 12:25 PM. The removal plan was was accepted on 10/22/20 at 4:47 PM. The facility's IJ removal plan included: * Licensed nurses were scheduled to work and complete COVID-19 symptom screening assessments, scheduled nursing assessments, and complete medication pass for COVID-19 positive residents on the unit. A medication cart was delivered and accessible by the licensed nurses to administer medications for residents located on the COVID-19 positive unit. Computer access to EMR and electronic charting was available on the COVID-19 positive unit. Surveyors completed onsite verification on the removal of the IJ and confirmed the IJ was removed as of 10/22/20 at 7:46 PM. On 10/23/20 at 9:30 AM, the Administrator, DNS, and the Regional Resource Nurse were verbally informed the immediacy was removed based on onsite verification the IJ removal plan was implemented.

Based on observation, record review, facility policy and procedure review, and staff, resident, and family interviews, it was determined the facility failed to provide adequate supervision to meet residents' needs. This was true for 2 of 5 residents (#4 and #21) reviewed for falls and accident hazards. Resident #21 was harmed when he sustained a burn requiring wound treatment, and this failure created the potential for harm when Resident #4 and Resident #21 experienced multiple falls. Findings include: The facility's policy and procedure for Dining Service Standards, revised 6/15/18, documented all staff involved with meal service are trained on general serving tasks, including safe food handling practices, and adaptive devices are provided as indicated on the resident's care plan. The facility's Food and Nutrition Services Guidelines for Hot Beverages, dated 4/1/14, documented the following: * Hot beverages such as coffee, tea and hot chocolate are often brewed and held at high temperatures (160-185 degrees.) .Brief exposures to liquids in this temperature range can cause significant scald burns. * Discourage residents from carrying a cup containing a hot beverage without a lid when walking or moving in a wheelchair. * When serving hot liquids to a resident, place the beverage away from the edge of the table and position the beverage near the dominant hand. * Identify residents at higher risk of spilling hot beverages, such as those with tremors, those with poor hand control from a stroke, arthritis, weakness, etc. 1. Resident #21 was re-admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness, history of falling, [MEDICAL CONDITION], difficulty in walking, reduced mobility, idiopathic peripheral autonomic [MEDICAL CONDITION] (nerve damage), and [MEDICAL CONDITION]. Resident #21's annual MDS assessment, dated 6/14/18, documented the following: * Severe cognitive impairment. * Independent with transfers and walking. * No setup or physical help from staff with eating. * Balance steady at all times. * A walker was used for mobility. * Two or more falls since admission or prior assessment. * No other ulcers, wounds, and skin problems. Resident #21's quarterly MDS assessment, dated 8/21/18, documented the following: * Severe cognitive impairment. * Independent with transfers, walking, and toileting. * No setup or physical help from staff with eating. * Balance not steady during transitions and walking, but able to stabilize without human assistance. * A walker was used for mobility. * Two or more falls since admission or prior assessment. *Burn(s) (second or third degree). * Application of non-surgical dressings and ointments/medications. Resident #21's current care plan documented the following: * At risk for falls, initiated on 9/23/16. Staff were directed to assist with mobilty and transfers as needed, conitnue/encourage use of assistive devices, encourage him to sit on the edge of the bed and dangle feet prior to transferring, ensure he has non-skid footwear, ensure the walker is in reach when he is in bed, and offer frequent toileting. * At risk for injuries related to excessive weakness from [MEDICAL CONDITION], initiated on 9/23/16. * At risk for [MEDICAL CONDITION] activity, initiated on 9/23/16. - Staff were directed to maintain a safe environment, initiated on 9/23/16. * Actual skin breakdown was present related a burn on the left thigh, initiated on 8/2/18. Staff were directed to: * Special coffee mugs to prevent spilling, initiated 8/7/18. Resident #21's Change in Condition Evaluation, dated 8/1/18 at 3:41 PM, documented the following: * He became agitated after spilling coffee. * His left thigh had a 22 by 24 cm area of slight redness with mild pain. No blistering noted. * He experienced acute burning pain. * The CNA stated Resident #21 had spilled coffee in the past. An I& A Report, dated 8/1/18 at 5:00 PM, documented Resident #21 was sitting in the recliner near the nurses' station drinking a cup of coffee and he fell asleep. The coffee spilled on him causing a red, painful area on the upper, inner left thigh. Resident #21 and staff were educated regarding hot drinks. Staff were educated that he should not be given hot coffee, to make sure the coffee was cooled, and to provide a protective cover on his lap when he drinks. A Progress Note, dated 8/1/18 at 9:00 PM, documented Resident #21 spilled coffee on that evening and had a red area on the upper, inner left thigh. An ice pack was applied and the area was tender to touch. A Progress Note, dated 8/1/18 at 11:41 PM, documented Resident #21 had three blisters on the burn area to the left left upper inner thigh. An ice pack and dressing were applied. A Progress Note, dated 8/2/18 at 1:30 PM, documented the physician examined Resident #21 and was aware of the blisters to the resident's thigh. No new orders were received. A Progress Note, dated 8/2/18 at 5:30 PM, documented Resident #21 was protective of left upper thigh area. States it hurts and will not allow nurse to see it. Assessing facial expression, posture and protectiveness pain level is 5-6 on 0-10 scale. A Physical Therapy Initial Examination, dated 8/21/18, documented Resident #21 spilled a cup of coffee, which resulted in a burn to the left thigh. Resident #21 complained of pain described as sharp and rated as a 7 (on a scale of 0-10 with 10 being the worst imaginable pain.) The goal was to heal the wound and reduce pain. It was recommended to provide sharp debridement (removal of non-viable tissue) and daily dressing changes. An untitled facility document, dated 9/20/18, documented Resident #21 drank coffee, had [MEDICAL CONDITION], and could not safely hold a mug. An untitled facility document, dated 9/21/18, documented IDT (interdisciplinary team) met (and)decided to change all coffee mugs, and was signed by the DON. On 10/10/18 at 10:14 AM, LPN #2 performed a dressing change to Resident #21's left thigh. LPN #2 said Resident #21 spilled coffee on 8/1/18, causing the wound on his left thigh, and he liked coffee very hot. One large, mildly reddened area and one smaller, mildly reddened area were observed on his left upper, inner thigh. On 10/10/18 at 11:24 AM, Resident #21's family member stated he spilled coffee and caused a burn on his leg. Resident #21's family member stated it was an accident when the resident was reaching for something with one hand and spilled the coffee with the other hand. On 10/10/18 at 12:40 PM, Resident #21 was observed in the dining room at the table drinking from a small plastic mug with no lid. The plastic mug contained dark brown liquid that was steaming. On 10/11/18 at 9:32 AM, CNA #2 said staff had to be careful with Resident #21's coffee. CNA #2 said Resident #21 had to have a special mug with a special lid that screws on so it would not spill on him. CNA #2 said Resident #21 liked the coffee very hot. On 10/11/18 at 9:37 AM, the UM said Resident #21 needed only setup assistance with dining, including when drinking coffee in the dining room. On 10/11/18 at 4:47 PM, the UM said Resident #21 spilled coffee and sustained a burn to his leg. The UM said at the time of the burn, an assessment was completed and the physician saw Resident #21. The UM said the DON did a sweep of the building to identify other residents at risk, two residents were identified, and they had spill proof mugs. The UM said Resident #21 did everything by himself except dining and coffee, any staff member could get his mug and screw the lid on. On 10/11/18 at 5:36 PM, Resident #21 was in the dining room sitting at the table with a small plastic mug in front of him that was approximately one-half full of dark brown liquid. Resident #21 said he was drinking coffee. CNA #3 said she set him up for dinner and he did not need any special equipment. CNA #3 said if a resident required special equipment the kitchen would send it. Resident #21's meal ticket did not document any special equipment was needed. On 10/11/18 at 4:54 PM, the DON said all residents who prefer coffee were assessed for safety, and those who were felt to be at a higher risk received a cup with a twist top. The DON said Resident #21 was independent with dining at the time he received the burn from the spilled coffee, and the Resident was still independent. On 10/11/18 at 5:43 PM, the DON said if a resident required special equipment for dining it should be documented on the meal ticket, and the special mug should be on Resident #21's meal ticket. The DON said Resident #21 now had his special mug as they just gave it to him. b. The facility's policy and procedure for Falls management, dated 3/15/16, documented the following: * Patients will be assessed for risk of falling as part of the nursing assessment. Residents determined to be at risk will receive appropriate interventions to decrease risk and minimize injury. * Facility staff were directed to identify the resident's fall risk, communicate the fall risk to caregivers, and review and update the care plan regularly. A Progress Note, dated 6/12/18 at 8:00 PM, documented Resident #21 fell on [DATE] at night. A Change in Condition assessment, dated 6/13/18 at 10:30 PM, documented Resident #21 fell on [DATE]. Interventions directed staff to remind him to put shoes or slippers on when getting up. A Progress Note, dated 6/14/18 at 5:30 PM, documented Resident #21 ambulated to meals and in the unit without assistance. A Nursing Assessment, dated 6/14/18 at 6:15 PM, documented Resident #21 had one fall since admission or the prior assessment and was receiving anti-[MEDICAL CONDITION] and sedative medications. A Progress Note, dated 6/18/18 at 8:47 AM, documented Resident #21 fell on [DATE] when transferring from bed. Resident #21 had socks on and slid to the floor. Resident #21 was able to transfer independently using a front wheel walker, and staff were to encourage the Resident to wear non-skid socks and/or shoes for transfers and mobility. A Progress Note, dated 6/27/18 at 6:50 AM, documented Resident #21 had a large fading bruise to the left thigh from a fall during the previous week. An I&A Report, dated 8/10/18 at 11:50 PM, documented the following: * Resident #21 was found sitting on the floor next to his bed, and he slipped off the side of the bed. * Preventive measures prior to the fall included call light and personal items within reach, frequent checks, and reminding him to dangle his feet before standing up and to use the walker. * Interventions added after the fall included assess the Resident, Neuro checks, frequent checks when in bed, and walker and personal items within reach. * Corrective actions included frequent checks when Resident #21 was restless/confused, and keep personal items and walker within reach. A Progress Note, dated 8/10/18 at 11:57 PM, documented Resident #21 was found sitting on the floor next to the bed, and he stated he slipped off the bed. There was noted possible increased confusion. An I&A Report, dated 8/12/18 at 5:00 PM, documented the following: * Resident #21 slipped and fell in the bathroom. * Preventative measures in place prior to the fall included a transfer pole in the bathroom, non-skid shoes, and a walker. * Interventions added after the fall included reminding him to use the call light to request assistance with ambulating and toileting. * Corrective actions included reminding him to request assistance and all safety devices (walker, transfer pole, and bathroom rails) in use. A Progress Note, dated 8/12/18 at 5:37 PM, documented Resident #21 fell on that day in the afternoon. A Progress note, dated 8/14/18 at 2:54 AM, documented Resident #21's door was left slightly open for frequent room checks related to risk of falls. A Change in Condition Followup Assessment, dated 8/14/18 at 2:54 AM, documented nursing interventions included close supervision and frequent room checks. An I&A Report, dated 8/21/18 at 11:55 PM, documented the following: * Resident #21 fell in the bathroom. * Preventative measures in place prior to the fall included call light within reach, non-skid socks/slippers, and non-skid strips in front of bed. * Interventions added after the fall included non-skid strips in front of the toilet and slippers with a better grip on the bottom. * Corrective actions included non-skid strips in front of the toilet and new slippers. A Progress Note, dated 8/21/18 at 11:58 PM, documented Resident #21 was found in the bathroom sitting on the floor in front of the toilet, and he said his feet slipped out from under him. A dark purple bruise, measuring 8 cm by 4 cm, was present on his right sacrum (upper buttock area). Non-skid strips were ordered to be placed in front of the toilet, and Possible new slippers as (the Resident's) current slippers .has (sic) a bare area to center which could have contributed to fall. An I&A Report, dated 8/24/18 at 2:30 AM, documented the following: * Resident #21 fell in his room next to the bed. * Interventions in place prior to the fall included non-skid strips in front of the bed and in the bathroom, and call light and walker within reach. * Interventions added after the fall included new slippers and frequent checks at night. * Corrective actions included requesting new slippers and frequent checks at night due to increased unsteadiness and confusion. A Progress Note, dated 8/24/18 at 4:19 AM, documented Resident #21 had another fall at 2:30 AM as he slipped when attempting to get up out of bed. Action taken included non-skid strips and frequent checks during the night. A Progress Note, dated 8/24/18 at 6:40 AM, documented at 9:35 PM the previous night, Resident #21 was found lying flat on his back next to the recliner, and he said he did not know what happened. Resident #21 had been sitting in the recliner with the feet down. The CNA said she had just checked on him a few minutes ago and asked if he wanted to go to bed yet and he had stated no.Education was provided to not leave him in the recliner after dinner. A Change in Condition Evaluation, dated 8/24/18 at 6:42 AM, documented Resident #21 fell on [DATE] in the morning while attempting to get out of bed to go to the bathroom. Resident #21 slipped and fell next to the bed and landed on his right side. A Progress Note, dated 9/5/18 at 11:41 AM, documented a care team review was performed. Resident #21 fell on [DATE] and was found in the bathroom on the floor. A transfer pole was in place in the bathroom. Resident #21's slippers were slick on the bottom, facility slippers were offered and new slippers were requested. Resident #21 fell on [DATE] and was found lying on the floor next to the bed. He was unable to provide information about what happened. He was receiving therapy, a transfer pole was placed next to his bed as resident tends to walk holding onto furniture in (the Resident's) room and transfer pole will allow (the Resident) to stand straight and gain (the Resident's) balance. On 10/10/18 at 11:27 AM, Resident #21's family member said he had fallen recently, and the nurse told her he slipped on a wet floor in the bathroom and fell . Resident #21's family member said he fell a couple of times in September. On 10/11/18 at 9:37 AM the UM said Resident #21 had some falls and was independent with transferring and ambulating. The UM said she did not know what could have been done differently to prevent the falls. On 10/11/18 at 10:19 AM and 3:15 PM, the DON said Resident #21 had falls and he preferred to be independent. The DON said frequent checks were not documented for Resident #21, and frequent checks consisted of staff members walking by his room all the time. The DON said staff tried to do everything they could to prevent Resident #21's falls. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness, unspecified dementia, and [MEDICAL CONDITION] (paralysis on one side) and [MEDICAL CONDITION] (weakness on one side) following a stroke affecting the right side. Resident #4's quarterly MDS assessment, dated 7/31/18, documented the following: * Severe cognitive impairment. * Extensive assistance of two persons with bed mobility, transfers, and toileting. * Not steady when moving from seated to standing position and only able to stabilize with human assistance. * A wheelchair was used for mobility. * One fall since admission or the last assessment. Resident #4's current care plan documented the following: * Resident #4 was at risk for falls due to impaired mobility, history of falls, [MEDICAL CONDITION], resistive to cares, intolerant of close supervision, and medications, initiated on 5/14/16. * Assist the Resident with mobility and transfers as he allows, initiated on 5/14/16 and revised on 5/16/17. * Encourage the Resident to express needs and ask for assistance, initiated on 5/14/16. * Encourage the Resident to transfer and change position slowly, initiated on 5/14/16. * Offer toileting frequently, initiated on 5/14/16. * Ensure the use of non-skid footwear, initiated on 5/14/16. * One-person assistance with ambulation with front wheel walker, initiated on 5/14/16. * One-person assistance with transfers, initiated on 5/14/16. * Resident #4 had a self-care deficit related to impaired mobility due to a history of stroke with right-sided weakness, initiated on 5/14/16. * Encourage the Resident to sit on the edge of the bed and dangle feet before transferring, initiated on 5/14/16. * One to two person assistance with toileting, initiated on 5/14/16 and revised on 8/14/18. * Two person assistance with bed mobility, initiated on 5/14/16 and revised on 5/16/17. * Non-skid strips in front of recliner, initiated on 5/16/16. * Non-skid strips in front of the bathroom, initiated on 5/26/16. * Non-skid strips in front of dresser, initiated on 9/6/16. * The Resident removes shoes and will self-transfer to the bathroom, bed, and wheelchair. The Resident refuses non-skid socks. Non-skid strips in place to reduce risk of falls, initiated on 11/14/16. * gait belt with transfers, resident frequently refuses the gait belt, do not argue with resident as agitation causes increased risk for falls, allow resident to not use gait belt, initiated on 1/26/17 and revised on 2/8/17. * Encourage the Resident to sit in the recliner in between meals, initiated on 10/13/17. * Encourage the Resident to wear shoes when in the wheelchair, initiated on 8/3/18. * If the Resident demonstrates agitation, attempt transfers and mobility with two persons. If agitation worsens, resume with one staff member assistance with transfers, initiated on 9/5/18. Resident #4's I&A Reports, documented Resident #4 fell 9 times in four months. The falls occured on the following dates and time: 4/22/18 at 4:00 PM, 6/14/18 at 7:45 PM, 6/17/18 at 1:45 PM, 6/17/18 at 5:20 PM, 7/29/18 at 4:10 PM, 8/12/18 at 9:30 AM, 8/19/18 at 12:00 AM, 8/23/18 at 9:35 PM, and 8/29/18 at 7:30 PM, documented Resident #4 fell . An I&A Report, dated 4/22/18 at 4:00 PM, documented Resident #4 was found lying on his back by the chair, and he said he fell out of the chair onto the floor. Preventative measures in place prior to the fall included a self releasing seat belt, increased supervision, and educated him not to self-transfer. An I&A Report, dated 6/14/18 at 7:45 PM, documented a CNA found Resident #4 lying on his back between the bed and wheelchair. Preventative measures in place prior to the fall included call light within reach, shoes on feet, and door positioned so he was visible. An I&A Report, dated 6/17/18 at 1:45 PM, documented Resident #4 was found on the floor by a CNA. Resident #4 stated he attempted to stand up from the chair and fell . He was educated to wait for assistance before transferring. Preventative measures in place prior to the fall included self-releasing seatbelt and supervision. Interventions added after the fall included educating him about self-transferring. An I&A Report, dated 6/17/18 at 5:20 PM, documented Resident #4 had an unwitnessed fall in his room. He was attempting to self-transfer from his wheelchair. Preventative measures in place prior to the fall included shoes on feet and wheelchair seatbelt in place. Interventions added after the fall included placing Resident #4 on 15 minute checks. An I&A Report, dated 7/29/18 at 4:10 PM, documented Resident #4 was changing clothes and slid too far forward in the chair. He was assisted to the floor by an aide. Preventative measures in place prior to the fall included alarm on and functioning, and assistance. Interventions added after the fall included assisted to put shoes on. Education. An I&A Report, dated 8/12/18 at 9:30 AM, documented Resident #4 was found on the floor between the bed and wall. He was educated to not self-transfer. He was eating breakfast in bed and rolled out of bed. Preventative measures in place prior to the fall included a transfer pole beside Resident #4's bed, the bed was to be at a certain height when he was in the bed, and wear shoes when getting out of bed. Interventions added after the fall included frequent checks and remind him to request assistance with transfers. Corrective actions included keep the call light and personal items within reach, remind the him to request and wait for assistance, Medicate and assist with eating as needed. An I&A Report, dated 8/19/18 at 12:00 AM, documented Resident #4 fell when a CNA was transferring him from bed to the chair. He attempted to place his feet on the pedals of the wheelchair, the CNA asked him not to do that and instructed him to pivot and sit in the chair. He bent forward and fell . Preventative measures in place prior to the fall included a transfer pole by the bed, non-skid strips, and restorative therapy. Interventions added after the fall included he was assessed and assisted with cares. Corrective actions included two staff members to assist him if he became combative. An I&A Report, dated 8/23/18 at 9:35 PM, documented Resident #4 was found lying on his back next to the recliner, and he said he did not know what happened. He was sitting in the recliner with the feet down. A CNA said she checked on Resident #4 a few minutes ago and asked him if he wanted to go to bed and he said no. Preventative measures in place prior to the fall included frequent checks and make sure the call light is in place. Interventions added after the fall included staff educated to not leave him in the recliner after dinner, re-approach or have another staff member attempt if he refuses care, and notify the nurse immediately if he still refuses. An I&A Report, dated 8/29/18 at 7:30 PM, documented the CNA notified the nurse at 7:30 PM Resident #4 was on the floor, and he was found lying on the floor on the right side of his bed. He said he wanted to sleep on the floor and watch the game. Preventative measures in place prior to the fall included bed in low position, call light in place, frequent checks, transfer pole, and non-skid strips. Interventions added after the fall included continue bed in low position, frequent checks, and possible perimeter mattress or larger bed. Corrective actions included frequent checks as he allows and continue therapy evaluation. On 10/10/18 at 8:50 AM, 10/10/18 at 10:57 AM, 10/11/18 at 8:42 AM, and 10/11/18 at 1:49 PM, there were no non-skid strips observed in Resident #4's room. On 10/11/18 at 2:07 PM, the UM said Resident #4 previously had non-skid strips in his room. The UM said the DON and administrator were going through the building and trying to clean up the non-skid strips and she was not sure what happened to the non-skid strips. On 10/11/18 at 2:46 PM, the UM said the non-skid strips were not present in Resident #4's room. On 10/11/18 at 2:05 PM, the UM said Resident #4 had multiple falls, and when asked what could have been done to prevent the falls the UM said she was surprised at the number of falls Resident #4 had. On 10/11/18 at 3:20 PM, the DON said Resident #4 had multiple falls. The DON said when they tried to add more supervision to Resident #4 it could cause more agitation and injury. The DON said after each fall it was discussed in the interdisciplinary team meeting and she would enter a note. On 10/11/18 at 3:30 PM, the DON said they tried really hard to prevent more falls for Resident #4 and she could not think of anything else that could have been done.

Based on staff interview, review of resident records and review of the facility's Risk Management System (RMS) reports and smoking policy, it was determined the facility failed to ensure nursing staff were informed of the need for increased assistance for transfers to prevent a fall with injury. This was true for 1 of 7 sampled residents (#5). Resident #5 was harmed when she fell , sustained a right ankle fracture, and required surgical intervention. Additionally, the facility failed to ensure a resident had been assessed to be safe to smoke without supervision. This was true for 1 of 1 sampled resident (#4). Findings included: 1. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/8/14 at 8:30 PM Interdisciplinary Progress Notes (IPN) documented the resident received a medication for nausea and vomiting which was ineffective due to "vomiting." An RMS report dated 11/8/14 at 9:00 PM documented a CNA assisted the resident to the restroom due to, "weakness/nausea and vomiting." The resident who was being assisted back to bed, stated she was going to fall and was lowered to the floor by the CNA. Three CNA's then assisted the resident from the floor back to bed. The RMS documented there were no physical injuries. An RMS report dated 11/9/14 documented that after the fall on 11/8/14 at 9:00 PM, the resident needed, "two staff for transfers." The report further documented the resident fell on [DATE] at 1:30 AM while being transferred by one staff. The report concluded that the fall resulted in a fracture and dislocation of the resident's right ankle. On 11/9/14 4:45 AM an IPN documented the resident was not having signs or symptoms of pain or distress related to "recent fall at this time." An emergency room Report documented the resident arrived at the local hospital on [DATE] at 3:56 PM. The History of Illness section documented an injury to the right ankle that "happened last night." The Physical Exam section stated, "severe tenderness and swelling, small abrasion and moderate deformity consistent with an ankle fracture and dislocated ankle. Limited ROM (range of motion) secondary to pain." The resident's ankle was surgically repaired on 11/10/14. A Summary of Investigation (SI) report, conducted to rule out neglect, documented RN #8 had verbally instructed CNA #9 that the resident was, "a two person assist." Additionally, RN #8 had instructed CNA #9 to inform the "next shift" and had placed the information in the in-service book to be reviewed by nursing staff. The SI identified the change in the resident's care was not documented on the report sheet, the shift notes or the "walking rounds" at shift change. The resident's 10/24/14 Care Plan with a goal to, "improve with ADL function" included interventions added on 11/14/14 to have 2 staff for transfers, bed mobility and toileting. On 12/17/14 at 11:30 AM CNA #10 was observed pushing the resident into her room in a wheelchair. Without assistance of a second staff person, CNA #10 then transferred the resident from her wheelchair to her easy chair. On 12/17/14 at 1:30 PM the DON stated that just prior to the fall that resulted in the fracture, the resident told the CNA who was helping her that she preferred a different CNA to assist her. The preferred CNA had not been informed of the change in care requiring two staff to assist the resident. The preferred CNA walked with the resident to the bed with a walker and then the resident fell , which resulted in the fracture. The DON was informed of the observation that took place earlier that day when one CNA transferred the resident. The DON stated there should have been two staff to transfer the resident from the wheelchair to the easy chair. Later that day, the DON provided a "Record of Counseling" for CNA #10 regarding not following the resident's Care Plan. The CNA acknowledged that he knew he should have had a second person to assist with the transfer. On 12/18/14 at 10:15 AM the Administrator and the DON were informed of the above concern. The facility provided no further information. 2. Resident #4 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 10/10/14 admission MDS documented intact cognition with a BIMS of 13 and tobacco use. The resident's care plan (CP) included the focus area, "...smokes cigarettes and is found to be safe with smoking" created on 10/3/14. Interventions were, "(S)moking materials to be stored by nursing; Report any non compliance with smoking safety rules to MD (physician), responsible party, and administrator; Supervised smoking per facility policy; Observe for mental status changes that would warrant smoking reassessment; Remind resident to return cigarettes and lighter after smoking break." The resident was interviewed on 12/15/14 from 8:50 to 9:00 a.m. and later that morning from 10:00 to 10:30 a.m. Both times, the resident said she smoked cigarettes. The resident ended the second interview at 10:30 a.m. because it was time for a smoke break. A smoking assessment was not found in the resident's clinical record when it was reviewed on 12/15/14. On 12/15/14 at 1:30 p.m., LN #4 was asked to provide the resident's smoking assessment. The LN looked through the resident's clinical record then said she did not find a smoking assessment but she would keep looking. Later in the afternoon on 12/15/14, the Unit Manager (UM) provided a copy of the facility's 2 page "Policy Statement" which referenced a "Safe Smoking Evaluation" to determine the level of assistance needed: "Assisted Smokers" or "Independent Smokers." The second page of the "Policy Statement" contained the statement, "I (blank) acknowledge that I have received a copy of the facility smoking rules" and it included areas for the resident's and a witness' signature. The UM also provided an another copy of the second page of the Policy Statement that was signed by the resident; however, it was not dated or signed by a witness. The UM said she knew a smoking assessment had been done but she had not located it. On 12/17/14 at 6:10 p.m., the Administrator, DON, and Nurse Consultant were informed of issue. The DON confirmed the facility had not found a Safe Smoking Evaluation for the resident. The facility did not provide any other information regarding the issue.

Based on staff interview and record review, it was determined the facility did not ensure a resident who entered the facility without a pressure ulcer, remained free from pressure ulcers. This was true for 1 of 1 residents (Resident #5) sampled for pressure ulcers. Resident #5 was harmed when she developed a Suspected Deep Tissue Injury (SDTI) in the facility which later opened to a Stage III pressure ulcer. Findings included: Resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #5's admission MDS assessment, dated 11/24/12, documented no pressure ulcers present. Resident #5's most recent quarterly MDS, dated [DATE], coded: *BIMS of 9, indicating moderately impaired cognitive skills. *Extensive assistance of 2 persons for bed mobility and transfers. *Extensive assistance of 1 person for wheelchair mobility. *Did not ambulate. *Unhealed Stage III pressure ulcer (PU), not present or present at a lesser stage on the previous assessment. *Skin and ulcer treatment of [REDACTED]. *No turning or repositioning program. Resident # 5's care plan documented: *Alteration in skin integrity R/T (related to) SDTI to right heel, initiated on 3/12/13. Modified on 6/12/13 as a Stage III PU. *Float heels, initiated 3/12/13. *Podus boots on at all times, initiated 3/12/13. *Pressure reducing/relieving devices as ordered, initiated 3/12/13. (NOTE: The above items were all discontinued on 8/12/13, when the PU was documented as healed.) *Low air loss mattress with bolsters, initiated 4/23/13, discontinued 6/6/13. *Assist to turn and reposition as needed to promote comfort and skin integrity, initiated 11/26/12. Resident #5's physician's orders [REDACTED]. *11/24/12 - Low Air Loss (LAL) mattress with a bolster sheet. (NOTE: The LAL mattress was not noted on Resident #5's care plan until 4/23/13.) *3/11/13 - Float Heels, night shift, day shift, everyday. *3/11/13 - Podus Boots on at all times - night shift, day shift, everyday. Resident #5's Norton Plus Pressure Ulcer Scale form documented: (NOTE: The form documented a score of 10 and below indicated a high risk for pressure ulcers.): *12/5/12, score of 6. *1/23/13, score of 5. *2/13/13, score of 5. *3/11/13, score of 9 (NOTE: This was the date the facility noted a SDTI. The score from this date indicated Resident #5 was at high risk of developing pressure ulcers, but at less risk than she had been on the previous assessment.) *4/3/13, score of 5. *5/1/13, score of 5. *6/4/13, score of 5. Resident #5's Interdisciplinary Progress Notes (PN's) documented: *1/30/13 at 12:30 PM, "Care team review - Resident completed ABT (antibiotic) for UTI..." * 2/6/13 at 6:30 PM, "Received critical creatinine value...MD notified..." *2/7/13 at 4:00 PM, "...New orders received for CMP (Complete Metabolic Panel) today and UA (urinalysis) (with) culture." *2/8/13 at 10:00 AM, "...refused to get up for breakfast..." *2/9/13 at 2:45 PM, "...has been medicated (with) [MEDICATION NAME] X 1 for N&V (nausea and vomiting). Emesis appears to be mostly bile..." *2/9/13 at 3:00 PM, "Large amount liq(uid) brown emesis..." *2/9/13 at 2:30 PM, "Resident vomiting quite a lot pale in color family request for resident to be sent to the ER for evaluation. Ambulance called resident transported..." (NOTE: This was the order the entries appeared in Resident #5's record, even though this entry indicates the date and time was before the previous two entries.) *2/9/13 at 7:00 PM, "Resident returned from ER. IV (intravenous fluids) placed..." *2/11/13 at 2:00 PM, "Medicated for N/V this AM (and) helped..." *2/11/13 at 9:30 PM, "...Random crackles in (right) lower lobe...swelling in ankles and feet..." *2/13/13 at 11:30 AM, "Care team review - (weight) (down) average meal/fluid intakes (down)...Resident (complains of) N/V frequently. MD aware...Resident given IV fluids...Completed ABT for UTI...Uses LAL mattress...impaired mobility...Norton = 5 (high risk for PU development)...Continue current POC (plan of care)." *2/18/13 at 11:30 AM, "Res(ident) c/o N/V at 9:30 AM. Emesis X 1. Light green, small..." *2/18/13 at 8:30 PM, "Resident found with emesis on her face and clothing..." *2/20/13 at 11:30 AM, "Care team review - (weight) (up) slightly. Average meal/fluid intakes (down). Fluids and meals encouraged..." *2/24/13 at 8:00 PM, "Resident c/o not feeling well but denies nausea and refuses medication for nausea..." *2/25/13 at 11:00 AM, "Care team review - (weight) down). Continues (with) health shake. Will have MD review..." *3/6/13 at 2:00 PM, "Care team review - (weight) (down) average meal/fluid intakes (down). Resident c/o N/V (at) times. Noted (with) critical labs, start IV fluids X 2 days..." *3/7/13 at 9:40 AM, "Resident has been very agitated. Refused IV started hitting staff..." *3/8/13 at 2:00 PM, "Staff reported that she had emesis X 2." *3/11/13 at 9:00 AM, "Care team review...Resident found this AM (with) SDTI to (right) heel..." Resident #5's Pressure Ulcer Documentation Forms documented: *SDTI to the right heel on 3/11/13, measuring 3.4 centimeters (cm) long X 2.8 cm wide. *The SDTI continued to be monitored as present on 3/16/13, 3/22/13, 3/30/13, 4/6/13, 4/14/13, 4/54/13, 4/27/13, 5/4/13, 5/11/13, 5/18/13, 5/25/13, 6/1/13, and 6/8/13. *In the column following the entry for 6/8/13 the form documented, "See new sheet now Stage III." Resident #5's Skin Integrity Report form documented: *In house acquired SDTI initially noted on 3/11/13, re-staged as a Stage III PU on 6/12/13 and healed on 8/12/13. *On 6/12/13, the PU was noted as 3 cm X 2.8 cm X 0.2 cm, with serous drainage present. *The Stage III PU was noted present on 6/12/13, 6/15/13, 6/25/13, 6/29/13, 7/10/13, 7/13/13, 7/10/13, 7/27/13, 8/2/13, and 8/9/13. Resident #5's Nursing Home Visit forms (Physician's Progress Notes) documented: *1/15/13, "(Resident #5) seems to be declining...She is comfortable and the nurses have no real concerns about her...No new medical issues are reported..." *2/1/13, "She is confined to a wheelchair and unable to walk. I don't think she is going to improve dramatically...No new medical issues reported. The patient seems to be stable..." *3/12/13, "The nursing staff has noticed some swelling on the right jaw for the past 12 hours...No new medical issues are reported. The patient seems stable...Extremities: No cyanosis or clubbing. Minimal [MEDICAL CONDITION]" (NOTE: This entry was made the day after the facility first documented the SDTI. However, the physician did not address the SDTI in the progress note.) *4/16/13, "...No new medical issues are reported..." *5/14/13, "...No new medical issues are reported..." *6/25/13, "...No new medical issues are reported..." (NOTE: This is the first entry from Resident #5's physician after the SDTI was re-staged as a Stage III PU. 13 days had passed since the PU was staged. The physician did not address the PU in the progress note.) *7/16/13, "...No new medical issues are reported..." On 10/1/13 at 8:40 AM, the DNS was asked about the development of the SDTI and subsequent Stage III PU for Resident #5. The DNS stated when Resident #5 was originally admitted to the facility in November 2012, the facility had implemented the LAL mattress as an intervention, due to the resident being assessed as high risk of developing pressure ulcers. The DNS stated beginning in February 2012, Resident #5 began to develop nausea and began vomiting, "every day, every meal, all the time." Resident #5 was eventually diagnosed with [REDACTED]. The DNS stated even when Resident #5 was very sick, the facility still got her out of her bed and into her wheelchair for meals 3 to 4 times per day, as they felt she was too much of an aspiration risk to be left unattended in her bed to eat meals. The DNS stated Resident #5's heels had been floated from the time of admission, and Podus boots placed as soon as the SDTI was found. (NOTE: Resident #5's care plan did not document her heels were to be floated until 3/12/13, the day after the SDTI was found.) The DNS stated the facility felt the SDTI was related to Resident #5's nutritional status, as there was, "no identifiable trauma" to the resident's heel. The DNS stated when Resident #5's gastroparesis had been successfully treated, her nausea and vomiting resolved, and the PU to her heel eventually healed. The DNS stated she would further research what interventions had been in place to protect Resident #5's heels, both in bed and in her wheelchair, prior to the development of the SDTI. On 10/1/13 at 2:25 PM, the DNS reported back to the surveyor with her findings. The DNS stated Resident #5 was noted to be at increased risk for PUs upon admission, so the facility implemented a LAL mattress. The DNS stated the facility continued to repeat the Norton PU scale monthly due to the resident's increased risk at developing PU's. After the SDTI developed, the facility implemented the approaches of using the Podus boots and floating the resident's heels in bed. The DNS re-iterated Resident #5's nutritional status was the root cause of the SDTI due to decreased meal intakes and low [MEDICATION NAME] levels in February 2013. The DNS stated the facility implemented nutritional interventions and involved the MD in the situation. (NOTE: MD progress notes for this period of time do not address either Resident #5's nutritional status, nor the SDTI to her right heel.) The DNS stated the facility noticed no signs of skin problems, such as mushy or boggy heels, prior to the development of the SDTI. The DNS stated, "It was not there one week, then there the next." The DNS stated the facility did not feel additional interventions for the prevention of skin breakdown were warranted prior to the development of the SDTI due to the LAL mattress, and the fact that Resident #5 was eating better and her nutritional status was improving as evidenced by increased intakes. On 10/1/13 at 2:25 PM, the DNS was asked about the facility's decision to discontinue Resident #5's LAL mattress on 6/6/13, and the conversion of the SDTI to a Stage III PU just 6 days later. The DNS stated Resident #5 had slid off the LAL mattress onto the floor on 6/5/13, so the facility felt the mattress was no longer the safest measure for Resident #5. The DNS stated, "But one has nothing to do with the other. We had the Podus boots on her. The LAL mattress in addition to that did not help her heels at all, but was only preventive for other areas of her skin that might break down." On 10/2/13 at 9:25 AM, the DNS was asked again about care plan interventions for prevention of skin breakdown in conjunction with Resident #5's illness, such as a more aggressive repositioning schedule, pressure relief for her heels when she was in her wheelchair, or floating her heels while in bed. The DNS stated everyone had a care plan for the same turning schedule, which was every 2 hours and as needed. The DNS stated that turning schedule should have been adequate for Resident #5, even if she needed to be re-positioned more frequently, due to the "as needed" clause. The DNS stated Resident #5's heels were floated from the time she was admitted . When asked why it was only added to Resident #5's care plan on 3/12/13, the DNS stated, "That's when we noticed the PU", and that she would research further. The DNS was asked again what kind of pressure relief was in place for Resident #5's heels when she was sitting in her wheelchair, prior to the discovery of the SDTI. The DNS stated, "I'm not sure. I'll have to check." On 10/2/13 at 3:05 PM, the DNS returned to the surveyor with Resident #5's care plan for skin integrity from 11/24/12 through 3/12/13. There were no new interventions documented for Resident #5's skin protection during that time. The DNS stated, "I don't think we harmed her. We had her on an air mattress from the time of admission. I really didn't think the N/V would go on for 4 weeks. We were concentrating on her nutrition. That was our primary concern." While the facility did recognize Resident #5's illness, and its potential impact on her nutritional status, they did not apply that knowledge to other areas of her declining status. The facility did not implement new measures to protect her skin, such as heel protection when she was in her wheelchair, offloading of her heels in bed, or a more aggressive turning schedule. Resident #5 was harmed when she developed a SDTI to her right heel during an acute illness, which later converted to a Stage III PU. On 10/2/13 at 5:00 PM, the Administrator and DNS were informed of these findings. The facility offered no further information to resolve the concern.

Based on observations, staff interview and record review, it was determined the facility failed to: * implement alternative precautionary measures including increased turning and positioning when the Clinitron II sand bed failed to function properly. This resulted in harm when Resident #3 acquired five Stage III and IV pressure sores; * implement measures to prevent Resident #8 from acquiring a Stage II pressure sore on her coccyx; * to ensure preventative interventions were implemented for a resident who was at risk for pressure ulcers and/or develop a care plan for a resident with identified skin issues. This was true for 4 of 9 (#s 3, 4, 8 and 9) sampled residents. Findings included: 1. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 3/15/11, documented the resident: * was cognitively intact, * required total dependence of one to two staff for transfers, dressing, eating, personal hygiene and bathing, * had a catheter and ostomy for bowel and bladder control. The resident's care plan, dated 1/10/2011, documented, "Skin Intergrity (sic) care plan (Resident #3) is at risk for skin alterations d/t: (due to) quadraplegia (sic)." The interventions were: * "(Name) is on a Clinitron II bed to promote skin integrity and relieve pressure." * "Keep (name) clean, dry, and free from irritants." * "(Name) has a pressure reducing cushion to wheelchair." * "Observe, assess and document skin condition/location qweek (each week) and PRN (as needed)." * "Turn and reposition (name) q2hours (every 2 hours) as needed and PRN to relieve pressure. Use care when lifting or turning to prevent skin alterations." * "Treatments/dressings as ordered. Notify MD if treatments are not effective." * "Observe for discoloration, bruises, swelling, skin tears, redness, and report." * "Use good infection control when dealing with wounds and dressing changes." * "Report S/S (signs and symptoms) of infection, increased drainage, odor, color, pain, redness, inflammation to MD." * "Encourage fluids and check skin turgor if fluid intake is poor." * "Pain medication as needed prior to treatments PRN." * "Dressing changes per peg tube site as ordered." * "Maintain safe environment to prevent skin injuries." * "Float heels as needed." "As resident allows" was added sometime later without a date or time noted. * "RD to assess diet for protein, calories, vitamin and mineral supplements, monitor nutritional intake. Weight (See nutrition care plan)." * "Lotions/barrier creams." * "Skin assessment per facility protocol." * "Encourage adequate nutrition." * "8/5/2009 encourage (name) to attend meals as tolerated to increase po (oral) intake." * "Up for showers twice weekly." * "1/28/2009 - Beneprotien per physician order [REDACTED]. * "Consult with Dr (name) as needed." The resident "MDS Kardex Report" (CNA care guide) dated 3/8/11 documented for "Skin Care": * "Pressure relief." Chair and bed are designated. * "Turn & (and) reposition." The form does not specify a frequency. * "Ointment/cream." Does not specify type or frequency. * "Other protective skin care: Clinitron 11 mattress." NOTE: The skin care section did not have any further documentation instructing the CNAs on providing skin care to the resident. The resident was seen by the wound clinic for two pressure sores prior to 3/14/11. The 1/6/2011 report documented the resident had two pressure sores. These were documented as: * Stage III sacral pressure ulcer, acquired on 3/9/10 and measured 0.5 cm (centimeter) long x 1 cm wide x 0.1 cm deep. The area had scant exudate of sero-sanguinous drainage. * Stage III left, lateral heel pressure ulcer, acquired on 6/1/10 and measured 1.4 cm long x 1 cm wide x 0.2 cm deep. The area had small amount of sero-sanguinous exudate. The resident was discharged from the wound clinic with orders to "Follow up PRN." The pressure sores continued to improve. The DON was interviewed on 4/13/11 at 11:30 a.m. The DON indicated that the areas were almost resolved until 3/12/11, when staff called her about the sores deteriorating. The "Interdisciplinary Progress Notes" documented: * "3/12/11 - Skin (check) complete...Lt (left) lower leg outer foot & heel dsg (dressing) applied. Rt (right) foot dressing applied and legs wrapped. Coccyx has open area width 6.0 cm x length 4.5 cm (with) no drainage noted. No other skin issues noted." * "3/14/11 - Wound assessment to coccyx area requested by staff to assess resident due to odor and open area to coccyx measuring 4 cm x 6 cm (with) 25% slough with copius amount of brown drainage with foul odor. Area cleansed (with) wound cleanser. [MEDICATION NAME] Ag applied, covered with [MEDICATION NAME]." * "3/16 - 0936 (9:36 a.m.) - Resident in shower room, asked by staff to look at resident lower extremities. Rt lateral foot noted to have a 4 cm x 5 cm x 0.1 cm open area. Also noted to have to have (sic) 4 cm x 2 cm open area to heel. Also noted to have 7.5 x 1.8 open area to left lateral foot and 4 x 4 cm open area to left heel. Resident had previous open area to left lateral foot measuring 2cm x 2cm from an abrasion. Resident placed back in bed (after) shower. Resident was evaluated for positioning...." The resident was seen in the wound clinic on 3/18/2011 and the report documented: *Sacral: Stage IV pressure ulcer: measurements: length 7cm, width 8 cm, depth 0.3 cm; wound progress: deteriorating; exudate: moderate sero-sanguinous. * Left lateral heel: Necrotic tissue (unstageable) pressure ulcer: length 4 cm, width 3 cm, depth 0.5 cm: wound progress: deteriorating; exudate: moderate sero-sanguinous. * Left lateral foot: Necrotic tissue (unstageable) pressure ulcer: length 8 cm, width 2 cm, depth 0.5 cm: wound progress: initial exam: exudate: moderate sero-sanguinous. * Right lateral foot: Stage IV pressure ulcer: length 2.5 cm, width 4 cm, depth 0.5 cm: wound progress: initial exam: exudate: moderate sero-sanguinous. * Right heel: necrotic tissue (unstageable) pressure ulcer: length 3cm, width 2cm, depth 0.3 cm: wound progress: initial exam: exudate: small sero-sanguinous. The wound clinic ordered treatments and [MEDICATION NAME] of the wounds and to have follow-up appointments. The resident was going to have another flap repair to the sacral ulcer sometime in the future, according to the DON. The resident had a Norton Plus risk assessment completed on 3/9/11 with a score of 12 which translates to the resident was at a risk level of high. The wounds were observed on 4/13/11 at 10:05 a.m. The size of the sores remained about the same as the wound clinic report. There was no drainage noted and the left foot and heel were still not stagable due to necrotic tissue present. The DON was interviewed on 4/13/11 at 11:15 a.m. about the pressure sores. The resident was on a Hill Rom Clinitron II bed since admission in February 2009. The bed was a sand air bed and the Hill Rom representative was in the facility on 3/9/11 and changed the sheet over the sand. The representative indicated that the bed was functioning at that time. The resident had a bath on 3/12/11 when the deterioration of the sacral sore was discovered. The resident remained on the bed and after the wound clinic visit on 3/18/11 it was felt the bed was not functioning. The Hill Rom representative evaluated the bed on 3/22/11, determined the sand had clumped and replaced the bed on 3/23/11. The DON stated the bed was at fault in causing the sores. When questioned about increasing preventative measures, she responded that there was nothing to show the facility made any changes in cares even though the residents skin deteriorated over the 4 days from 3/12 -16/11. The facility does not have anyone on staff who is able to evaluate the Clinitron II bed to ensure it was functioning properly and not putting the resident at risk. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent significant change MDS assessment, dated 10/12/10, documented the resident: * had short and long term memory problems, * was moderately impaired with decision making skills, * required extensive assistance of one staff with transfers, ambulation, dressing, personal hygiene and bathing, * was frequently incontinent of bladder and occasionally incontinent of bowels, * was at risk for developing a pressure sore and had a Stage I pressure sore. The most recent quarterly MDS assessment, dated 1/10/11, documented the resident did not have a pressure sore. The resident's care plan, dated 10/21/10, documented for "Potential for skin breakdown related to: incontinence, cognitive impairment" the following interventions: * "Keep skin clean and dry." * "Labs as ordered. Notify physician of abnormal lab values." * "Observe skin every shift for s/sx (signs and symptoms) of potential skin breakdown (e.g. redness/ discoloration or open areas). Alert charge nurse if observed for notification of physician as needed for tx (treatment) orders." * "Pressure reducing/ relieving devices as ordered." * "Provide pericare if incontinence occurs." * "Report food and fluid intake of less that 50% for three consecutive meals to licensed nurse and dietitian." * "Toilet resident frequently to discourage incontinence." * "Use positioning devices as ordered." * "Weekly skin assessment." * " Medications as ordered." * "Assist (name) to turn (and) reposition as needed." The resident "MDS Kardex Report" (CNA care guide), dated 3/8/11, documented for "Skin Care":* use "ointment/cream" NOTE: The specific "ointment/cream" was not designated. * "Other protective skin care, Joerns pro mattress to bed, pressure reducing cushions to w/c (wheelchair). NOTE: The facility failed to designate when and how often the resident was to be turned and repositioned on the CNA Kardex The "Interdisciplinary Progress Notes" documented the following: * "9/29/10 - Skin (check) completed. Resident has blister below coccyx. Barrier cream applied...." NOTE: There was no other mention of the blister or what happened to it. * "2/14/11 - Skin assessment. Open area to Rt (right) sacrum reported by staff. Area measures 2 cm (centimeter) x 1 cm [MEDICATION NAME] tissue. No evidence of pain...." * "2/16/11 - IDT (interdisciplinary team) review - (R) Sacral area (with) 2 cm x 1 cm Stage II open area. [MEDICATION NAME] cream applied...." * "2/18/11 - Skin (check) complete...small reddened area on coccyx...." * "2/23/11 - IDT review - ...open area to Rt Ischium measuring 1 cm x 1 cm improvement noted...." * "2/25/11 - Skin (check) complete...small reddened area on coccyx...." * "2/28/11 - Reported by staff that resident noted to have new open areas to sacrum. Upon inspection it was noted to be non pressure area presents (with) [DIAGNOSES REDACTED] (with) 3 small excoriated areas, resident denies pain to area. [MEDICATION NAME] applied. Cushion to be placed in recliner as preventative measure...Pressure area to Rt (right) buttock noted at 0.5 cm x 0.5 cm." NOTE: The non pressure area skin issue was a new skin problem and was in addition to the Rt buttock pressure sore. * "3/2/11 - IDT review - ...Stage II Rt ischium decreased in size. no (change) in tx (treatment). New excoriation to lower back 3 open areas noted. Skin is blanchable during skin assessment, skin around coccyx area is purple in color. Keen cushion to recliner...." * "3/16/11 - wound on coccyx resolved...." The resident had a Norton Plus risk assessment completed on 4/7/11 with a score of 10 which translates to the resident was at a "high" risk level. The DON was informed on 4/14/11 at 12:30 p.m. about the resident's pressure sore. The DON stated the resident no longer had a pressure sore the area had healed up. On 4/15/11 at 8:00 a.m., the Administrator, the DON, and the corporate regional Registered Dietitian were informed of the finding. No further information was provided by the facility. The resident had moderately impaired cognitive skills and was dependant on staff for turning and repositioning. The facility failed to ensure implementation of measures to prevent Resident #8 from acquiring a Stage II pressure sore on the coccyx and failed to ensure consistent documentation related to the pressure sore. 3. Resident #4 was admitted to the facility on [DATE] after a fall at home and subsequent [MEDICAL CONDITION]. The fracture was surgically repaired and the resident was admitted to the facility for "after care" related to the hip repair. [DIAGNOSES REDACTED]. The facility's initial "Nursing Assessment" was dated 2/8/11. The assessment included a "Norton Plus Pressure Ulcer Scale (Norton assessment)." The Norton assessment determined a score of 9 for the resident's pressure sore risk. (Score of 10 or less = High Risk). The assessment also indicated the resident was occasionally incontinent and had very limited mobility. The same assessment documented the resident's skin as it appeared on admission as follows: a reddish purple coccyx and both heels, the inside of the left ankle and the left small toe were red. The form had body diagrams and the areas were indicated on them. However, no staging was indicated. The incision and bruises from an IV site to the arm were also indicated. The resident's initial 3.0 MDS assessment was dated 2/15/11. The resident was coded for extensive assist with bed mobility and transfers with the assistance of two staff. The resident required extensive assistance for all other ADLs. The resident had a catheter upon admission but was coded as frequently incontinent of bowel. The resident was indicated at risk to develop pressure ulcers but did not have any when admitted or when the MDS was completed. The documentation indicated the resident's weight was 73 pounds and she was 60 inches tall. The initial care plan was undated. The only reference to pressure sores was "Skin preventions: air overlay, float heels while in bed." A wheel chair cushion was indicated. The current care plan was not dated. The care plan included an identified problem for potential skin breakdown (pressure ulcers) dated 2/18/11. Interventions (all initiated 2/18/11) to prevent pressure ulcers were as follows: * "Apply protective/preventative barrier to skin every shift. *Assist to turn and reposition as (sic) every 2 hours and prn as needed. (NOTE: From the word "every" to the end of the sentence, the words were yellowed through as if highlighted.) *Keep skin clean and dry. *Labs as ordered. Notify physician of abnormal lab values. *Observe skin every shift for s/s (signs/symptoms) of potential skin breakdown (e.g. redness/discoloration or open areas). Alert charge nurse if observed for notification of physician as needed for tx (treatment) orders. *Pressure reducing/relieving devices as ordered. *Provide pericare if incontinence occurs. *Report food and fluid intake of less than 50% for three consecutive meals to licensed nurse and dietitian. *Toilet resident frequently to discourage incontinence. *Weekly skin assessment." Observations of the resident were as follows: *4/12/11 at 7:35 am, Resident #4 was seated in her wheel chair in the dining room and waiting for breakfast service. The resident was a very slow eater and was assisted to eat by staff. She remained in the dining room for approximately one hour and 15 minutes. It was unknown how long she had been in the dining room before she was observed at 7:35 am. After she left the dining room, she was placed out by the nurses station on hall one. This was close to her room. She had a seat belt on and a cushion on the seat of her wheel chair. The surveyor conversed with the resident at 8:55 am, while she still sat in her wheel chair by the nurses' station. She was observed in her room at 11:15 am, seated in her wheel chair. She was taken to the dining room for lunch which was served at 12:15 pm. The resident was still in the dining room sitting in her wheel chair at 12:50 pm. A CNA sat across from her and assisted her to eat. At 1:12 pm, the resident was in her room, still seated in her wheel chair and sleeping. At 2:00 pm, Resident #4 was sitting in her wheel chair in her room. She was picking at lint on her sweat shirt. At 2:56 pm, the resident had been taken to the activity room and was seated in her wheel chair at a table where a game was in progress. *4/13/11 at 7:55 am, Resident #4 was in the dining room, seated in her wheel chair. Later the surveyor walked past her room at least two times (approximately 9:00 am and 10:00 am) and found the resident sitting in her wheel chair. At 10:30 am, the resident was in her room sitting in her wheel chair and a family member was visiting with her. The family member was assisting the resident to eat a snack provided by the facility. The physical therapist came and got the resident to complete some therapy. At 11:57 am, the resident was seated in her wheel chair in the dining room with a family member who helped her eat. Similar observations were made for 4/14/11 with the resident seated in her wheel chair. The resident was only observed out of her wheel chair when she ambulated using a walker and was assisted by the therapist. The DON was interviewed on 4/14/11 at 8:25 am. The resident's record was reviewed by the surveyor and DON during the interview. The DON agreed the resident had been assessed at high risk for development of pressure ulcers and that risk had not changed. The DON was asked to look at the care plan for pressure ulcer prevention and then asked what the yellow line drawn through "every 2 hours and prn as needed" regarding positioning frequency meant. She said that meant the intervention was discontinued. She agreed there was no date as to when the intervention was discontinued or initials that indicated who discontinued it. The DON said she would ask the MDS nurse if she was aware of the discontinued intervention. She left momentarily and then returned. She said the MDS nurse was aware of this but did not know who had discontinued it. The DON said she did not know who discontinued the intervention. She said, "I would not have discontinued that." The DON was advised that the resident was seated in her wheel chair most of the time and never observed to lie down. The DON also agreed that the resident had lost a lot of weight (current weight was at 65.8 pounds) and this placed her at more risk of having pressure sores. The DON was asked to provide any skin report forms not in the record that described the resident's skin. (NOTE: The facility had intervened appropriately to keep the resident from losing weight; however, according to the family the resident always had low body weight. The physician documented in the record, unavoidable weight loss, dated 4/4/11. Tube feeding was discussed with the family but refused as an alternative). The DON provided the following documentation descriptions of the resident's skin: 2/12/11, (9:00 pm)- "Skin (check) complete. Large bruises on left lower arm. Heels red but blanchable, pillow under feet. Coccyx red propped on pillows on R(ight) side. Will cont(inue) to roll from side to side (every 2 hours)." (NOTE: Nothing was documented regarding the inner left ankle or the left foot small toe. This description was documented four days after the admission assessment was done). 2/18/11, (9:30 pm)- "...coccyx red, but intact. Heels less red, continue (with) pillow under feet. [MEDICAL CONDITION] noted bil(lateral) family states was on [MEDICATION NAME] at home every other day, notified Dr. (name)." 2/26/11, (9:30 pm)- "...coccyx red, intact and dry. Heels blanchable. Pitting [MEDICAL CONDITION] noted BLE (both lower extremities) +2." (NOTE: 8 days since last assessment). 3/5/11, (9:30 pm)- "...No redness noted on coccyx. Will continue to monitor..." (NOTE: Nothing was documented regarding the resident's heels). 3/12/11, (7:00 pm)- "...Coccyx is red, no [MEDICAL CONDITION] on R leg but 3+ [MEDICAL CONDITION] on L(eft). No other issues." 3/29/11, (10:00 pm)- "Weekly skin check complete. Skin is intact buttocks is a dark color but blanchable...trace [MEDICAL CONDITION] to left leg)." (NOTE: 17 days since last documentation on 3/12/11). The DON was interviewed on 4/14/11 at 8:25 am, about the 3/29/11 entry that indicated the buttocks were a dark color. She checked with the nurse who wrote the entry and told the surveyor it was just the natural dark color of the resident's skin on her buttocks. The DON also did an assessment on the resident dated 4/14/11. She documented, "Skin assessment completed. Area to coccyx noted to be dark in color, (pigmented) blanches without difficulty. Skin intact with no open areas." The facility did not continue to document on the condition of the resident's left foot with two reddened areas. The facility did not document at least every week when the coccyx continued to be reddened. The facility allowed the resident to sit placing more pressure on her coccyx, for long periods of time, and did not change her position to relieve the pressure. The care plan had discontinued the frequency of repositioning the resident every two hours, although she was still at high risk for pressure ulcers. There was no indication of when this had been discontinued or if the interdisciplinary team had made the decision to stop repositioning the resident every 2 hours as previously care planned. The facility failed to implement all possible prevention strategies to prevent the resident from developing a pressure ulcer. On 4/15/11 at 8:00 a.m., the Administrator, the DON, and the corporate regional Registered Dietitian were informed of the finding. No further information was provided by the facility. 4. Resident #9 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent annual 6/28/10 MDS assessment coded moderately impaired cognitive skills for daily decision-making, short- and long-term memory problems, occasionally incontinent of bowel, indwelling catheter, totally dependent on staff for transfer, dressing, hygiene and bathing, no current pressure ulcers, and no history of resolved pressure ulcers. The resident's 6/30/10 RAPs, Section V, identified pressure ulcers as a triggered problem area and were care planned. The subsequent "Trigger Listing & RAP Information" form documented in the subsection titled Additional Notes, "...(resident's name) is a risk for skin break down d/t (due to) immobility...cannot turn herself...wears briefs...peri care as needed...no current pressure issue to her skin at this time..." The resident's 3/8/11 quarterly MDS assessment coded severely impaired cognitive skills, indwelling catheter, frequently incontinent of bowel, and in Section M subsection M0210 Unhealed Pressure Ulcer(s), "0 (zero, no unhealed pressure ulcer(s))." Please refer to F278 as it related to pressure ulcer accuracy. The resident's 2/16/11 "Incident/Accident" report form documented the "Event, staff handling" "Injury, abrasion" and in the section titled, describe the circumstances of the event and what actions, if any have been taken lately; "Attend (incontinence brief) caught on residents {sic} skin under right gluteal fold causing a 5cm (centimeter) abrasion. Area cleansed and [MEDICATION NAME] Cream applied." The subsequent 2/16/11 "Risk Management System" form documented, "Care Plan Updated? Yes." The Describe Corrective or Proactive Actions Being Taken section documented, "Take caution with attend placement due to resident's positioning." The resident's current care plan identified the 3/11/2011 focus area of; potential for skin breakdown related to: immobility, incontinence, and cognitive impairment. One of the focus interventions was, "Assist to turn and reposition as needed." Note: The current care plan did not identify any open skin areas. Therefore, the surveyor requested and received the resident's previous care plan from medical records, that was in use at the time of the 2/16/11 5cm skin abrasion. The resident's previous Skin Care Plan included the 4/3/09 problem of "(resident's name) is at risk for skin alterations..." The Care Plan included 17 problem approaches. Two of the approaches were, "(resident's name) wears incontinent briefs. Check and change q (every) 2 hours and prn when wet or soiled." and "Assist (resident's name) to turn and reposition q 2 hours and prn to relieve pressure. Use care when lifting or turning to prevent skin alterations..." Note: The previous Care Plan was not updated to include the 2/16/11 5cm skin abrasion. The resident's Interdisciplinary Progress Notes (IPNs), dated 2/21/11 through 3/21/11, documented: * 2/21/11, "...1/2" sore, open, on (right) lower buttock...(one-half inch open area on right lower buttock...)." * 3/6/11, "...sore smaller in size..." * 3/14/11, "...sore on (right lower) buttock healing..." * 3/21/11, "...pressure sore on (right) buttock is scabby {sic} over and healing..." * 3/28/11, no documentation regarding the resident's right buttock * 4/4/11, "Skin (check) completed (no) new issues..." * 4/11/11, "Skin (check) completed (no) new issues..." * 4/14/11, at 11:55 a.m., "Open area to rt (right) buttocks noted. Measuring 1 cm x 1.5 cm. 100% [MEDICATION NAME] tissue. Order obtained for puracol cover with border gauze (change) 3 x weekly (change gauze 3 times weekly)..." On 4/14/11 at 10:45 a.m., two surveyors and the DON observed Resident #9's skin condition. The resident's skin had an approximate 1.5 cm circular open area on the right lower buttock area. The surveyors questioned the DON as to the cause of the open area on the right lower buttock area. The DON indicated that the resident's skin was "torn when they (staff) took the resident's attends off (as on the 2/16/11 report)." The surveyors informed the DON that when a resident's skin tears during changing of an attends, the cause would be pressure. The DON acknowledged agreement. On 4/14/11 at 11:00 a.m., the surveyor informed the DON that when the resident sustained [REDACTED]. The DON acknowledged agreement that the care plan was not updated. On 4/15/11 at 7:45 a.m., the DON provided the surveyor with an update to the current care plan, "Stage 2 pressure ulcer rt (right) buttocks." The interventions listed were, "cleanse wound with NC (normal saline). Apply Puracol to affected area and cover with border gauzeChange 3x week" and "Assess for pain prior to, during and after treatment." In addition, the DON provided a "Pressure Ulcer Documentation Form," dated 4/14/11, that documented a Stage 2, 1 cm in "length" by 1.5 cm in "width." No depth was documented. On 4/15/11 at 8:00 a.m., the Administrator, the DON, and the corporate regional Registered Dietitian were informed of the finding. No further information was provided from the facility. Resident #9 was dependent on staff for toileting and turning and positioning. The resident sustained [REDACTED]. The facility did not update the resident's care plan to include the open area on the resident's right lower buttock or include interventions to address how to prevent the pressure ulcer from re-occurring.