Every finding on record at Thalia Gardens Rehabilitation and Nursing

Based on observations, resident and staff interviews, clinical record review, and facility document review, it was determined that facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents across 3 of the facility's 3 units, constituting substandard quality of care (SQC).The findings include:On 4/22/26 at 11:00 AM, a Resident Council meeting was held with the President and four other residents who regularly attend the group meeting. All attendees agreed that the facility was not a safe, clean, comfortable, and homelike environment. 1. Resident #22 was admitted to the facility on [DATE]. The residents' diagnoses included high blood pressure and asthma. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/20/2026, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident # 22's cognitive abilities for daily decision-making were intact. On 4/22/26 at approximately 11:17 AM, an interview was conducted with Resident #22. Resident #22 stated that there are large flying roaches in the facility, and the shower room is unclean. She stated that she thought they at times landed on her bed and questioned whether she should avoid showering. 2. Resident #27 was admitted to the facility on [DATE]. The residents' diagnoses included diabetes and depression. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/7/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 0 out of 15. This indicated that Resident # 27's cognitive abilities for daily decision-making were severely impaired. Although Resident #27's BIMS score is low, staff interviews and resident statements validated that she is alert and oriented times 4. On 4/22/26 at approximately 11:22 AM, an interview was conducted with Resident #27. Resident #27 stated that there are flying roaches in the facility during the day and at night, and that they have worsened since construction began. 3. Resident #34 was admitted to the facility on [DATE]. The residents' diagnosis included cirrhosis of the liver and hepatic encephalopathy. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/7/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #34's cognitive abilities for daily decision-making were intact. On 4/22/26 at approximately 11:27 AM, an interview was conducted with Resident #34. Resident #34 reported that the shower room is very unclean, with poor drainage resulting in standing water, necessitating the use of shoes in the shower. The resident also stated that there is little to no privacy in the shower room because the curtain at the door does not obstruct those passing by from viewing the person showering. 4. Resident #43 was admitted to the facility on [DATE]. The residents' diagnoses included protein-calorie malnutrition and COPD. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/12/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #43's cognitive abilities for daily decision-making were intact. On 4/22/26 at approximately 11:32 AM, an interview was conducted with Resident #43. Resident #43 stated that the roaches crawl on the ceilings and walls, making it difficult to sleep. The resident also stated that they had not seen pest control treat their room for the roaches. 5. Resident #108 was admitted to the facility on [DATE]. The residents' diagnosis included a non-pressure chronic ulcer, left calf, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 4/17/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #108's cognitive abilities for daily decision-making were intact. On 4/22/26 at approximately 11:37 AM, an interview was conducted with Resident #108. Resident #108 stated that roaches are seen throughout the facility and that sightings have not improved. On 4/28/26 at approximately 4:45 pm, a final interview was conducted with the Interim Administrator, the Regional [NAME] President of Operations, the Director of Nursing, the Assistant Director of Nursing, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns. 6. For several Residents on the Fine Unit, the facility staff failed to ensure a clean, comfortable, homelike environment. During the initial tour on 04/21/2026, there were several observations of the issues regarding the lack of a clean, comfortable, home-like environment. Subsequent rounds during the survey revealed more observations of issues affecting several residents. Observations included but were not limited to the following: There was a gap in the threshold from the hall to the courtyard. It was observed that the semi-private rooms appeared to be small. The A beds by the doors in the semiprivate rooms were abutted against the walls. The bed in room [ROOM NUMBER] was abutted against the wall but there was only one resident in that room. The semiprivate rooms of concern were Rooms-301, 302, 303, 304, 305, 306, 307, 310, 311, 319 and 308- with only one resident in the room. Further review revealed a list of concerns: There were issues with the environment on the Fine Unit, including but not limited to the following: -There was a gap in the threshold from the hall to the courtyard. -The wall was in disrepair between rooms [ROOM NUMBERS]. -The door to room [ROOM NUMBER] was in disrepair with frayed and tattered edging along the length of the door. The edges appeared to be swollen and slightly larger than the rest of the door. The back of the toilet (cistern) in the bathroom between rooms [ROOM NUMBERS] was leaking water. A pan sat on the floor to catch the water leaking from the cistern. Water was observed actively leaking into the pan. Roaches were observed in the bathroom. -In room [ROOM NUMBER], the floor looked very dirty with trash debris noted, buildup of debris in corners and the outlet near the HVAC (heating, ventilation and air conditioning) unit was exposed with noted sharp edges. -Numerous ceiling tiles in the halls and some of the residents' rooms were in disrepair. Some were stained, bulging, had holes, and/or did not fit into the grooves or were missing. room [ROOM NUMBER] A and B- had bowed out heavily stained ceiling tiles over their beds -It was observed that several semi-private rooms appeared to be small on the Fine Unit. The A beds by the doors in the semiprivate rooms were abutted against the walls. The rooms 301, 302, 303, 304, 305, 306, 307, 308, 310, 311, and 319 all had beds against the wall by the doors. The bed in room [ROOM NUMBER] was abutted against the wall, but there was only one resident in that room. -Furniture, equipment, and supplies were stored in the hallway at the far end of the Fine Unit near rooms [ROOM NUMBERS]. Items were noted on both sides in the hallway. On the right side, there was a mattress leaning against the wall, a rollator leaning against the mattress, seven cardboard boxes lined against the wall, and two pallets of white boxes (fourteen boxes on each pallet). On the left side near the end of the hallway, there was a large gray trash can and a rolling hamper. The sizes of the semi-private rooms on the Fine Unit were in stark contrast to those on the other two units, where there was room on both sides of each resident's bed. The other units did not have beds abutted against the walls. There was enough space for residents, visitors, and staff to walk around both sides of each bed in the semi-private rooms on the other units. The Administrator stated that the rooms on the Fine Unit were the original rooms. He stated the facility was built in 1963. He stated that the facility had plans to renovate all the rooms eventually. One resident stated that she wished the facility had started with renovations on the oldest rooms first. She stated that she saw the other units were getting renovations, but that those rooms were already better than hers on the Fine unit. She stated that she had seen roaches in the building. On 4/22/2026 at 11:40 a.m., a certified nursing assistant (who preferred anonymity) stated that it was difficult to provide care to residents in beds abutted against the wall. The certified nursing assistant stated that when providing care, the bed would have to be pulled from the wall to access that side of the resident. Then, the beds would have to be pushed back against the wall. She also stated that the residents in the beds by the windows had more space. It was easier to access both sides of the residents in those beds since they were not against the wall. Interviews were conducted with family members and visitors. On 4/22/2026 at 1:05 p.m., an interview was conducted with a family member who stated that when she visited her loved one, whose bed was against the wall, she felt very cramped up in the room. She stated that she had to sit on the resident's bed or in a chair in the space near the privacy curtain between the two residents. She stated that if she put the chair at the foot of the bed, she was in the way of anyone who wanted to enter to care for or visit the roommate. The family member stated that when sitting in the chair near the privacy curtain, she felt she was too close to the other resident. She stated that she did not feel she had full privacy when visiting her loved one because the room was so small. On 04/23/2026, the Maintenance Director went with the surveyor to measure the size of some of the semi-private rooms on the Fine Unit. The measurement was 163.5 inches x 141.5 inches =160.666 square feet. The Administrator provided a copy of the floor plan review. The Maintenance Director also provided a copy of the blueprints. On 4/23/2026 at 2:15 p.m., a visitor in the dining room was asked about the facility. She stated that she was glad to see renovations, but wished they would do something in the old section. She said, It looks awful over there, and stated, The rooms are so small. The visitor also stated she had seen roaches in the building. On 04/23/2026 at 2:45 p.m., the surveyor walked around the facility with the Maintenance Director to review the observations. FINE Unit: The surveyor showed the Maintenance Director the gap at the threshold (Courtyard door). He stated that they removed it because residents could not get their wheelchairs over it. He agreed that it was an entry point for bugs (roaches specifically). The floor outside this door was uneven (posing a risk that people walking or using walkers could lose balance). room [ROOM NUMBER]: -Bed against the wall, floor filthy, trash debris. Outlet near HVAC exposed, sharp. room [ROOM NUMBER] A: Heavily stained ceiling tiles and the bed against the wall. room [ROOM NUMBER]A: Bed against the wall 7. room [ROOM NUMBER]B: Resident # 109 was in the room in her wheelchair. Resident # 109 was alert, oriented (with a BIMS score of 14-indicating no cognitive impairment) and wheeled herself around the room and in the bathroom. The loose HVAC (heating, ventilation and air conditioning) cover was observed. When the Maintenance Director tried to secure it, it popped off, and he laid it over the HVAC unit and stated, I will have to come back and take care of this. The floor was sticky, and food accumulated around the perimeter of the room. Dark yellow/brown substance on the floor in the corner to the right of the HVAC. A copious amount of brown drippage was observed behind the headboard, down to the floor. Regarding wires that were not secure in the wiring duct raceway strip, the Maintenance Director stated, I will have to replace this-no one told me. Resident # 109 said, That is not true, y'all know about all of this stuff. Let's not talk about the roaches in my room and bathroom. The surveyor went into the bathroom, and there were four roaches on the floor: two dead and two alive (on their backs, wiggling). The Maintenance Director did not pick them up, did nothing. Observed two roach houses in the room: one under the basin and one in the corner. The Maintenance Director saw the plastic container under the toilet's on/off valve, which had accumulated water up to about two inches from the top. He stated, I did not know about this, but this bathroom floods, as to why that is there. It probably attracts the roaches, too. There were heavily stained, loose tiles in the bathroom. No comment was made about the tiles in the bathroom. On rounds an hour later, it was observed that the Maintenance Director had wrapped white Teflon thread tape around the valve connections; water was still coming through and dripping. On 04/23/2026 at 3:30 p.m., rounds were conducted with the housekeeper to review the observations. room [ROOM NUMBER] B: The floor was sticky, and food accumulated around the perimeter of the room. Dark yellow/brown substance on the floor in the corner to the right of the HVAC. A copious amount of [NAME] drippage behind the headboard, down to the floor. Resident # 109 said that she had told housekeeping about how dirty her room was and that the roaches crawl and fly around her room and bathroom. The surveyor and housekeeper went into the bathroom and observed roaches on the floor. The housekeeper picked them up and flushed them down the toilet. She also saw that the Maintenance Director had wrapped white Teflon thread tape around the valve connections; water was still coming through. She was shown the heavily stained, loose tiles in the bathroom. Resident # 109 was a [AGE] year-old admitted to the facility on [DATE]. Diagnoses included cerebral infarction and hemiplegia. The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 03/23/2026. Resident # 109's BIMS (Brief Interview for Mental Status) Score was 14 out of 15, indicating no cognitive impairment 8. room [ROOM NUMBER]A &B: Bowed out heavily stained ceiling tiles over their beds. The Maintenance Director stated, I did not know about this, but I will replace them. Residents # 33 and #78 resided in the room. Residents # 33 (BIMS score of 13, indicating no cognitive impairment) and # 78 (BIMS score of 7, indicating severe cognitive impairment. Bed A-Resident # 33's bed was against the wall near the door. There were clothes and books on the bed, propped against the wall, clothes hanging on a walker on the right side of the bed near the privacy curtain, two bins of clothes were sitting in the chair across from the foot of the bed, and one bin was under the chair. Residents were observed lying in bed with body parts resting on the walls where the beds abutted to the walls. 9. In room [ROOM NUMBER] A, Resident # 58 was observed several times with his head resting on the wall. Stains were noted on the wall along the area where Resident # 58 rested his head on the wall. Resident # 58 was admitted to the facility on [DATE]. The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 03/10/2026. Resident # 58's BIMS (Brief Interview for Mental Status) Score was 00 out of 15, indicating severe cognitive impairment. During each day of the survey, Resident #58 was observed lying with his head resting on the wall. There was an obvious large stain on the wall were Resident # 58 was lying with his head resting on the wall. During daily rounds on the Fine Unit, housekeeping staff members were observed cleaning rooms. Housekeeping staff were noted mopping floors and cleaning around beds. On several dates during the survey, a housekeeping staff member was observed pushing beds away from the wall to sweep around the bed. The resident was not in the room. When interviewed, the housekeeping staff member stated that it was difficult to squeeze behind the beds to clean the areas around the beds that were against the wall. Interviews were conducted with housekeeping staff members who stated they had difficulty cleaning around beds abutting the wall. 10. On 4/22/2026 at 11:10 a.m., Resident # 26 was observed sitting in the wheelchair next to the bed, which was abutted against the wall. There was very little space between the side of the bed and the wheelchair, and limited space between the wheelchair and the privacy curtain between Resident # 26 and the roommate. Resident # 26 was admitted to the facility on [DATE]. The most recent Minimum Data Set (MDS) was a comprehensive assessment with an Assessment Reference Date (ARD) of 03/24/2026. Resident # 26's BIMS (Brief Interview for Mental Status) Score was 08 out of 15, indicating severe cognitive impairment. 11. For Resident # 6 in room [ROOM NUMBER], the facility staff failed to keep the room clean. Resident # 6 was admitted to the facility on [DATE]. Diagnoses included but were not limited to hypertension, non-Alzheimer's dementia, seizure disorder, bipolar disorder, schizophrenia, and psychotic disorder. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 02/02/2026. Resident # 6's BIMS (Brief Interview for Mental Status) Score was a 00 out of 15, indicating severe cognitive impairment. Resident # 6 required assistance with Activities of Daily Living. During the initial rounds on 04/21/2026 at 12:50 p.m., Resident # 6 was observed sitting in the wheelchair in the room. The room was barren and the floor appeared to be very dirty. There was trash debris on the floor. The bed against the wall, floor was filthy, trash debris. The outlet near the HVAC (heating, ventilation and air conditioning) unit was exposed with noted sharp edges. On 04/21/2026 at 2:50 p.m., Resident # 6 was observed propelling himself in the wheelchair in his room. There was a reddish colored substance observed in middle of the floor. The substance looked like reddish vomit. Staff members were in the hallway. Two Certified Nursing Assistant came into the room and stated they would get housekeeping staff. A housekeeping staff member came into the room and started cleaning the substance from the floor. She stated that everyone needed to make sure to put on shoe covers because of stuff on the floor. There was a sign posted on the door about Enhanced Barrier precautions and one about wearing shoe covers. On 04/22/2026 at 10:30 a.m., a substance was noted on the floor. The floor looked filthy. There was debris in the room. Registered Nurse #1 came into the room and stated that Resident # 6 would often spit on the floor. Several observations were made on different days during the survey. The floor consistently looked dirty and with debris. On 4/23/26 at 3:50 p.m., rounds were made with the Housekeeping Director to review some of the areas identified. In room [ROOM NUMBER] where Resident # 6 resided, the housekeeper observed that the floor was filthy, and she saw all the trash and debris in the room. Accumulated brown drainage-type stains throughout the room, walls, and cove base were observed. She was informed that the survey team had been observing the same situation every day. She said they clean the room three times a day, but she thought the medication the resident takes acts like acid, spitting around the room and leaving permanent stains. On 4/23/2026 during the end of day debriefing, the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional [NAME] President were informed of the findings. They were informed about the gap at the threshold from the hallway door to courtyard posed a risk for loss of balance and increased the potential for falls for the residents. It also could be a point of entry for insects and roaches. There were many complaints about roaches. There were roaches observed in the facility. They were also informed about the other concerns on the Fine Unit. On 4/24/2026 at 11:10 a.m., the State Life Safety Inspector toured the Fine unit with the surveyor. The Life Safety Inspector stated that the beds should not be abutted against the wall. He stated the rooms were small. He was informed that the size of the rooms were measured in room [ROOM NUMBER] at163.5 inches x 141.5 inches equaling = 160.6666 square feet. He stated that there should be enough room for stretchers to enter the room to assist either resident in the case of an emergency. When looking in the rooms, he stated that the residents by the door had no space on one side of the bed while the roommates by the window had space on both sides of the bed. On 4/28/2026 during the end of day debriefing, the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant were again informed of the findings. No further information was provided. 12. During the initial tour of the shower room on 04/21/2026 at approximately 12:20 pm. Upon entry to the shower room located on Unit 2, the [NAME] unit. The bathroom located in the shower was cluttered with shower chairs, a pair of shoes was observed on the floor, and the toilet was covered in black plastic with an orange sign reading Please Do Not Use. Needs Repairing or Replacing. A used Latex glove was observed on the plastic. Latex gloves turned inside out were observed on the floor near a corner in the bathroom. A gray bucket used in commodes was observed sitting on top of a commode chair with dried up, brown-looking substance, with what appeared to be used latex gloves, a small white top, and a disposable packaged spoon. Upon entrance to the shower area, a brown substance was observed on the wall and floor, and wet hair was on the floor near the drain. A wet-looking washcloth was observed on the legs of a shower bed. 13. The following observations were made on Unit 1, [NAME] Hall: room [ROOM NUMBER]: On 4/21/26 at approximately 12:30 pm., during the initial tour of room [ROOM NUMBER], the residents were observed lying in their beds. The resident in bed 217 A, located near the door, said, There is a wasp nest by the window. Resident #99 in bed 217 B, located near the window, said, When they sting me, I swell up. Upon visual observation of the window located between the screen window and the glass, there were 2 wasp nests. One nest was located high in the corner, resting between the bricks and screen, with what appeared to have about ten (10) round, greyish, whitish, circular, egg-looking sacs. The other cells in the same nest, which were many, appeared empty with a hexagonal-like appearance. The second nest was located high above the screen. The second nest appeared much smaller than the first nest. A live wasp was observed sitting on top of one of the empty cells. No eggs were observed in the second nest. There was about 1/4 inch gap between the outside screen and the window leading to the sill in the resident's room. Observed at the bottom of the 1/4 gap or opening appeared to be a dead wasp; air could be felt coming from the outside. Resident #99 and Resident #12 agreed they don't want to get stung, that the nest has been up there for about 3 weeks, and that the staff is aware. 14. room [ROOM NUMBER] and room [ROOM NUMBER]: 4/21/26 at 12:25 pm, located across from resident rooms [ROOM NUMBERS] near a shower room no longer in use, were wheelchairs, a shower bed, several chairs, two (2) oxygen concentrators, mats, and positioning devices. Observed on the opposite side of the hall was a laundry cart, a Hoyer lift, and a wheelchair. 15. On 4/21/26 at 12:28 pm, an interview was conducted with Family Member #1, who complained that if an emergency event took place, it would be hard to evacuate her loved Resident #16 from room [ROOM NUMBER] A due to the clutter in the hallway. FM #1 also said that her loved one is visually impaired, ambulates well, but may wander outside of her room into the hall and fall or get injured due to the clutter. 16. On 4/22/26, room [ROOM NUMBER] and room [ROOM NUMBER]: The next day, additional items were observed in the hallway across from rooms [ROOM NUMBERS]: 1 office chair with a broken back, 1 bedside commode. 17. On 4/21/26 at approximately 11:53 pm, an initial tour of the shared bathroom for Residents in rooms [ROOM NUMBERS] (room [ROOM NUMBER] A is the only resident who ambulates to the bathroom). The emergency alarm, located in the bathroom, appeared non-functional (it wouldn't light up or send an alert to the nurse's station). Resident #16, located in room [ROOM NUMBER]A, was observed throughout the survey ambulating independently to the restroom, which has a non-operable emergency call system. 18. On 4/24/26 at approximately 10:15 am, the emergency pull cord was checked to see if it was in operation. The emergency cord was pulled, but it didn't send an alert to the call enunciator located at the nurse's station. Certified Nurse's assistant (CNA) #3 was asked whether he could tell whether the emergency pull-cord alarm sent an alert while at the nurse's station. CNA #3 said he wasn't aware. On 04/28/26 at approximately 1:45 p.m., the above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but none was provided. 19. Resident #11's room was not clean, comfortable, or homelike. Resident #11 was admitted to the facility on [DATE]. The residents' current diagnoses included a stroke with aphasia and anxiety. The Significant Change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/24/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 4 out of 15. This indicated that Resident # 11's cognitive abilities for daily decision-making were severely impaired. On 4/21/26 at approximately 2:40 PM, the resident was observed asleep in a low bed. On the floor was a fall mat between the two residents' beds. On the fall mat was debris and footprints. The trash can was observed near the bed, and a soiled glove was noted on the floor. The floor was noticeably dirty and needed mopping. On 4/28/26 at 3:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing (DON), Regional Nurse Consultant, and Regional Minimum Data Set Consultant. The DON stated. 20. The [NAME] Unit Shower Room: On 4/21/26 at approximately 2:50 PM, an observation was made of the shower room on the [NAME] unit. The shower room was full of clutter, including many shower chairs with items sitting in them, such as bags of soiled clothing. The bathtub in the shower room was full of incontinence products, towels, shirts, dust, and sheets. The shower area had water constantly dripping from the head, and water could be heard draining. At the sight of the shower drain, a used dressing was observed saturated and with pink and yellow secretions. From corner to corner, the shower room was soiled and dusty, with the tiles looking muted as if they were not clean, and the floor appeared unclean. The water closet in the shower room was extremely cluttered with shower chairs and over-the-toilet hoppers. The toilet seat was sealed with plastic and tape. A note read out of order. 21. The Laundry Room: On 4/23/26 at approximately 12:40 PM, an observation was made of the laundry room. The laundry room had washed clothing waiting in the washers, the dryers had stopped, and clothing was sitting in all three waiting to be folded. All tables in the laundry were piled halfway to the ceiling with unfolded clothing. Two shelves were also observed to contain many plastic bags of clothing items, which the laundry aide stated were personal belongings to be donated. The laundry room floors were grossly soiled, and a large bin of soiled laundry was identified with soiled pillows that had a yellowish-brown substance on the ends. The pillows were mixed in with soiled bed linens. On 4/28/26 at 3:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Regional [NAME] President of Operations, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. The facility's team made no comments and offered no additional information. 22. The facility staff failed to maintain a clean and homelike environment for Resident #59, replace missing floor tiles in the kitchen, and replace a damaged dining room entry door. Resident #59 was originally admitted to the facility 11/25/2020 after an acute care hospital stay. The admission diagnoses included; traumatic hemorrhage of cerebrum, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and morbid obesity. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/5/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 06 out of a possible 15. This indicated Resident #59's cognitive abilities for daily decision making were severely impaired. On 4/21/26 at 3:30 PM, during an observation tour of room [ROOM NUMBER], it was observed that the wall under the window was dirty and needed painting. Also, crusty material was on the floor, on the wall, and on the baseboard behind the bed. An interview was conducted with Resident #59 on 4/21/26 at 3:40 PM. Resident #59 stated that the staff never cleans her room. Resident #59 also stated that she has to look out the window and see the nasty mess and wall. On 4/23/26 at 2:45 PM, during an observation tour of room [ROOM NUMBER] with the Director of Maintenance, copious amounts of accumulated brown substance were observed on the walls, floor, and cove base. A member of the housekeeping staff was in the room using a flat mop to clean the floor. The housekeeping staff stated that each time she comes back, she cleans the floor where the resident has been spitting. The housekeeping staff also stated that most of the encrusted brown substances on the floor and cove base cannot be removed. The Housekeeping Director stated that she would explore cleaning substances that could soak the areas to remove the encrusted spit. On 4/24/26 at 1:05 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the room should have been a high focus area for cleaning. The DON also stated that the room is a concern, and the staff is going to make it a high focus area for cleaning moving forward. 23. On 4/21/26 at 11:30 AM, during an observation tour of the kitchen, it was observed that floor tiles were missing on the floor when entering through the kitchen door. It was also observed that the missing tiles were placed on a pellet warmer next to the missing tiles. On 4/23/26 at 4:00 PM, an interview was conducted with the Director of Maintenance. The Director of Maintenance stated that the floor tiles in the kitchen were removed a couple of months ago. The Director of Maintenance also stated that due to the floor in the kitchen having missing tiles, this could be an area where the staff could trip and fall. The Direc

Based on staff interview, clinical record review, and review of facility documents, the facility staff failed to provide a drug regimen review that was reviewed monthly by a licensed pharmacist for 6 of 63 residents (Resident #2, #10, #11, #23, #6, and #107), in the survey sample.The findings included:1. Resident #2 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included fracture of unspecified part of neck of right femur, alcoholic cirrhosis of liver without ascites, essential hypertension, and depression. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/14/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 09 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were moderately impaired. Review of the clinical record was conducted 04/21/2026 to 04/28/2026. Review of the progress notes revealed no documentation of the facility responding to irregularities identified by the Pharmacist during Monthly Drug Regimen Reviews. On 4/28/2026 at 11:40 AM an interview was conducted with the Director of Nursing (DON). The DON stated that she does not know where the monthly resident drug regimen reviews are located and she does not have them. On 04/28/2026 at 2:15 PM the DON stated that the facility has no other information regarding the location of the monthly resident drug regimen reviews and is unable to provide this information at this time. On 4/28/26 at 3:30 p.m., a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. They had no further comments and voiced no concerns regarding the above information. No further information was provided prior to the end of the survey. 2. Resident #10 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included type 2 diabetes mellitus, chronic kidney disease, muscle weakness, and essential hypertension. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/21/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 06 out of a possible 15. This indicated Resident #10's cognitive abilities for daily decision making were severely impaired. Review of the clinical record was conducted 04/21/2026 to 04/28/2026. Review of the progress notes revealed no documentation of the facility responding to irregularities identified by the Pharmacist during Monthly Drug Regimen Reviews. On 4/28/2026 at 11:40 AM an interview was conducted with the Director of Nursing (DON). The DON stated that she does not know where the monthly resident drug regimen reviews are located and she does not have them. On 04/28/2026 at 2:15 PM the DON stated that the facility has no other information regarding the location of the monthly resident drug regimen reviews and is unable to provide this information at this time. On 4/28/26 at 3:30 p.m., a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. They had no further comments and voiced no concerns regarding the above information. No further information was provided prior to the end of the survey. 3. The facility's staff failed to ensure that Resident #11's drug regimen was reviewed at least once each month by a licensed pharmacist. Resident #11 was admitted to the facility on [DATE]. The residents' current diagnoses included a stroke with aphasia and anxiety. The Significant Change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/24/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 4 out of 15. This indicated that Resident # 11's cognitive abilities for daily decision-making were severely impaired. A review of the resident's physician order summary revealed an order dated 4/06/2026 for Lorazepam Tablet 0.5 MG; give 0.5 mg via G-Tube every 4 hours as needed for anxiety. Another order was for Morphine PF 20mg/ml. Give 0.25 ml sublingually every 1 hour as needed for mild pain/distress dissolve 0.25 ml under tongue (PSR 1-3) (5mg); Give 0.5 ml sublingually every 1 hour as needed for moderate pain/distress by mouth or sublingually (PSR 4-6) (10mg) and Give 1 ml sublingually every 1 hours as needed for severe pain or distress PSR (7-10) (20mg). This medication was frequently administered without pharmacy reviews or recommendations. An appraisal of pharmacy reviews revealed that, over the past 12 months (April 2025 through March 2026), no monthly pharmacy reviews were documented in the resident's clinical record. The last review identified in the clinical record was dated 3/30/2025, and the last recommendation was dated 9/25/2025. On 4/24/26 at 2:10 PM, an interview was conducted with the Director of Nursing (DON) concerning the monthly pharmacist reviews. The DON stated that she had started a pharmacy review and recommendation binder, but it was still in its early stages. The DON further stated she would attempt to obtain more information to present. On 4/28/26 at 3:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. The DON stated there was no further information to give. 4. The facility's staff failed to ensure that Resident #23's drug regimen was reviewed at least once each month by a licensed pharmacist. Resident #23 was admitted to the facility on [DATE]. The residents' current diagnoses included cataracts and anxiety. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 4/6/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 9 out of 15. This indicated that Resident #23's cognitive abilities for daily decision-making were moderately impaired. An appraisal of pharmacy reviews revealed that, over the past 12 months (April 2025 through March 2026), no monthly pharmacy reviews were documented in the resident's clinical record. The last review identified in the clinical record was dated 3/28/2025, and the last recommendation was dated 11/18/2025. On 4/24/26 at 2:10 PM, an interview was conducted with the Director of Nursing (DON) concerning the monthly pharmacist reviews. The DON stated that she had started a pharmacy review and recommendation binder, but it was still in its early stages. The DON further stated she would attempt to obtain more information to present. On 4/28/26 at 3:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. The DON stated there was no further information to give. 5. For Resident # 6, the facility staff failed to implement policies and procedures which address steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Resident # 6 was admitted to the facility on [DATE]. Diagnoses included but were not limited to hypertension, non-Alzheimer's dementia, seizure disorder, bipolar disorder, schizophrenia, and psychotic disorder. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 02/02/2026. Resident # 6's BIMS (Brief Interview for Mental Status) Score was a 00 out of 15, indicating severe cognitive impairment. Resident # 6 required assistance with Activities of Daily Living. Review of the clinical record was conducted 04/21/2026 to 04/28/2026. Review of the progress notes revealed no documentation of the facility responding to irregularities identified by the Pharmacist during Monthly Drug Regimen Reviews. On 04/28/2026 at 11:40 a.m., an interview was conducted with the Director of Nursing who stated that she did not have a process for responding to the irregularities identified by the Pharmacist. The Director of Nursing stated that she had been employed at the facility since March 2026 and had not developed a system for responding to the irregularities identified. On 04/28/2026 at 2:15 p.m., the Director of Nursing stated that the facility had no other information regarding the location of the monthly resident drug regimen reviews and was unable to provide the information. During the end of day debriefing on 04/28/2026, the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant were informed of the findings. No further information was provided . 6. For Resident # 107, the facility staff failed to implement policies and procedures which address steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Resident # 107 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: chronic respiratory failure with hypoxia, diabetes with diabetic autonomic poly neuropathy, lymphedema, gastroesophageal reflux disease, cirrhosis of the liver ,nonalcoholic steatohepatitis (NASH), hepatic fibrosis, advanced fibrosis, chronic obstructive pulmonary disease, body mass index 60.0-69.9, ventral hernia with obstruction, gastroparesis, panic disorder, chronic kidney disease Stage 3B, major depressive disorder, and anxiety disorder. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 04/22/2026. Resident # 107's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident # 107 required assistance with Activities of Daily Living. Review of the clinical record was conducted 04/21/2026 to 04/28/2026. Review of the progress notes revealed no documentation of the facility responding to irregularities identified by the Pharmacist. On 04/28/2026 at 11:40 a.m., an interview was conducted with the Director of Nursing who stated that she did not have a process for responding to the irregularities identified by the Pharmacist. The Director of Nursing stated that she had been employed at the facility since March 2026 and had not developed a system for responding to the irregularities identified. On 04/28/2026 at 2:15 p.m., the Director of Nursing stated that the facility had no other information regarding the location of the monthly resident drug regimen reviews and was unable to provide the information. During the end of day debriefing on 04/28/2026, the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant were informed of the findings. No further information was provided . During the end of day debriefing on 04/28/2026, During the end of day debriefing on 04/28/2026, the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant were informed of the findings. No further information was provided prior to the end of the survey.

Based on staff interview and facility documentation review, the facility failed to ensure the implementation of policies regarding the management and operations of the facility potentially affecting all residents in the facility.The findings included:For all residents in the facility, the governing body failed to ensure that the facility had an effective QAPI Quality Assurance Performance Improvement program. The facility had multiple areas in which deficient practices were identified, including environmental services, sanitary, clean-and-safe building, infection control practices, medication storage, and administration. These issues affected the residents' quality of life in the facility.During the survey, investigations revealed the facility had issues involving multiple systems. There had been recent changes in administration and key personnel. There were several new employees in management positions who had been employed for a month or less. The Director of Nursing had been employed for approximately one month at the time of the survey. The Social Services Director had been employed for one week. The Human Resources Director was newly hired. The Maintenance Director was new in his role. Long-term residents complained about the facility and some of the issues going on. There were issues with environmental services, including laundry. Residents were complaining about not having adequate linens and not getting their personal clothing washed and returned in a timely manner. Staff members were observed while performing duties and providing care. Surveyors interviewed staff members who stated there had been issues with the laundry for a while. Inspection of the laundry department revealed unsatisfactory conditions, including mounds of clean and dry laundry waiting to be folded, and other issues were identified. The facility failed to maintain an effective QAPI (Quality Assurance Performance Improvement) program. There was no documentation of a Performance Improvement Plan and no QAPT meeting for three of four quarters.From 04/21/2026 to 04/28/2026, the survey team reviewed the facility's systems and processes to correct previously cited deficiencies and address resident care concerns. It was noted that the facility had failures and remained out of compliance in areas previously cited as deficient during abbreviated surveys. The Maintenance logs and Pest control logs were reviewed by the survey team. There were issues identified.A review of the Resident Council minutes and Grievance logs shows that the facility's administration was aware of the concerns raised by residents and families. The issues continued for several months without resolution.On 04/23/2026 at approximately 3:20 p.m., an interview was conducted with the Administrator, who stated that the facility was making improvements and renovations. He stated it was important for the facility to have a clean, comfortable, homelike environment for the residents.Substandard quality of care was identified at the facility during the survey resulting in an extended survey from 04/24/2026-04/28/2026.The facility staff also failed to notify the State survey and certification agency when fire watch commenced on 3/17/26. The Maintenance Director presented the Fire Watch Patrol Log Sheet to the survey team on 4/24/26 at approximately 5:00 pm. On 3/17/26 at 8:30 AM, there were two trouble alarms on the fire control panel; at that time, fire watch was initiated every 15 minutes on all three units, including the lobby, laundry, kitchen, and dining room. On 3/18/26, the monitoring company evaluated the system on-site, and the technician restored the system functionality, reprogrammed the panel, and confirmed the system was operational and actively transmitting alarm signals to the monitoring service. The monitoring company's service request confirmed that signals were properly being sent over phone lines on 3/18/26, and the fire watch was lifted. The Maintenance Director stated, I fully understand and have a clear message that I need to report this to the State as coming from the Life Safety Code inspector and you all. The Administrator also stated that it was his responsibility to ensure a report to the state was made whenever a firewatch is initiated, including an explanation, the plan, and when it is lifted.During the end-of-day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, the Assistant Administrator, the Regional Nurse Consultants, and the Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team, resulting in an extended survey task to be completed by the survey team. During the extended survey and investigation, it was determined that the facility lacked an effective training program. The facility failed to maintain an effective training program for employees on required topics, including, but not limited to, QAPI, effective communication, and behavioral health.During the end-of-day debriefings on 04/27/2026 and 04/28/2026, the Facility's Administrator, Assistant Administrator, Regional Nurse Consultant, and Director of Nursing were informed of the findings. The governing body should have been made aware of the issues identified by the survey team. The Administrator stated that he would address all identified issues.No further information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to implement and maintain an effective Quality Assurance Performance Improvement (QAPI) Program/Plan for three of four quarters reviewed, affecting all residents in the facilityThe Findings included: During the survey, investigations revealed the facility had issues involving multiple systems. There was no documentation of the issues being discussed during QAPI meetings. These issues affected the quality of life of the residents in the facility.The facility failed to maintain an effective QAPI (Quality Assurance Performance Improvement) program. There was no documentation of a Performance Improvement Plan and no QAPT meeting for three of four quarters.Throughout the survey conducted 04/21/2026 - 04/28/2026, the survey team inspected and investigated the facility's systems and processes regarding correcting previously cited deficiencies and resident care concerns. It was noted the facility had failures and remained out of compliance in areas that had previously been cited as deficient during previous abbreviated surveys. The Maintenance logs and Pest control logs were reviewed by the survey team. There were issues identified.Review of the Resident Council minutes and Grievance logs revealed the facility's administration was aware of issues/concerns voiced by residents and families. The issues continued for several months without resolution.On 04/23/2026 at approximately 3:20 p.m., an interview was conducted with the Administrator who stated the facility was making improvements and renovations in the facility. He stated it was important for the facility to have a clean, comfortable homelike environment for the residents.Substandard quality of care was identified at the facility during the survey resulting in an extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended survey task to be completed by the survey team. On 04/27/2026 at 4:01 p.m., an interview was conducted with the Assistant Administrator who stated she did not have any information about QAPI prior to January 2026. She stated the current administrative staff could not find documentation of any QAPI activities from the previous administrator. The Assistant Administrator stated the facility was expected to meet monthly to discuss Quality Assurance and quarterly for the QAPI meetings. She stated there was no current Performance Improvement Project being conducted.During the extended survey, investigations, it was determined that the facility did not have an effective training program. The facility failed to maintain an effective training program regarding required training for employees regarding topics including but not limited to: QAPI, effective communication and behavioral health.During the end of day debriefings on 04/27/2026 and 04/28/2026, the Facility's Administrator, Assistant Administrator, Regional Nurse Consultant and Director of Nursing were informed of the findings. The Administrator stated he would address the issues identified.No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure implementation of a comprehensive QAPI (Quality Assurance Performance Improvement) Program/Plan included performance improvement projects potentially for three of four quarters affecting all residents in the facility The Findings included:Substandard quality of care was identified at the facility during the survey resulting in an extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended survey task to be completed by the survey team. On 04/27/2026 at 4:01 p.m., an interview was conducted with the Assistant Administrator who stated she did not have any information about QAPI prior to January 2026. She stated the current administrative staff could not find documentation of any QAPI activities from the previous administrator. The Assistant Administrator stated the facility was expected to meet monthly to discuss Quality Assurance and quarterly for the QAPI meetings. She stated there was no current Performance Improvement Project being conducted. Four quarters were reviewed. Three quarters had no informationDuring the end of day debriefings on 04/27/2026 and 04/28/2026, the Facility's Administrator, Assistant Administrator, Regional Nurse Consultant and Director of Nursing were informed of the findings. The Administrator stated he would address the issues identified.No further information was provided.

Based on information obtained during the Infection Control task, the facility staff failed to document each staff member's COVID-19 information. The findings included: On 4/23/26 at approximately 1:05 PM, the Infection Control information for the facility's staff was requested. The Infection Preventionist (IP) stated at 3:38 PM that she was not directed to maintain staff's COVID-19 vaccination status. The IP also stated that she had no documentation indicating that any staff had been provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine, nor that staff were offered the COVID-19 vaccine or any information on obtaining it, because she was not directed to do so.On 4/28/26 at 3:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. The facility's team made no comments and offered no additional information regarding staff COVID-19 data.

Based on staff interview and facility documentation review, the facility staff failed to develop, implement, and maintain an effective training program for all staff, including training on QAPI (Qualiity Assurance Performance improvement) for 5 (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) of 5 staff records reviewed. Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistant (CNA) The Findings included: Substandard Quality of Care was identified by the survey team on resulting in extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended survey task to be completed by the survey team. During the extended survey, investigations, it was determined that the facility did not have an effective training program. The facility failed to maintain an effective training program regarding required training for employees regarding topics including but not limited to QAPI.On 04/28/2026 at 10:12 a.m., an interview was conducted with the Staff Development Coordinator in her office. The Staff Development Coordinator was asked about the training schedules and to provide documentation of the staff training. The Staff Development Coordinator stated she did not have any evidence of training being provided to all staff on QAPI. She stated that she did not do training on QAPI and that she thought it was done by the Human Resources department when staff was hired. She stated some of the staff members received different types of training on the computer. The Staff Development Coordinator presented a copy of the educational calendar she used for education annually. The Staff Development Coordinator was asked for a list of employees to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) and other disciplines.On 04/28/2026 at 10:32 a.m., an interview was conducted with the Human Resources Director who stated she did not provide QAPI education with new hires. A copy of the topics discussed during Orientation was reviewed. Those topics were: Employee Benefits, Health and Safety, Customer Service and Admissions, Resident Rights, Life Enrichment (Activities), Environmental Services, Fire Safety, Food Service, Therapy Department, Infection Control, (Name of Electronic Health Record System redacted) Navigation , Risk Management (Nurses/CNAs-Certified Nursing Assistants), Competencies (Nurses), Competencies (Aides). There was no mention of QAPI on the list for orientation. Review of the annual calendar presented by the Staff Development Coordinator revealed the calendar was a 2017 Annual Education Calendar and did not have QAPI listed as a topic. Review of the educational records of 5 nursing staff members (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) revealed no documentation of training on QAPI. Staff members were asked during the survey if they had received training on QAPI. All responded they could not remember any training on QAPI. They stated that sometimes training was done in person and some were on the computer.The training sample of 5 employees included Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA).The training records for RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7 were reviewed. None of the records had documentation of education on QAPI.On 04/28/2026 at 3:15 p.m., the Staff Development Coordinator stated that she found some documentation on QAPI. She submitted copies of computer-based training on QAPI. When asked it the list included all employees, the Staff Development Coordinator stated that she was not sure. Review of the documentation revealed a list of 14 employees in different disciplines who received QAPI in-service education in March 2026. There were 117 employees who completed QAPI training that was assigned on 07/01/2025. Employees from all disciplines completed that training. However, not all employees were listed and there was no evidence of training after new goals with QAPI.On 04/28/2026 during the end of day debriefing, the Administrator, Assistant Administrator and Director of Nursing were made aware of the findings. They stated there were no more education documents for those staff on record. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to develop, implement, and maintain an effective training program for all staff, including training on behavioral health care and services for 5 (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) of 5 staff records reviewed. Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistant (CNA)The Findings included:Substandard Quality of Care was identified by the survey team on resulting in extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended survey task to be completed by the survey team. On 04/28/2026 at 10:12 a.m., an interview was conducted with the Staff Development Coordinator in her office. The Staff Development Coordinator was asked about the training schedules and to provide documentation of the staff training. The Staff Development Coordinator stated she did not have any evidence of behavioral health training being provided to all staff. She stated some of the staff members received training on the computer. The Staff Development Coordinator was asked for a list of employees to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) and other disciplines.Review of the educational records of 5 nursing staff members (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) revealed no documentation of training on behavioral health care. Staff members were asked during the survey if they had received training on behavioral health. All responded they could not remember any training. They were asked who provided training and they stated some were done in person and some were on the computer.The training sample of 5 employees included Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA).The training records for RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7 were reviewed. None of the records had documentation of education on behavioral health.The Staff Development Coordinator stated she did not have documentation of any employees receiving training on behavioral health careDuring the extended survey investigations, it was determined that the facility did not have an effective training program. The facility failed to maintain an effective training program regarding required training for employees regarding topics including but not limited to behavioral health.On 04/28/2026 during the end of day debriefings, the Administrator., Assistant Administrator, Regional Nurse Consultant and Director of Nursing were made aware of the findings. They stated that all staff should receive required training including training on behavioral health. They stated the education/training documents were maintained by the Staff Development Coordinator.No further information was provided.

Based on resident and staff interviews and a review of clinical records, the facility staff failed to assist the resident to maintain personal belongings for 1 of 63 residents (Resident #101) in the survey sampleThe findings included:Resident #101 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included cancer, hypertension, and hyperlipidemia. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/13/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of 15. This indicated Resident # 101's cognitive abilities for daily decision making were intact. On 4/21/26 at 3:27 pm, during an interview with resident #101. The resident stated, My stuff is stolen every week. The resident proceeded to list missing items: soaps, lotions, clothes, and a broken bottle of perfume. The resident stated that my daughter and I have reported it to the staff, prior administrators, and nursing many times, but nothing has been done. The resident and daughter reported the missing items again at the care plan meeting on 4/22/26. On 4/22/26 at 10:20 am, an interview was conducted with CNA #7 regarding the missing items for resident #101. CNA #7 was aware of the resident's allegation that her personal items have been missing periodically. CNA #7 stated that if a resident reports something missing to them, they would look for the items and or report it to the charge nurse or Director of Nursing. CNA #7 was not aware whether resident #101's items were reported as missing. On 4/22/26, at 10:28 am, an interview was conducted with CNA #3. CNA #3 stated that they remembered in the past that resident #101 alleged that she had missing items. CNA #3 was unsure whether this had been reported to anyone. On 4/23/26 at 11:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the expectation is that when a resident reports missing, lost, or stolen items, a grievance is completed. The only grievance provided by the DON was completed on 4/22/26. On 4/28/26 at approximately 4:45 pm, a final interview was conducted with the Interim Administrator, Director of Nursing, Assistant Director of Nursing, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on observation, resident interview, staff interview and clinical record documentation review, the facility staff failed to ensure accommodation of needs for 4 residents (Resident # 97, # 21, #26 and # 5) in a survey sample of 63 residents.The Findings included:1. For Resident # 97, the facility staff failed to ensure the large clock on the bedroom wall was working. The room was shared with a roommate who also was not included in the sample.Resident # 97 was admitted to the facility with the diagnoses of but not limited to: anemia hypertension, anxiety and depression.The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 03/18/2026. Resident # 97's BIMS (Brief Interview for Mental Status) Score was 6 out of 15, indicating severe cognitive impairment.Review of the clinical record was conducted on 04/212026-04/28/2026.During the initial tour on 04/21/2026 at 12:15 p.m., the clock on the wall in Resident # 97's room was observed to have the time of 5:51. Resident # 97 was in the room, lying in the bed and watching television.On 04/21/2026 at 2:10 p.m., the clock had the time of 5:51. On 04/22/2026 at 9:40 a.m., the clock had the time of 5:51. The second hand was not moving. On 04/22/2026 at 3:00 p.m., the clock had the time of 5:51 Resident # 97 was sitting in the wheelchair. On 04/23/2026 at 8:45 a.m., the clock had the time of 5:51. Resident 97 was sitting in the wheelchair.On 04/23/2026 at 12:38 p.m., the clock had the time of 5:51. Resident 97 was not in the room.Staff members were observed in the room picking up food trays, delivering ice and water and providing care to during the survey. No staff person addressed the issue of the clock having the wrong time.On 04/23/2026 at 3:05 p.m., an interview was conducted with the Unit Manager who stated it was important for clocks to be accurate in the residents' rooms. The Unit Manager stated the clock in the room should have had the correct time because it was important for the orientation of the residents. The Unit Manager stated staff members should have observed the clock was wrong.During the end of day debriefing on 04/23/2026, the Facility Administrator, the Assistant Administrator, the Regional [NAME] President of Operations, and the Director of Nursing were informed of the issue. They all stated the clocks in residents' rooms should be accurate. The Director of Nursing stated it was important for clocks to be accurate because they would help with orientation of the residents. The Director of Nursing stated the staff members should have observed that the clocks were not working. No further information was provided. 2. For Resident # 21, the facility staff failed to ensure the large clock on the bedroom wall was working. The room was shared with a roommate who was also not included in the sample.Resident # 21 was admitted to the facility on [DATE] with the diagnoses of, but not limited to:The most recent Minimum Data Set (MDS) was a comprehensive assessment with an Assessment Reference Date (ARD) of 02/24/2026. Resident # 21's BIMS (Brief Interview for Mental Status) Score was00 out of 15, indicating severe cognitive impairment.Review of the clinical record was conducted on 04/212026-04/28/2026.During the initial tour on 04/21/2026 at 12:20 p.m., the clock on the wall in Resident # 21's room was observed to have the time of 4:20. Resident # 21 was in the room, lying in the bed and watching television.On 04/21/2026 at 2:10 p.m., the clock had the time of 4:20. Resident # 21 was lying in bed.On 04/22/2026 at 9:40 a.m., the clock had the time of 4:20. The hands were not moving. On 04/22/2026 at 3:00 p.m., the clock had the time of 4:20. Resident # 21 was sitting in the wheelchair. On 04/23/2026 at 8:45 a.m., the clock had the time of 4:20. Resident 21 was sitting in the wheelchair.On 04/23/2026 at 12:38 p.m., the clock had the time of 4:20. Resident 21 was sitting in the wheelchair.Staff members were observed in the room picking up food trays, delivering ice and water and providing care to during the survey. No staff person addressed the issue of the clock having the wrong time.On 04/23/2026 at 3:05 p.m., an interview was conducted with the Unit Manager who stated it was important for clocks to be accurate in the residents' rooms. The Unit Manager stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. The Unit Manager stated staff members should have observed the clock was wrong.During the end of day debriefing on 04/23/2026, the Facility Administrator, the Assistant Administrator, the Regional [NAME] President of Operations, and the Director of Nursing were informed of the issue. They all stated the clocks in residents' rooms should be accurate. The Director of Nursing stated it was important for clocks to be accurate because they would help with orientation of the residents. The Director of Nursing stated the staff members should have observed that the clocks were not working.No further information was provided. 3. For Resident # 26, the facility staff failed to ensure the large clock on the bedroom wall was working. The room was shared with a roommate who also was not included in the sample.Resident # 26 was admitted to the facility on [DATE] with the diagnoses of but not limited to:The most recent Minimum Data Set (MDS) was a comprehensive assessment with an Assessment Reference Date (ARD) of 03/24/2026. Resident # 26's BIMS (Brief Interview for Mental Status) Score was 08 out of 15, indicating severe cognitive impairment.Review of the clinical record was conducted on 04/212026-04/28/2026.During the initial tour on 04/21/2026 at 12:30 p.m., the clock on the wall in Resident # 26's room was observed to have the time of 10:50. Resident # 26 was in the room, sitting in the wheelchair and watching television.305 8:30 a.m. and 9:20 -time 10:50On 04/21/2026 at 2:10 p.m., the clock had the time of 4:20. Resident # 26 was lying in bed.On 04/22/2026 at 8:30 a.m. and 9:20 -time on the clock had 10:50.On 04/22/2026 at 12:10 p.m.- time on clock had the time of 1:38. An interview was conducted with Resident # 5. When asked what time lunch was being served, Resident # 26 looked at the clock and stated she did not know.On 04/22/2026 at 3:00 p.m., the clock had the time of 4:20. Resident # 26 was sitting in the wheelchair. On 4/23/2026 at-1015 a.m.th4 clock had the time of 11:34 Resident 26 was sitting in the wheelchair.On 04/23/2026 at 12:38 p.m., the clock had the time of 2:02. Resident 26 was sitting in the wheelchair beside the bed.Staff members were observed in the room picking up food trays, delivering ice and water and providing care to during the survey. No staff person addressed the issue of the clock having the wrong time.On 04/23/2026 at 3:05 p.m., an interview was conducted with the Unit Manager who stated it was important for clocks to be accurate in the residents' rooms. The Unit Manager stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. The Unit Manager stated staff members should have observed the clock was wrong.During the end of day debriefing on 04/23/2026, the Facility Administrator, the Assistant Administrator, the Regional [NAME] President of Operations, and the Director of Nursing were informed of the issue. They all stated the clocks in residents' rooms should be accurate. The Director of Nursing stated it was important for clocks to be accurate because they would help with orientation of the residents. The Director of Nursing stated the staff members should have observed that the clocks were not working.No further information was provided. 4. For Resident # 5, the facility staff failed to ensure the large clock on the bedroom wall was working. The room was shared with a roommate (Resident # 58) who was also included in the survey sample.Resident # 5 was admitted to the facility on [DATE] with the diagnoses of but not limited to: diabetes, cerebral infarction, hemiplegia and aphasia.The most recent Minimum Data Set (MDS) was a comprehensive assessment with an Assessment Reference Date (ARD) of 04/13/2026. Resident # 5's BIMS (Brief Interview for Mental Status) Score was 6 out of 15, indicating severe cognitive impairment.Review of the clinical record was conducted on 04/212026-04/28/2026.During the initial tour on 04/21/2026 at 12:30 p.m., the clock on the wall in Resident # 5's room was observed to have the time of 2:47. Resident # 5 was in the room, lying in the bed and watching television.On 04/21/2026 at 2:10 p.m., the clock had the time of 2:47. Resident # 5 was lying in bed.On 04/22/2026 at 9:40 a.m., the clock had the time of 2:47. Resident # 5 stated the clock was wrong. The hands were not moving. On 04/22/2026 at 3:00 p.m., the clock had the time of 2:47. Resident # 5 was sitting in the wheelchair near the bed.On 04/23/2026 at 8:45 a.m., the clock had the time of 2:47 Resident 5 was sitting in the wheelchair. When asked about the time, Resident # 5 stated the clock did not work. On 04/23/2026 at 12:38 p.m., the clock had the time of 2:47. Resident 5 was sitting in the wheelchair.Staff members were observed in the room picking up food trays, delivering ice and water and providing care to during the survey. No staff person addressed the issue of the clock having the wrong time.On 04/23/2026 at 3:05 p.m., an interview was conducted with the Unit Manager who stated it was important for clocks to be accurate in the residents' rooms. The Unit Manager stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. The Unit Manager stated staff members should have observed the clock was wrong.During the end of day debriefing on 04/23/2026, the Facility Administrator, the Assistant Administrator, the Regional [NAME] President of Operations, and the Director of Nursing were informed of the issue. They all stated the clocks in residents' rooms should be accurate. The Director of Nursing stated it was important for clocks to be accurate because they would help with orientation of the residents. The Director of Nursing stated the staff members should have observed that the clocks were not working.No further information was provided.

Based on information obtained during the resident group meeting and a review of facility documents, the facility staff failed to ensure that 5 of 5 residents in the group meeting knew where the survey results binder was located without having to ask someone. The findings included:On 4/22/26 at 11:00 AM, a Resident Group meeting was held with the Resident Council President and four residents who regularly attend the group. There was consensus among all attendees that they were unaware they could review the survey book or even have access to it. No one could state where the book was located, and the president suggested that it must be behind the nurse's station. On 4/23/26 at 11:30 AM, an interview was conducted with the Director of Activities. The Activities director stated that the residents are educated in every resident council meeting on where to locate the survey results binder, and it was documented in the resident council minutes that they were provided with the information. No suggestions were offered on how the residents would be updated moving forward. On 4/28/26 at approximately 4:45 pm, a final interview was conducted with the Interim Administrator, Director of Nursing, Assistant Director of Nursing, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on a review of facility documents and staff interviews, the facility staff failed to thoroughly investigate prospective employees' histories before hiring.The findings included: A review of current and past employees hired over the last 2 years was conducted on 4/22/26. Eleven of 25 employee records are missing at least one of the following documents: the sworn statement, the state police criminal background search, or verification of a certificate or license. On 4/22/26 at 12:20 PM, an interview was conducted with the Human Resources Director. The HR Director stated that they had conducted an in-house audit of employee records, and they identified that specific documents were missing. The HR Director also stated that they had not taken action to correct the problem, nor had they referred the matter to the Quality Assurance committee. The HR Director stated that on 4/22/26, an employee was terminated before clocking in because, on the evening of 4/21/26, the sister facility had emailed the criminal background report indicating that the employee had barrier crimes. The HR Director stated that upon receipt and review of the criminal background report, it revealed the employee had assaulted a family member and was guilty of malicious wounding and indecent exposure. This employee was hired on 4/7/26, the background check was requested on 4/8/26, and the report was received on 4/21/26. 4/22/26 at 1:20 PM, an interview was conducted with the Regional HR Director. She explained that the facility's process was to receive background checks and ensure all required documents were completed for a thorough screening. The Regional HR Director stated that it is their policy not to hire employees with past criminal prosecutions and that all new hires be screened in accordance with the policies and regulations. The Regional HR Director further said that the in-house HR Director had been experiencing issues with the online process on the state police website; therefore, they relied on the HR Director from a sister facility to obtain the documents for the facility. The Regional HR Director stated that the problem with the state police website had been resolved. On 4/24/26 at 2:15 PM, an interview was conducted with the Administrator, Assistant Administrator, Regional [NAME] President of Operations, DON, Regional Nurse Consultant, and Regional Minimum Data Set Consultant regarding the above allegation. They offered no additional information. On 4/28/26 at 3:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, DON, Regional [NAME] President of Operations, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. The facility's staff voiced no comments.

Based on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure that one (1) resident (Resident #16) and their family members were able to attend their person-centered care plan meetings, and the facility staff failed to review and revise a care plan for one (1) resident (Resident #11) of 63 residents in the survey sample. The findings included: 1.The facility staff failed to invite resident #16 and her family member to care plan meetings. Resident #16 was originally admitted to the facility 4/30/24 after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included; Type 2 Diabetes without complications and Alzheimer's Disease. The quarterly revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/13/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #16 cognitive abilities for daily decision making were severely impaired. In section GG (Functional Abilities Goals), the resident was coded as requiring set-up or cleanup assistance with oral hygiene, upper- and lower-body dressing, and eating. The resident requires supervision or touching assistance with toileting hygiene, putting on and taking off footwear, and personal hygiene. Requires partial-to-moderate assistance with showering/bathing self. The person-centered care plan revised 1/28/26 read that resident has a communication problem r/t Dementia and primary language is Spanish although she does understand and speak some English. A Goal for the resident was to make basic needs known on a daily basis. The interventions for the resident included: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, resident prefers to communicate in Spanish, Discuss with resident/family concerns or feelings regarding communication difficulty, monitor effectiveness of communication strategies and assistive devices, monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed, monitor/document residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend, monitor/document/report PRN any changes in: Ability to communicate, Potential contributing factors for communication problems, potential for improvement, provide translator as necessary to communicate with the resident. On 4/22/26 at approximately 12:35 pm, an interview was conducted with the resident's daughter (Family Member/FM #1). According to FM #1, they have never received an invitation or attended a care plan meeting. On 4/23/26 at approximately 2:53 pm, an interview was conducted with the Social Worker (SW). The SW said that care plan meetings are conducted on admission and quarterly. A review of medical records showed that two (2) care plan meetings were conducted, but it did not mention whether the resident or family members were present. On 04/28/26 at approximately 1:45 p.m., the above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but none was provided. 2. The facility's staff failed to review and revise Resident #11's person-centered care plan as her status changed. Resident #11 was admitted to the facility on [DATE]. The residents' current diagnoses included a stroke with aphasia and anxiety. The Significant Change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/24/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 4 out of 15. This indicated that Resident # 11's cognitive abilities for daily decision-making were severely impaired. In section GG0130 (Functional Abilities), the resident was coded as dependent with all ADL care. On 4/21/26 at approximately 2:40 PM, the resident was observed asleep in bed. A bedside drainage bag was not observed. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 4/24/26. CNA #1 stated that Resident #11 had not had an indwelling catheter for at least two months. CNA #1 stated the resident was incontinent of urine and uncovered the resident's peri area to validate the information was accurate. The only indwelling catheter order identified was dated 8/03/2025. The order stated an Indwelling Urinary (Foley) Catheter to Straight Drainage, 16 French, with a 10 ml balloon, for comfort care every shift. This order was discontinued on 10/23/2025, per a nurse's note at 3:10 PM. The nurses' note didn't state the rationale for discontinuation. A review of Resident #11's care plan revealed a problem dated 6/12/2025 stating that Resident #11 currently had a 16 French indwelling catheter with a 10ml balloon for end-of-life. The goal stated that the resident will be/remain free from catheter-related trauma through the review date. The interventions included positioning the catheter bag and tubing below the bladder level and away from the entrance room door. A nurse Practitioner's progress note dated 4/21/26 revealed, in the review of systems, that the resident continued to use an indwelling catheter for urinary retention. The person-centered care plan also had a problem dated 9/08/2025 for Hospice services secondary to an end-stage diagnosis. The goal stated that the resident would remain comfortable through the next review date. The interventions included collaborating with all disciplines, family, and Hospice to meet resident needs. A review of the hospice certification note dated 2/18/26 stated the resident's certification for services would end on 2/21/26 because the resident would be discharged , as she was no longer considered terminal. On 4/28/26 at 3:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing (DON), Regional Nurse Consultant, and Regional Minimum Data Set Consultant. The DON stated they would need to determine whether the resident still needed the catheter.

Based on observation and staff interview, the facility staff failed to provide a resident environment free of accident hazards.The findings included: The facility staff failed to replace missing floor tiles in the kitchen, and replace a damaged dining room entry door which resulted in an accident hazard. On 4/21/26 at 11:30 AM during an observation tour of the kitchen, it was observed that floor tiles were missing on the floor when entering through the kitchen door. It was also observed that the missing tiles were placed on a pellet warmer next to the missing tiles. On 4/23/26 at 4:00 PM an interview was conducted with the Director of Maintenance. The Director of Maintenance stated that the floor tiles in the kitchen were removed a couple months ago. The Director of Maintenance also stated that due to the floor in the kitchen missing tiles, this could be an area that the staff could trip and fall. The Director of Maintenance further stated that this could be a hazard. On 4/21/26 at 11:45 AM during an observation tour of the dining room, it was observed that the entry door to the dining room was splitting apart and the bottom door hinge was not attached to the door. On 4/23/26 at 4:05 PM an interview was conducted with the Director of Maintenance. The Director of Maintenance stated that the dining room entry door is being replaced. The Director of Maintenance also stated that the door currently is propped open due to the bottom door hinge being broken. The Director of Maintenance further stated that the door could fall if the staff attempts to close the door and this could be a hazard.On 4/28/26 at 2:03 p.m., a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional Minimum Data Set Consultant. They had no further comments and voiced no concerns regarding the above information.

Based on observation, staff interview, resident interview and facility documentation, the facility staff failed to ensure staffing information was posted daily at the receptionist's desk and/or on three of three units in a prominent place and readily accessible to all residents, staff and visitors.The Findings included:During the initial tour of the facility on 04/21/2026, there was no observation of the daily posting of the nurse staffing information on the nursing units. There was no posting noted at the receptionist's desk.On 04/22/2026 (the second day of survey), no nurse staffing information was observed on the units nor at the receptionist's desk.On 04/22/2026 at 11:00 a.m., a group interview was conducted by another surveyor with five alert and oriented individuals. The surveyor reported that each resident stated that the residents did not know where to find information about the nurse staffing each day.On 04/22/2026 during rounds at 1:20 p.m., an interview was conducted with an alert resident sitting in the hallway who stated he did not know how to determine how many staff members were working.On 04 /23/2026 at 12:50 p.m., a visitor was interviewed about the nurse staffing. The visitor stated she did not know where that information was located. The visitor stated that she visited the facility regularly but did not see that information posted.On 04/24/2026, there were no observations of the posting of the daily nurse staffing. On 04/27/2026 at approximately 11:30 a.m., an interview was conducted with the Administrator who stated that he was not sure of where the nurse staffing information was posted. The Administrator stated the surveyor should check with the Assistant Administrator. On 04/27/2026 at approximately 11:31 a.m., an interview was conducted with the Assistant Administrator who stated the nurse staffing information was posted on the bulletin board in the Human Resources Hall. The Assistant Administrator walked with the surveyor to the bulletin board where a copy of the as worked schedule for Monday, April 27, 2026, was posted. The document noted the information was for the 7a-3p shift and the census was 109. The Assistant Administrator walked with the surveyor to the receptionist's desk. The Administrator asked where the nurse posting was located. The receptionist stated it was usually located on the left lower ledge of the desk. She reached under the desk and presented a new picture frame with a stock photo under the glass. The receptionist stated they were replacing the frame. The Assistant Administrator stated the form should be posted and have name of the facility, the shift, nursing positions and the census number. The Assistant Administrator stated she did not know if the facility kept copies of the postings for 18 months.On 04/27/2026 at 11:35 a.m., an interview was conducted with the staffing coordinator who stated she usually posted the nurse staffing each day. She stated that the copies of previous postings were available but she did not know if she had them for the past 18 months. Copies were requested and received at 1:10 p.m.Review of the postings presented by the staffing coordinator revealed documentation from August 25, 2025, to March 5, 2026. There was a total of 48 sheets of paper presented for that seven-month period. Numerous dates were missing. Some of the dates had missing information including: no documentation of the daily census and several dates had blanks under the Registered Nurse time slots on the 3-11 shift, along with a few blanks on the 11-7 shift. The facility's policy stated facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.During the end of day debriefing on 04/27/2026, the Administrator, Assistant Administrator and Director of Nursing were informed of the findings that the nurse staffing information was not posted on several dates and not readily accessible to all residents, staff and visitors. They stated that the information should have been posted but it was not. No further information was provided.

Based on observation and Staff interview the facility staff failed to discard 2 bottles of expired insulin from 2 out of 3 medication carts. The findings included: On [DATE] at approximately 2:05 pm, a medication cart audit was conducted on the [NAME] unit, Front Hall medication Cart with Licensed Practical Nurse (LPN) #7. A bottle of Humulin R, 100 units of insulin, with an open date of [DATE]. LPN #7 said it should have been discarded after 28 days of opening.On [DATE] at approximately 2:27 pm, a medication cart audit was conducted on the Fine Unit, Cart #2, with LPN #8. Upon inspection, 1 bottle of Humulin R insulin with an open date of [DATE] was observed. LPN #8 said that it should have been discarded 28 days from the open date. LPN #8 also said that I have to get rid of it, it's no good.On [DATE] at 1:45 pm., a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing (DON), Regional Nurse Consultant, and Regional Minimum Data Set Consultant. No further information was provided

Based on staff interview and facility documentation review, the facility staff failed to ensure QAPI (Quality Assurance Performance Improvement) meetings were conducted quarterly for 3 of 4 quarters sampled.The Findings included:Throughout the survey conducted 04/21/2026 - 04/28/2026, the survey team inspected and investigated the facility's systems and processes regarding correcting previously cited deficiencies and resident care concerns. It was noted the facility had failures and remained out of compliance in areas that had previously been cited as deficient during previous abbreviated surveys. The Maintenance logs and Pest control logs were reviewed by the survey team. There were issues identified.Review of the Resident Council minutes and Grievance logs revealed the facility's administration was aware of issues/concerns voiced by residents and families. The issues continued for several months without resolution.On 04/23/2026 at approximately 3:20 p.m., an interview was conducted with the Administrator who stated the facility was making improvements and renovations in the facility. He stated it was important for the facility to have a clean, comfortable homelike environment for the residents.Substandard quality of care was identified at the facility during the survey resulting in an extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended survey task to be completed by the survey team. On 04/27/2026 at 4:01 p.m., an interview was conducted with the Assistant Administrator who stated she did not have any information about QAPI prior to January 2026. She stated the current administrative staff could not find documentation of any QAPI activities from the previous administrator. The Assistant Administrator stated the facility was expected to meet monthly to discuss Quality Assurance and quarterly for the QAPI meetings. She stated there was no current Performance Improvement Project being conducted. Review of four quarters revealed no documentation for last three quarters in 2025 . The only documentation was in the first quarter of 2026.During the extended survey, investigations, it was determined that the facility did not have an effective training program. The facility failed to maintain an effective training program regarding required training for employees regarding topics including but not limited to: QAPI, effective communication and behavioral health.During the end of day debriefings on 04/27/2026 and 04/28/2026, the Facility's Administrator, Assistant Administrator, Regional Nurse Consultant and Director of Nursing were informed of the findings. The governing body should have been made aware of the issues identified by the survey team. There was no documentation of the governing body being aware of and/or acting on the issues identified. The Administrator stated he would address the issues identified.No further information was provided.

Based on observation and staff interview the facility's staff failed to have a functional emergency call system (Emergency Pull cord) available for a resident who ambulates to the bathroom frequently For 1 of 63 residents (Resident #16), in the survey Resident #16 was originally admitted to the facility on [DATE] after an acute care hospital stay and re-admitted on [DATE]. The current diagnoses included: Type 2 Diabetes without complications and Alzheimer's Disease. The quarterly revision Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/13/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated that Resident #16's cognitive abilities for daily decision-making were severely impaired.In section GG (Functional Abilities Goals), the resident was coded as requiring set-up or cleanup assistance with oral hygiene, upper- and lower-body dressing, and eating. The resident requires supervision or touching assistance with toileting hygiene, putting on and taking off footwear, and personal hygiene. Requires partial-to-moderate assistance with showering/bathing self. The person-centered care plan, revised 1/28/26, states that the resident has a communication problem r/t Dementia and that her primary language is Spanish, although she understands and speaks some English. A Goal for the resident was to make basic needs known daily. The interventions for the resident included: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, resident prefers to communicate in Spanish, Discuss with resident/family concerns or feelings regarding communication difficulty, monitor effectiveness of communication strategies and assistive devices, monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed, monitor/document residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend, monitor/document/report PRN any changes in: Ability to communicate, Potential contributing factors for communication problems, potential for improvement, provide translator as necessary to communicate with the resident.On 4/21/26 at approximately 11:53 pm, an initial tour of the bathroom shared by rooms [ROOM NUMBERS] was conducted on unit 1. The emergency pull alarm, located in the bathroom, appeared non-functional (it wouldn't light up or be heard at the nurses' station). Resident #16, located in room [ROOM NUMBER]A, was observed throughout the survey ambulating independently to the restroom, which has a non-operable emergency call system.On 4/24/26 at approximately 10:15 am, the emergency pull cord was checked to see if it was in operation. The emergency cord was pulled, but it didn't send an alert to the call enunciator located at the nurse's station. Certified Nurse's assistant (CNA) #3 was asked whether he could tell whether the emergency pull-cord alarm sent an alert while at the nurse's station. CNA #3 said he wasn't aware.The above information was shared with the facility staff on 4/24/26 at approximately 1:00 pm. No information was given at this time.

The facility staff failed to maintain an effective pest control program. Residents during the group meeting with the inspectors that represented all three nursing units, were in consensus that roaches were identified in their rooms.The findings included: On 4/22/26 at 11:00 AM, a Resident Council meeting was held with the President and four other residents who regularly attend the group meeting. All attendees agreed that the facility was not a safe, clean, comfortable, and homelike environment. 1. Resident #22 was admitted to the facility on [DATE]. The residents' diagnoses included high blood pressure and asthma. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/20/2026, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident # 22's cognitive abilities for daily decision-making were intact.On 4/22/26 at approximately 11:17 AM, an interview was conducted with Resident #22. Resident #22 stated that there are large flying roaches in the facility, and the shower room is unclean. She stated that she thought they at times landed on her bed and questioned whether she should avoid showering.2. Resident #27 was admitted to the facility on [DATE]. The residents' diagnoses included diabetes and depression. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/7/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 0 out of 15. This indicated that Resident # 27's cognitive abilities for daily decision-making were severely impaired. Although Resident #27's BIMS score is low, staff interviews and resident statements validated that she is alert and oriented times 4.On 4/22/26 at approximately 11:22 AM, an interview was conducted with Resident #27. Resident #27 stated that there are flying roaches in the facility during the day and at night, and that they have worsened since construction began.3. Resident #43 was admitted to the facility on [DATE]. The residents' diagnoses included protein-calorie malnutrition and COPD. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/12/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #43's cognitive abilities for daily decision-making were intact.On 4/22/26 at approximately 11:32 AM, an interview was conducted with Resident #43. Resident #43 stated that the roaches crawl on the ceilings and walls, making it difficult to sleep. The resident also stated that they had not seen pest control treat their room for the roaches.4. Resident #108 was admitted to the facility on [DATE]. The residents' diagnosis included a non-pressure chronic ulcer, left calf, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 4/17/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #108's cognitive abilities for daily decision-making were intact.On 4/22/26 at approximately 11:37 AM, an interview was conducted with Resident #108. Resident #108 stated that roaches are seen throughout the facility and that sightings have not improved.5. On 4/23/2026 at 2:15 p.m., a visitor in the dining room was asked about the facility. She stated that she was glad to see renovations, but wished they would do something in the old section. The visitor also stated she had seen roaches in the building.6. Resident # 109 was in the room in her wheelchair. Resident # 109 was alert, oriented (with a BIMS score of 14, indicating no cognitive impairment), and wheeled herself around the room and in the bathroom. Regarding wires that were not secure in the wiring duct raceway strip, the Maintenance Director stated, I will have to replace this-no one told me. Resident # 109 said, That is not true, y'all know about all of this stuff. Let's not talk about the roaches in my room and bathroom. The surveyor went into the bathroom, and there were four roaches on the floor: two dead and two alive (on their backs, wiggling). The Maintenance Director did not pick them up, did nothing. Observed two roach houses in the room: one under the basin and one in the corner. The Maintenance Director saw the plastic container under the toilet's on/off valve, which had accumulated water up to about two inches from the top. He stated, I did not know about this, but this bathroom floods, as to why that is there. It probably attracts the roaches, too. On 04/23/2026 at 3:30 p.m., rounds were conducted with the housekeeper to review the observations. Resident # 109 said that she had told housekeeping about how dirty her room was and that the roaches crawl and fly around her room and bathroom. The surveyor and housekeeper went into the bathroom and observed roaches on the floor. The housekeeper picked them up and flushed them down the toilet. Resident # 109 was a [AGE] year-old admitted to the facility on [DATE]. Diagnoses included cerebral infarction and hemiplegia. The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 03/23/2026. Resident # 109's BIMS (Brief Interview for Mental Status) Score was 14 out of 15, indicating no cognitive impairment7. The following observations were made on Unit 1, [NAME] Hall:room [ROOM NUMBER]: On 4/21/26 at approximately 12:30 pm., during the initial tour of room [ROOM NUMBER], the residents were observed lying in their beds. The resident in bed 217 A, located near the door, said, There is a wasp nest by the window. Resident #99 in bed 217 B, located near the window, said, When they sting me, I swell up. Upon visual observation of the window located between the screen window and the glass, there were 2 wasp nests. One nest was located high in the corner, resting between the bricks and screen, with what appeared to have about ten (10) round, greyish, whitish, circular, egg-looking sacs. The other cells in the same nest, which were many, appeared empty with a hexagonal-like appearance. The second nest was located high above the screen. The second nest appeared much smaller than the first nest. A live wasp was observed sitting on top of one of the empty cells. No eggs were observed in the second nest. There was about 1/4 inch gap between the outside screen and the window leading to the sill in the resident's room. Observed at the bottom of the 1/4 gap or opening appeared to be a dead wasp; air could be felt coming from the outside. Resident #99 and Resident #12 agreed they don't want to get stung, that the nest has been up there for about 3 weeks, and that the staff is aware.On 4/23/2026, during the end-of-day debriefing, the Administrator, Assistant Administrator, Director of Nursing, Regional Nurse Consultant, and Regional [NAME] President were informed of the findings. They were informed that the gap at the threshold from the hallway door to the courtyard could be a point of entry for insects and roaches. There were many resident complaints about roaches. Surveyors observed roaches in the facility. It was noted that the facility's contracted pest control company services were not completed in January and February due to a lapse in vendor payment processing. The pest control logs had been destroyed by the Maintenance Director across all units, leaving them blank and failing to reflect the pest sightings residents complained about, namely, roaches. The wasp nests in room [ROOM NUMBER] were a current issue brought to the facility's attention by the survey team, not entered into the unit's pest control log.

Based on staff interview and facility documentation review, the facility staff failed to develop, implement, and maintain an effective training program for all staff, including training on Communication for 5 (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) of 5 staff records reviewed. Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistant (CNA) The Findings included:Substandard Quality of Care was identified by the survey team on resulting in extended survey from 04/24/2026-04/28/2026.During the end of day debriefing on 04/24/2026, the Facility Administrator, the Regional [NAME] President of Operations, Assistant Administrator, Regional Nurse Consultants and Director of Nursing were informed of the findings of the substandard quality of care that were identified by the survey team resulting in an extended survey task to be completed by the survey team. On 04/28/2026 at 10:12 a.m., an interview was conducted with the Staff Development Coordinator in her office. The Staff Development Coordinator was asked about the training schedules and to provide documentation of the staff training. The Staff Development Coordinator stated she did not have any evidence of behavioral health training being provided to all staff. She stated some of the staff members received training on the computer. The Staff Development Coordinator was asked for a list of employees to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) and other disciplines.Review of the educational records of 5 nursing staff members (RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7) revealed no documentation of training on behavioral health care. Staff members were asked during the survey if they had received training on communication. All responded they did not have any training on communication with a Spanish speaking resident. They stated the family of the resident would help to translate and that the Assistant Director of Nursing spoke Spanish.The training sample of 5 employees included Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA).The training records for RN #2, RN # 3, LPN # 7, CNA # 6, CNA #7 were reviewed. None of the records had documentation of education on Communication with a Spanish speaking resident.The Staff Development Coordinator stated she did not have documentation of any employees receiving training on communication with a Spanish speaking resident. There were no communication tools noted in the Spanish Speaking resident's room. There was no noted process developed and implemented by staff on how to communicate with the Spanish Speaking Resident. During the extended survey investigations, it was determined that the facility did not have an effective training program. The facility failed to maintain an effective training program regarding required training for employees regarding topics including but not limited to communication.On 04/28/2026 during the end of day debriefings, the Administrator., Assistant Administrator, Regional Nurse Consultant and Director of Nursing were made aware of the findings. They stated that all staff should receive required training including training on communication. They stated the education/training documents were maintained by the Staff Development Coordinator.No further information was provided.

Based on observations, staff interviews, and clinical record review, the facility staff failed to provide services to prevent development of a pressure ulcer for a resident with a known moderate risk for pressure ulcer development and to identify the left heel pressure ulcer prior to progression to a stage three (3) which measured 4 centimeters by 4 centimeters by 0.1 centimeters, and presenting with 40 percent slough and 60 percent of dermis, for 1 of 5 residents (Resident #50), with facility acquired pressure ulcer, which constituted harm. The findings included: Resident #50 was originally admitted to the facility 4/15/2022 and had not been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/17/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with dressing, toileting, and bathing, extensive assistance of one person with bed mobility and personal hygiene, supervision of one person with eating. On 6/7/22 at approximately 3:05 p.m., an interview was conducted with Resident #50. The resident stated she had obtained an open area to her left heel since she was admitted to the facility and it had been present for approximately one month. The resident stated the staff works on it every day but she didn't know if it was getting better or not because she hadn't been informed. A review of the facility's matrix reveal Resident #50 was coded for having a facility acquired stage three pressure ulcer. The following observations were made of Resident #50; on 6/7/22 at approximately 3:05 p.m., the resident was observed in bed lying on her back, looking out the doorway. On 6/8/22 at approximately 11:10 a.m. the resident was again observed in bed lying on her back. She remained talkative and answered appropriately. Another observation was made of Resident #50 on 6/9/22 at approximately 4:50 p.m., the resident was again in bed without any positioning devices in place. Resident #50 stated the pressure ulcer was always to the left heel, she complies with the staff whenever they provide care and follows instructions but she stated no one informed her to avoid lying on her left side. No pressure reducing devices were ordered or care planned for use. The 4/29/22 the completed Braden Scale for Predicting Pressure Sore Risk (BRADEN) assessment revealed Resident #50 had a moderate risk for pressure ulcer development secondary to responding only to painful stimuli or she had a sensory impairment which limited the ability to feel pain or discomfort over half of her body, her skin is occasionally moist, requiring an extra linen change approximately once a day, she is confined to the bed, and during movement her skin probably slides to some extent against sheets or other devices. A Dietary/Nutrition progress note dated 4/19/2022 at 3:16 p.m., read that the resident was aew resident is on regular mechanical soft with ground meat diet and that there was an area to the left buttock. The progress note indicate that the Intake barely met her needs for calories and protein and to help with wound healing would recommend adding ProMod, multivitamin, vitamin C and Zinc 220mg for 14 days and reassess after 2 weeks for a follow up with the Registered Dietitian (RD). The weekly skin assessment dated [DATE] revealed Resident #50 had only a left buttock abscess. The weekly skin assessment dated [DATE] revealed Resident #50 was with a new opened area to the right heel. A review of the active care plan revealed a problem dated 5/5/2022 which read; (name of the resident) has a pressure ulcer to the right heel related to Immobility. (On 5/31/22 the site for the heel pressure ulcer was updated to the left heel). The goal read; the resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions included; administer treatments as ordered and monitor for effectiveness. The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The wound care Nurse Practitioner (NP) assessment dated [DATE] revealed Resident #50 had an initial exam for a new opened area and the resident was identified with a Stage 3 pressure ulcer of the right heel which measured 4 centimeters by (x) 4 centimeters by 0.1 centimeters (cm), had a small amount of serous drainage, 40 percent (% ) slough and 60% of dermis. The wound care NP ordered; [MEDICATION(S)] and dry dressing, every three days and as needed. Recommendations offered included; facility pressure ulcer prevention protocol, pressure redistribution mattress per facility protocol, turn and reposition per facility protocol per resident's plan of care, float heels, and keep the resident off of her left side. The 5/13/22, wound care NP assessment revealed the following; a stage 3 pressure ulcer of the right heel which measured 3 cm x 4.5 cm x 0.1 cm, it presented with a moderate amount of serosanguinous drainage, 40 % slough, 60% of dermis and maceration of the peri-wound. The wound care NP stated the pressure ulcer was improving. The wound care NP ordered; Santyl on Dakin's gauze and dry dressing, every day and as needed. The 5/19/22, wound care NP assessment revealed the following; a stage 3 pressure ulcer of the right heel which measured 2 cm x 4.5 cm x 0.3 cm, it presented with a moderate amount of serosanguinous drainage, 50 % slough and 50% of dermis plus maceration and conservative sharp debridement was necessary to remove 4.5 square centimeters of nonviable tissue. The wound care NP stated the pressure ulcer was deteriorating. The wound care NP ordered; Santyl on Dakin's gauze, (Only put Santyl and Dakin's gauze on open wound bed.), skin prep to the periwound and a dry dressing every day and as needed. The 5/26/22, wound care NP assessment revealed the following; a stage 3 pressure ulcer of the right heel which measured 1.6 cm x 3 cm x 0.9 cm, it presented with a moderate amount of serous drainage, 40% slough, 20% dermis and 40% epithelial tissue. Conservative sharp debridement was necessary to remove 1.92 square centimeters of nonviable tissue. The wound care NP stated the pressure ulcer was improving. The wound care NP ordered; Santyl on Dakin's gauze, (Only put Santyl and Dakin's gauze on open wound bed.), skin prep to periwound and a dry dressing every day and as needed. The 6/2/22, wound care NP assessment revealed the following; a stage 3 pressure ulcer of the left heel which measured 1.4 cm x 2.5 cm x 0.4 cm, it presented with a moderate amount of sanguinous drainage, 50% slough and 50% granulation tissue plus periwound maceration and conservative debridement was completed to remove 1.75 square centimeters of nonviable tissue. The wound care NP stated the pressure ulcer was improving. The wound care NP ordered; Santyl on Dakin's gauze, (Only put Santyl and Dakin's gauze on open wound bed.), skin prep to periwound and a dry dressing every day and as needed. The 6/9/22, wound care NP assessment revealed the following; a stage 3 pressure ulcer of the left heel which measured 1.4 cm x 2.5 cm x 0.3 cm, a moderate amount of sanguinous drainage, 40% slough and 60% granulation tissue plus periwound maceration. The wound care NP stated the pressure ulcer was improving. The wound care NP ordered; Santyl on Dakin's gauze, (Only put Santyl and Dakin's gauze on open wound bed.), skin prep to periwound and dry dressing two times each day(every AM and every PM), and as needed. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Neither order was signed off as completed on the Treatment Administration Record (TAR). On 5/8/22 at 7:00 a.m., another order was obtained for the right heel; it read; cleanse the right heel pressure ulcer with wound cleaner, apply [MEDICATION(S)] and a dry dressing every three days for wound care. This order was signed off as completed as ordered on 5/8/22, 5/11/22 and 5/14/22. On 5/17/22 an order was obtained for Santyl Ointment ([MEDICATION(S)]), apply to right heel pressure ulcer topically every day shift for wound care. This order was signed off as completed 5/17/22 through 5/20/22, 5/21/22 through 5/23/22 and 5/25/22 through 5/27/22, then the order was discontinued 5/28/22. The wound care wasn't signed off as completed on 5/22/22 and 5/24/22. On 5/29/22 at 10:30 a.m., a new order was obtained which read; Santyl Ointment ([MEDICATION(S)]) apply to the left heel pressure ulcer topically as needed for wound care. This was the first order to treat the opened pressure ulcer to the left heel the affected heel. The 5/29/22 order was discontinued on 6/9/22. A review of the staff's documentation and orders prior to 6/2/22 indicated there was a pressure ulcer to the right heel therefore an interview was conducted with the Director of Nursing and the Administrator on 6/9/22 at approximately 6:30 p.m. The Administrator stated all the documentation and orders for the pressure ulcer of the right heel was an error. The Administrator stated she made an observation to determine the exact location of the pressure ulcer and it was to the left heel. The Administrator stated after her observation she instructed the staff to correct all documentation to reflect the accurate location of the heel pressure ulcer was the left and not the right heel. The Director of Nursing stated she was out of work when Resident #50's left heel pressure ulcer was identified but she stated during direct care the staff should focus on monitoring a resident's elbows, heels, the sacrum and bony areas. The Director of Nursing also stated pressure ulcer shouldn't be identified at a stage three or above for optimally changes in skin should be identified when there is continuous redness, definitely prior to the skin opening. The Director of Nursing further stated they don't write orders for pressure reducing devices, they simple use what's necessary to prevent prolonged pressure. The Administrator stated the Interdisciplinary Team didn't conduct a root-cause-analysis of the left heel pressure ulcer. On 6/9/22 at approximately 7:30 p.m., the above findings were shared with the Administrator and the Director of Nursing. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no concerns were voiced. A stage three pressure ulcer is a full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. (https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/) [MEDICATION(S)] is used to clean and remove necrotic tissue to promote wound healing. (https://mms.[NAME].com/product/ 3/[NAME]-Brand- ) [MEDICATION(S)] Santyl Ointment is indicated for [MEDICATION(S)] chronic dermal ulcers and severely burned areas. (https://santyl.com/sites/default/files/2019-12/SANTYL-PI.pdf) Dakin solution is a strong topical antiseptic widely used to clean infected wounds, ulcers, and [CONDITION(S)]. (https://www.ncbi.nlm.nih.gov/books/NBK 6/) Debridement is the removal of nonviable tissue within the wound. (https://www.ncbi.nlm.nih.gov/books/NBK 2/) ProMod is a liquid protein/medical food that provides a concentrated source of protein for people with increased protein needs. (https://abbottstore.com/therapeutic-nutrition/promod/prodmod/promod-liquid-protein/promod-liquid-protein-1-qt- e.html)

Based on observations, staff interviews, clinical record review and facility documentation review the facility failed to ensure 2 residents (Resident #2, #1) of 4 residents in the survey sample, were provided treatment and services to prevent the development of, promote the healing of, and prevent the decline of, a pressure ulcer, resulting in harm for Resident #2. The findings included: 1. For Resident #2, the facility staff failed to implement measures to prevent a left hip pressure ulcer and failed to identity the ulcer until it had advanced to a Stage III. The newly identified left hip pressure ulcer was first observed on [DATE] with no treatment put in place. On [DATE] there was a dressing covering the pressure ulcer to the left hip but no physician notification nor routine wound care treatment was put in place. On [DATE], the wound had advanced to a stage III pressure ulcer and presented with slough resulting in harm. Resident #2 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of [DATE] coded Resident #2 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The MDS coded Resident #2 requiring total dependence of two with toilet use and transfer, total dependence of one with personal hygiene, eating, bathing, dressing and extensive assistance of two with bed mobility. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #2 with impairment on one side to his lower extremity (hip, knee, ankle, foot). Resident #2 was coded as having no mood, rejection of care or behavioral problems. The MDS with an ARD of [DATE] under section M (Skin Condition - M0100) was coded for the using a Formal Assessment Instrument/tool (e.g., Braden, Norton or other) for the determination of Pressure Ulcer Risk. Under section (M0150) for Risk of Pressure Ulcers coded Resident #2 at risk for developing pressure ulcers and under section (M1200) for skin and treatments was coded for having pressure reducing device bed. Resident #2's person-centered comprehensive care plan revised on [DATE] documented Resident #2 with actual alteration in skin integrity acquired (Pressure Ulcer) to the left hip related to altered nutritional status, cognitive impairment, decreased mobility and urinary incontinence. The goal: resident's ulcer will be covered with [MEDICATION NAME] tissue or resurfaced with new skin even with possible discoloration. Some of the intervention/approaches to manage goal: administer multivitamin with mineral per physician order, institute Weekly Pressure Ulcer Condition Report, monitor for S/S of infection and report to physician for care and treatment or debride, Registered Dietitian (RD) will monitor, evaluate nutritional status and condition of wound and make recommendations as indicated and specialty mattress (air-loss)-applied on [DATE]. Prior to the left hip pressure Resident #2's comprehensive care plan initiated on [DATE] with a revision date of [DATE] documented Resident #2 as high risk for skin breakdown related to generalized weakness, dementia, incontinence and [MEDICAL CONDITIONS]. The goal: the resident will be free of skin breakdown through [DATE] (target date). Some of the intervention/approaches to manage goals included to assess Resident #2's skin weekly and as needed and to administer dietary supplements as ordered. A Braden Risk Assessment Report was last completed on [DATE]. A Braden Risk Assessment is used for predicting pressure sore risk. Resident #2 scored a 20 indicating not at risk for the development of pressure ulcers. On [DATE] at approximately 2:44 p.m., a phone interview was conducted with the Director of Nursing (DON) and LPN #1 (House Supervisor). The DON and LPN #1 were asked how often should the Braden Scale Assessment be completed and they replied, On a quarterly basis. The LPN said the Braden Scale Assessment is used to predetermine if the resident is at risk for the development of pressure ulcers along with their nutritional value. Review of Resident #2's Plan of Care Response History revealed the following information documented on [DATE] at approximately 10:31 p.m., by Certified Nursing Assistant (CNA) #1. Documented under skin observation was coded as having an open area. A phone interview was conducted with (CNA) #1 on [DATE] at approximately 11:30 a.m. The CNA said while providing care to Resident #2, on [DATE] (,[DATE] shift.) I observed an open area to Resident #2's left hip; the area was open but did not have a dressing. The CNA stated, I documented the open area and reported the open area to his nurse. The CNA said she informed Resident #2's nurse right away because they are able to give a more detailed/specific report about the residents open area. On [DATE] at approximately 4:00 p.m., a phone interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 was assigned to Resident #2 on [DATE] (,[DATE] shift). The LPN stated, I was never told or recall Resident #2 having a pressure ulcer/open area to his left hip. Review of Resident #2's Weekly skin review revealed the following: [DATE] - not completed [DATE] - not completed [DATE] - completed with the following information included but not limited to: (open area to left hip.) An interview was conducted with LPN #1 (House Supervisor) on [DATE], who stated, We were behind on completing our weekly skin reviews. She said Resident #2's weekly skin review was missed on [DATE] and [DATE] but completed on [DATE]. Review of Resident #2's Weekly Pressure Wound Observation Tool dated [DATE] completed by Registered Nurse (RN) #2 included the following documentation: Date acquired - [DATE] Pressure Ulcer to the left hip - Suspected Deep Tissue Injury (sDTI). Current wound stage III Visible tissue -improving - slough tissue present (yellow, tan, white, stringy) The extent (%) of necrosis and/or slough in the wound bed - 10% Small amount of serous drainage with odor present Wound measurements - 0.5 cm x 0.5 cm with 0 depth Distribution of per-wound tissue - hyper pigments with intact wound edges Under treatment - describe any changes to treatment pan in the last week - dry dressing applied to wound upon observation. Nurse Practitioner (NP) made aware with a new order for Santyl ointment. Evaluation- the site was noted on [DATE] at 3 cm x 4 cm and now is a 0.5 cm x 0.5 cm. Review of Resident #2's Skin/Wound Notes completed by RN #2 included the following documentation: [DATE] - left hip noted with a 3 cm x 4 cm hyperpigmented sited with a 0.5 cm x 0.5 cm with a pale white/green plug of slough in it, site cleaned with normal saline, dried, covered with Xeroform. The (NP) made aware with a new order for Santyl ointment and dressing daily. [DATE] - left hip noted with some non-viable tissue present and requested to change treatment from Alginate to Santyl ointment. Review of Resident #2's Treatment Administration Record (TAR) for [DATE] included the following left hip wound care order: [DATE]- Santyl ointment - apply to left hip - clean wound with wound cleanser, pay dry, apply Santyl to wound bed and cover with a saline moist gauze and cover what composite dressing - starting on [DATE]. [DATE] - D/C Santyl - start Alginate and boarder composite dressing - clean wound with dermal wound cleanser, pat dry, cut and fit Alginate and skin prep to peri wound skin and cover with boarder composite dressing every other day starting on [DATE]. [DATE] -D/C Alginate dressing - start Santyl ointment - apply to left hip - clean wound with wound cleanser, pay dry, apply Santyl to wound bed and cover with a saline moist gauze and cover what composite dressing starting on [DATE]. Review of Resident #2's (TAR) for [DATE] also included the following order: [DATE] - Low Air Loss Mattress every shift for Preventative Care. A phone interview was conducted with RN #2 on [DATE] at approximately 1:20 p.m. She said on [DATE] (7 AM-3 PM shift), the CNA who was assigned to Resident #2 reported while providing ADL care, she noticed a patch to his left hip. She said that prompted her to do an assessment because she was not aware that Resident #2 had a wound to his left hip. The RN said upon her observation, there was a dressing to Resident #2 left hip with a date of [DATE] but there were no nurses' initials present. The RN said she removed the dressing to discover a stage III pressure ulcer. She said the peri area around the wound was red, non-blanchable and the wound observed with drainage, odor, and a plug of white/yellow green slough. The RN said she was unable to locate an order for [REDACTED].#2's left hip with a new order to start Santyl ointment. When asked what type of ointment Santyl was, she replied, A debridement, since the wound has slough, the wound need to be debrided. When asked if she completed the Weekly Pressure Wound Observation Tool dated [DATE], she replied Yes. The RN stated she put the date the pressure ulcer was acquired for [DATE] because that was the date on the dressing; so someone know it was there. The RN said she put the original pressure ulcer stage as a STDI because of the outer appearance of the wound being red and non-blanchable but the wound as of [DATE] was a stage III, again because the wound bed was with noted with slough. Review of Resident #2's Telehealth -Integrated Wound Care Forms included but not limited to the following: On [DATE], the wound care specialist documented a stage II pressure ulcer to the left hip. The wound measured 0.5 cm x 0.3 cm x 0.1 cm with small amount of serous drainage. The wound care specialist documented that the wound improving with hyperpigmentation. Wound treatment - clean: wound cleaning spray -apply Santyl daily - might change to skin prep since would improving for protection. On [DATE], the wound care specialist documented the left hip with excoriation. Note; initially looked like pressure ulcer but now looks more like excoriation. Left hip wound noted with granulation tissue forming. Wound treatment - clean: wound cleaning spray-apply Venelex-put on today due to pressure ulcer last week, assess and change treatment as needed. On [DATE], the wound care specialist documented the left hip measuring 3.4 cm x 3.9 cm x 0 with 100% slough, macerated edged, no odor or drainage per DON. Wound treatment changed-clean: wound-apply Santyl, cover with border gauze daily and as needed. A phone interview was conducted with wound care specialist on [DATE] at approximately 10:54 a.m. She said at the time Telehealth was done on [DATE], the wound had improved and was definitely a stage II on [DATE]. She stated with my visit on [DATE], the wound continued to improve and at that point looked more like excoriation than a stage II pressure ulcer. On [DATE] at approximately 5:10 p.m., a phone interview was conducted with the wound nurse who said she had just finished her wound assessment on Resident #2 and the wound has deteriorated since my last telehealth visit on [DATE]. She said the wound is now covered with 100% slough, so the current treatment is being is discontinued and the new treatment is going to be Santyl ointment. Review of Resident #2's progress notes under nutrition included the following recommendation made by the Registered Dietitian: -[DATE] -Vitamin C 500 mg once daily x 14 days and Zinc 220 mg once daily x 14 days. -[DATE]-Vitamin C 500 mg once daily x 14 days and Zinc 220 mg once daily x 14 days. -[DATE]-Vitamin C 500 mg once daily x 14 days and Zinc 220 mg once daily x 14 days. -[DATE] - Registered Dietitian (RD) reviewed Resident #2 related to (r/t) skin breakdown. Vitamins and minerals in place that will aid in wound healing. Medications include but not limited to: Vitamin C and Zinc. Review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A phone interview was conducted with the Registered Dietitian on [DATE] at approximately 1:30 p.m. She said the recommendations made on [DATE], [DATE] and [DATE] for Vitamin C 500 mg once daily x 14 days and Zinc 220 mg once daily x 14 days was emailed to the Administrator, (DON) and Unit Manager. The dietitian said the recommendation for Vitamin C and Zinc was to assist with wound healing. The Dietitian said she was not aware of the pressure ulcer to Resident #2's left hip until [DATE]. She said Resident #2 had other areas prior to the left hip and that is why the Vitamin C and Zinc was first recommend on [DATE]. On [DATE] at approximately 3:45 p.m., during the pre-exit phone conference with the Administration staff. When asked if a Root Cause Analysis (RCA) or an investigation was completed on Resident #2's left hip pressure ulcer, the DON and LPN #1 (House Supervisor) both replied No. The facility's policy titled Prevention of Pressure Ulcers/Injuries with a revision date of ,[DATE]. -Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Risk Assessment: -Assess the resident on admission for existing pressure ulcer/injury risk. Repeat the risk assessment weekly and upon any changes in condition. -Monitoring Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. Definitions: *A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). Pressure Injury - Stage 3 (Full-thickness skin loss) Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages.) *Santyl is used to help the healing [MEDICAL CONDITION] ulcers. [MEDICATION NAME] is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (antibiotics <http://www.webmd.com/cold-and-flu/rm-quiz-antibiotics-myths-facts.) *Alginate Dressings are composed of calcium alginate, a gelatinous and water-insoluble substance. When in contact with a wound, the calcium alginate in the dressing reacts with sodium chloride from the wound. This turns the dressing into a [MEDICATION NAME] gel that maintains a moist environment for the wound (www.medicaldepartmentstore.com/Alginate-Dressings-s/286.htm.). 2. For Resident #1, the facility staff failed to accurately assess and ensure treatment orders were obtained and implemented timely. Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of [DATE] was coded with a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #1 as requiring extensive assistance of 1 for bed mobility and eating and total dependence of 1 for toilet use, personal hygiene and bathing. On [DATE] at 11:05 a.m., wound care to Resident #1's left heel was observed performed by Registered Nurse (RN) #3. Resident #1 was observed lying in bed on a low air loss mattress. RN #3 performed hand hygiene, donned clean gloves and removed the wound dressing from the residents left heel revealing a dark eschar plate covering the wound. When RN #3 was asked how she would describe the resident's wound on the left heel, RN #3 stated, It's a necrotic cap, unstageable. RN #3 performed hand hygiene, donned clean gloves and continued to perform wound care, cleaned left heel with Dakins Solution, applied gauze 4x4 dressing with [MEDICATION NAME] Solution to eschar plate and covered [MEDICATION NAME] dressing with ABD (Abdominal) Pad and wrapped left heel with kerlix. RN #3 removed dirty gloves and performed hand hygiene. On [DATE] Resident #1's clinical record was reviewed and revealed the following: Review of Admitting Daily Skin Assessment revealed the following: Date: [DATE] 16:05 Signed: [DATE] 23:39 Head To Toe Skin Checks 1. Skin Integrity 1p. Describe new or existing other issues: Open area to left heel. 3. Site: 50) Left heel Type: open area. Review of Weekly Pressure Wound Observation Tools revealed the following: Effective Date: [DATE] 14:37 B. OBSERVATIONS/DATA: 1. Location: Left Heel 4. PRESSURE ULCER STAGE: Original: III Current: III (stage 3) 5. VISIBLE TISSUE: 5c. Granulation tissue present (beefy red) 5i, Describe the extent (%) of necrosis and/or slough in the wound bed: 0. 8. Wound Measurements Length (mm): 24 Width (mm): 25 Depth (mm): 1 9. PERI-WOUND TISSUE: Normal 9b. Describe wound edges and shape: Well Defined C. TREATMENT: 1. Describe any changes to treatment plan in the last week: Medi-honey 2. Current treatment plan: [REDACTED]. Effective Date: [DATE] 17:43 B. OBSERVATIONS/DATA: 1. Location: Left Heel 4. PRESSURE ULCER STAGE: Original: II Current: II (stage 2). 5. VISIBLE TISSUE: 5c. Granulation tissue present (beefy red). 8. WOUND MEASUREMENTS: Length (mm): 25 Width (mm): 24 Depth (mm): 1 Effective Date: [DATE] 09:28 B. OBSERVATIONS/DATA: 1. Location: Left Heel 4. PRESSURE ULCER STAGE: Original: SDTI (suspected deep tissue injury) Current: IV (stage 4). 5. VISIBLE TISSUE: 5a. Overall Impression: d. Worsening. 5i. Describe the extent (%) of necrosis and/or slough in the wound bed: 75. 6. DRAINAGE: 6a. Type: Serosanguinous 6b. Amount: Moderate 8. WOUND MEASUREMENTS: Length (mm): 100 Width (mm): 80 Depth (mm): 0 9. PERI-WOUND TISSUE: 9a. Description of peri-wound tissue: ethic color. 9b. Describe wound edges and shape: Intact approx (Approximately) 50 (Fifty) % (Percent) and rolled 50%. C. TREATMENT: 1. Describe any changes to treatment plan in the last week: The site has been noted since admission and resident continues with treatment per hospice. 2. Current treatment plan: [REDACTED]. EVALUATION: Wound Progress: Noted the site has greatly deteriorated and has a faint odor. Review of Resident #1's Admission MDS assessment with an Assessment Reference Date of [DATE] revealed the following: Section M - Skin Conditions M0150. Risk of Pressure Ulcers-Question asks - Is this resident at risk of developing pressure ulcers? 1. Yes. M0210. Unhealed Pressure Ulcer(s) - Question asks - Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? 1. Yes. M0300. Current Number of Unhealed Pressure Ulcers at Each Stage - B. 1. Number of Stage 2 Pressure Ulcers - 3. B. 2. Number of these Stage 2 Pressure Ulcers that were present upon admission/reentry - 3. C. 1. Number of Stage 3 Pressure Ulcers - 0. D. 1. Number of Stage 4 Pressure Ulcers - 0. F. 1. Number of Unstageable Pressure Ulcers due to coverage of wound bed by slough and/or eschar - 0. M1200. Skin and Ulcer Treatments B. Pressure reducing device for bed. C. Turning / repositioning program. E. Pressure Ulcer Care. Review of Braden Scale For Predicting Pressure Sore Risk revealed the following: Date: [DATE] Score: 11.0 Category: HIGH RISK; Date: [DATE] Score: 10.0 Category: HIGH RISK: Date: [DATE] Score: 12.0 Category: HIGH RISK. Review of Weekly Skin Review revealed the following: Date: [DATE] SKIN CONDITION: 8a. Open Area Site - 53) Sacrum; Other (specify) - skin tears bilateral arms; 49) Right heel. Date: [DATE] SKIN CONDITION: 8a. Open Area 9. Other: Multiple skin tears bilateral upper arm, pressure ulcer left heel, paper thin skin bilateral arms and legs. Date: [DATE] SKIN CONDITION: 8a. Open Area 9. Other: Multiple skin tears bilateral upper arms, pressure ulcer left heel, paper thin skin bilateral arms and legs. Date: [DATE] SKIN CONDITION: 8a. Open Area 9. Other: Multiple skin tears bilateral upper arm, pressure ulcer left heel, paper thin bilateral arms and legs. Date: [DATE] SKIN CONDITION: 8a. Open Area Site - 50) left heel Description: tx (Treatment) in progress. Review of Resident #1's Order Summary Reports, Treatment Administration Records (TAR) and Medication Administration Records (MAR) for Periods [DATE] - [DATE] and [DATE] - [DATE] revealed the following treatment orders for the left heel: Cleanse left heel with wound cleanser and pat dry and apply dry dressing until healed q (every) day shift for measurements and monitoring as needed for wound care. Order Date: [DATE] Start Date: [DATE] D/C (Discontinued) Date: [DATE]. [MEDICATION NAME] Wound/Burn Dressing Gel (Wound Dressings) Apply to left heel topically every day shift every other day for wound care. Cleanse with wound cleanser, pat dry, skin prep periwound, apply to wound bed, cover with gauze, wrap with kerlix. Order Date: [DATE] Start Date: [DATE] D/C Date: [DATE]. [MEDICATION NAME] Wound/Burn Dressing Gel (Wound Dressings) Apply to left heel topically every day shift every other day for wound care. Cleanse with wound cleanser, pat dry, skin prep periwound, apply to wound bed, cover with gauze, wrap with kerlix. Order Date: [DATE] Start Date: [DATE] D/C Date: [DATE]. Tx (Treatment) - clean left heel, [MEDICATION NAME] gauze, wrap with kerlix every day shift. Order Date: [DATE] Start Date: [DATE] D/C Date: [DATE]. Tx - clean left heel with Dakins 0.25%, [MEDICATION NAME] gauze, wrap with kerlix every day shift for wound to heal. Order Date: [DATE] Start Date: [DATE]. Low Air Loss Mattress every shift for PREVENTATIVE CARE. Order Date: [DATE] Start Date: [DATE]. Review of Order Summary Report for ORDER DATE RANGE: [DATE] - [DATE] did not evidence any wound treatment order for the left heel prior to [DATE] or treatment to the left heel prior to [DATE]. On [DATE] at 12:45 p.m., a telephone interview was conducted with the Director of Nursing (DON), when asked when Resident #1 was admitted to the facility, the DON stated, [DATE]. When asked if he had an open wound on his left heel on admission, DON stated, Yes. When asked what stage the wound was on the left heel on admission, DON stated, Stage 3. When asked what were the wound measurements on admission, DON stated, 24 mm x 24 mm x 1 mm, tissue was normal, edges were defined. It was open. When asked if the resident had a treatment order for the left heel, DON stated, No, nothing came from the hospital. When asked when was the first treatment ordered for the left heel, DON stated, [DATE], the nurses got the order. When asked if Resident #1 should of had a treatment order prior to [DATE], DON stated, Yes, he should of had a treatment order. When asked why he didn't have a treatment order for the left heel prior to [DATE], DON stated, He was admitted by Hospice. I don't know why they didn't follow up with an order. When asked if the facility staff nurses check and follow up to ensure residents have orders as needed, the DON stated, Yes, but they didn't follow up. DON stated, (Resident name) was seen by the wound nurse on [DATE], that is when he got his order. When asked when Resident #1 should of had a treatment order for the left heel, DON stated, He should of had a treatment order on the date of admission. DON stated, We do not have a Wound Nurse and the Nurses on the units are doing wound care. When asked when Resident #1 was placed on the low air loss mattress, DON stated, [DATE]. When asked what type mattress Resident #1 was on prior to the low air loss mattress, DON stated, (Resident name) had been on a beige box egg crate overlay on the bed. The DON stated that staff are to off load Resident #1's heels with pillows and stated that Resident #1 could not have Prevalon Boots because his skin tears easily and he is a high bleeder. Reviewed left heel Weekly Pressure Wound Observation Tools with Effective Dates of [DATE] 14:37, [DATE] 17:43 and [DATE] 09:28 with the DON. Left heel pressure ulcer wound stages documented as follows: Stage 3 on [DATE], Stage 2 on [DATE] and a Stage 4 on [DATE]. The DON stated that she had wound measurements for the left heel dated [DATE] and the wound was unstageable. The DON stated, (Resident name) was referred to the Wound Doctor on [DATE]. When asked if the Wound Doctor was with (Name) Wound Care, DON stated, Yes. The DON stated that the last wound measurements available were done on [DATE]. A copy of wound measurements for [DATE] was requested from the DON. On [DATE] received and reviewed the Skin Wound Note dated [DATE] 16:22. Review of note revealed the following: Late Entry: Note Text: #1 wound left heel PrU (Pressure Ulcer) - 4.5 x 3 x 0- came from hospital with ulcer. Unstageable. Tx - clean, [MEDICATION NAME] gauze, wrap with kerlix - QD, PRN. Pt. (Patient) is Hospice. On [DATE] (Name) Wound Care Progress Notes were reviewed and revealed the following: Date of Service: [DATE] Encounter: Initial, Progress: Improving #1 Left Heel Pressure Ulcer Treatment Recommendations: Clean: Dakin's Solution 0.25% (,[DATE] S) Freq(Frequency): Daily (QD) & PRN (As Necessary). Instructions: Clean with Dakins, [MEDICATION NAME] gauze, wrap with kerlix. Pressure Relief/Off Loading: Facility pressure ulcer prevention protocol; Pressure redistribution mattress per facility protocol; Turn and reposition per schedule protocol; Heel offloading per facility protocol; Misc (Miscellaneous) order: Incontinence care prn; Optimize nutrition. Date of Service: [DATE] Encounter: Subsequent, Progress: deteriorating #1 Left Heel Pressure Ulcer Unstageable - L 10 cm x W 8 cm x D 0 cm. Tissue Type: 100% Necrotic. Treatment Recommendations: Clean: Dakin's Solution 0.25% (,[DATE] S) Freq: Daily & PRN. Instructions: Clean with Dakins, [MEDICATION NAME] gauze, wrap with kerlix. Pressure Relief/Off loading: Facility pressure ulcer prevention protocol; Pressure redistribution mattress per facility protocol; Heel offloading per facility protocol; Misc order: Incontinent care prn; Optimize nutrition. Date of Service: [DATE] Encounter: Subsequent, Progress: deteriorating #1 Left Heel Pressure Ulcer Unstageable L 10 cm x W 8 cm x D 0 cm Odor: Strong Tissue Type: 80% eschar 20% Necrotic Note: Left heel PrU (Pressure Ulcer) was obtained at hospital. Was found on admission to LTC (Long Term Care). Strong odor per DON (Director of Nursing). Says smalls like Burnt meat. Treatment Recommendations: Clean: Dakin's Solution 0.25% (,[DATE] S) Freq: Daily & PRN. Instruction: Clean with Dakins, [MEDICATION NAME] gauze, wrap with kerlix. Pressure Relief/Off loading: Facility pressure ulcer prevention protocol; Pressure redistribution mattress per facility protocol; Turn and reposition per schedule protocol; Heel offloading per facility protocol. Misc order: Incontinence care prn; Optimize nutrition. On [DATE] review of Resident #1's comprehensive care plan revealed the following: Focus: Actual alteration in skin integrity (Pressure Ulcer) stage 2 left heel. Date initiated: [DATE] Revision on: [DATE]. Goal: Wound will be free of infection. Date initiated: [DATE] Target Date: [DATE] Interventions/Tasks: Heels off loaded when in bed. Date initiated: [DATE]; Institute Weekly Pressure Ulcer Condition Report (refer to document for size and staging) Date initiated: [DATE]; Provide meals per physician order. Date initiated: [DATE]; Provide medical food supplement per physicians order. Date initiated: [DATE]; RD (Registered Dietician) will monitor and evaluate nutritional intake and condition of wound and make recommendations as indicated. Date initiated: [DATE]. There was no evidence that a pressure ulcer care plan was initiated prior to [DATE]. On [DATE] review of Resident #1's Medication Administration Record [REDACTED]. Cleanse with wound cleanser, pat dry, skin prep periwound, apply to wound bed, cover with gauze, wrap with kerlix. Start Date: [DATE] D/C Date: [DATE]. Review of the Medication Administration Record [REDACTED]. Review of the Treatment Administrative Record revealed that Resident #1 has an order for [REDACTED]. Review of the Treatment Administration Record revealed blank spaces on ,[DATE], ,[DATE], and [DATE]. On [DATE] at approximately 1:00 p.m., an interview was conducted with the DON. Reviewed findings with the DON and when asked what does a blank space on the MAR indicated [REDACTED]. Review of Hospice Visit Note Report on [DATE] revealed the following: Visit Date: [DATE] Heel, LT Unstage Onset Date: [DATE] - Wound Assessed - Yes, Measurements Taken - Yes, Length x Width x Depth (CM) 1.5 x 1.2 x 0.2, Depth Description - Necrotic, Granulation Tissue - None, Shape - Round, Exudate Type - Serous, Exudate Amount - Scant, Odor - None, Epithelization - < (Less Than) 25%, Necrotic Tissue Type - White, Necrotic Tissue Amount - 75 - <100%, Total Necrotic Tissue Slough - 75 - 100%, Total Necrotic Tissue Eschar - 0 - 25%. Wound Care Not Provided: Not Ordered This Visit. O (TRUNCATED)

Based on staff interviews, clinical record review and facility documentation review and in the course of a complaint investigation, the facility staff failed to ensure 1 of 6 residents in the survey sample, Resident #2, was provided treatment and services to prevent the development of, promote the healing of and prevent the decline of a pressure ulcer resulting in harm. The findings include: Resident #2 was originally admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #2's Admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 08/28/2019 was coded with a BI[CONDITION] (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #2 as requiring supervision with assistance of 1 for eating, extensive assistance of 1 for bed mobility, dressing, toileting and personal hygiene and total dependence of 1 for bathing and total dependence of 2 for transfer. On 02/28/2020 Resident #2's clinical record was reviewed and revealed the following: Review of Braden Scale For Predicting Pressure Sore Risk revealed the following: Effective Date: 08/22/2019 Score: 15 Category: AT RISK; Effective Date: 11/19/2019 Score: 17 Category: AT RISK Review of Weekly Skin Review revealed the following: Effective Date: 08/28/2019 SKIN CONDITION: 7b. Pre-existing 8a. Open Area 9. Other: Pt. (Patient) with ongoing tx (treatment) to sacrum and right upper thigh. Effective Date: 10/08/2019 SKIN CONDITION: 8a. Open Area 8b. Pre-existing Site - 49) Right heel 50) Left heel 52) Left toe(s) 53) Sacrum Effective Date: 10/15/2019 SKIN CONDITION: 8a. Open Area 8b. Pre-existing Effective Date: 10/29/2019 SKIN CONDITION: 7b. Pre-existing Site - 49) Right heel 50) Left heel 52) Left toe(s) 53) Sacrum Review of Medication Review Report revealed the following: Pt. (Patient) to be seen by wound care nurse. Order Date: 08/21/2019 Review of Integrated Wound Care Progress Notes revealed the following: Date of Service: 09/10/19 Encounter: #1 right Ankle Arterial Ulcer; #2 great toe Date of Service: 09/17/19 Encounter: #1 right Ankle Arterial Ulcer; #2 great toe Date of Service: 09/24/19 Encounter: #1 right Ankle Arterial Ulcer; #2 great toe Date of Service: 10/01/19 Encounter: #1 right Ankle Arterial Ulcer; #2 left great toe; #3 Toe Date of Service: 10/08/19 Wound to rt (right) heel; wound to left heel; wound to rt lateral foot; wound to lt (left) hellux; bilateral sacral wounds - unstageable to rt buttocks 5cm (centimeters) x 2 cm x 0.2 cm, [AGE]% slough, 25% pink, needs [MED] to wounds, cover with bordered gauze. Date of Service: [DATE] Wound to rt heel; wound to left heel; wound to rt lateral foot; wound to rt lower heel; wound to lt hellux; bilateral sacral wounds-unstageable to sacrum needs [MED] to wounds, cover with bordered gauze. Date of Service: 10/22/19 Wound to rt heel; wound to right outer heel; wound to rt lateral foot; wound to right hellux; bilateral unstageable sacral wounds - 6 x 3cm with 90% whitish yellow, 10% pink wound bed = [MED] to wounds, cover with bordered gauze daily. Date of Service: 10/29/19 Wound to rt heel; wound to right outer heel; wound to rt lateral foot; wound to right hellux; bilateral unstageable sacral wounds - 5.5 x 4.5 x 0.1m with 90% whitish yellow, 10% pink wound bed = [MED] to wounds, cover with bordered gauze daily. Patient is currently receiving IV fluids due to poor po intake and increased BUN (Blood Urea Nitrogen). Discussed care with NP (Nurse Practitioner) from primary care, significant decline in wounds and health in general. Review of Treatment Administration Record for the period of 08/01/2019 through 08/31/2019 revealed there was no treatment order for the sacral wound. It did contain: Pressure Reducing cushion to chair if needed every shift for pressure ulcer prevention. [ENTITY]t Date: 08/21/2019 D/C Date: 11/07/2019. Review of Treatment Administration Record for the period of 09/01/2019 through 0[DATE] revealed there was no treatment order for the sacral wound. It did contain: Pressure Reducing cushion to chair if needed every shift for pressure ulcer prevention. [ENTITY]t Date: 08/21/2019 D/C Date: 11/07/2019. Review of Treatment Administration Record for the period of 10/01/2019 through 10/31/2019 revealed the following: Sacrum: Cleanse with normal saline, apply normal saline moistened gauze with [MED] application, skin prep surrounding intact skin, and cover with foam dressing daily every 1 (one) hours as needed for unstageable open area. [ENTITY]t Date: 10/16/2019 D/C Date: 11/07/2019. Sacrum: Cleanse with normal saline, apply normal saline moistened gauze with [MED] application to wound bed, skin prep surrounding intact skin, and cover with foam dressing daily one time a day for unstagable open wound. [ENTITY]t Date: 10/17/2019 D/C Date 11/07/19 Pressure Reducing cushion to chair if needed every shift for pressure ulcer prevention. [ENTITY]t Date: 08/21/2019 D/C Date: 11/07/2019. Off-load heels while in bed every shift for wounds to bilateral feet. [ENTITY]t Date: 08/21/2019 D/C Date: 11/07/2019. Review of Order Summary Report for the period as of August 22, 2019 revealed the following: Barrier cream to affected area(s) after each incontinent episode and PRN (As Needed) for skin care. Order Date: 08/21/2019 [ENTITY]t Date: 08/21/2019; Pressure Reducing cushion to chair if needed every shift for pressure ulcer prevention. Order Date: 08/21/2019 [ENTITY]t Date: 08/21/2019. Review of Medication Review Report for period of On or After Date: 10/01/2019 included the following: May have pressure relieving / reducing device on bed every shift for pressure ulcer prevention. Order Date 11/18/2019 [ENTITY]t Date: 11/18/2019. On 02/28/2020 at 1:00 p.m., an interview was conducted with the Director of Nursing and when asked if Resident #2 had a wound on his sacrum when admitted to the facility on [DATE], Director of Nursing stated, No. When asked when the area on the residents sacrum was identified, Director of Nursing stated, On 08/28/2019 on the weekly skin review. When asked what was the area identified as, Director of Nursing stated, Usually areas on the sacral area are from pressure. When asked what was the stage of the wound on the sacrum when identified, Director of Nursing stated that she did not know. When asked what treatment was done for the wound on the sacrum in August 2019, Director of Nursing stated, Nothing is written on the August treatment kardex. The Director of Nursing stated, All I see is barrier cream. When asked for the wound measurements of the sacrum during that time, Director of Nursing stated, There are no wound measurements for that time frame. When asked when did they start getting wound measurements of the sacrum, Director of Nursing stated, There are no measurements. When asked if the resident had a treatment ordered for the wound on the sacrum in September 2019, Director of Nursing stated, No, there is nothing ordered on the TAR (Treatment Administration Record). Reviewed Integrated Wound Care Progress Note of 10/08/2019 with the Director of Nursing concerning unstageable bilateral sacral wounds and the need for [MED] to wounds. When asked who reviews the progress notes of the Wound Nurse Consultant, Director of Nursing stated, We have a wound nurse that rounds with the Nurse Practitioner from Integrated Wound Care and the orders are put in that day. The Nurse Practitioner makes recommendations, MD (Medical Doctor) is made aware for approval and then entered into the system. When asked why the resident didn't have a treatment started for the sacral wound until 10/17/2019, Director of Nursing stated, I don't have a reason for you. When asked if Resident #2 should have had a treatment to the sacrum before 10/16/2019, Director of Nursing stated, Yes it should. The Director of Nursing stated that the facility's current Wound Nurse has resigned and currently training her replacement. When asked if Resident #2 was ordered a pressure relieving mattress, Director of Nursing stated, Should have ordered a pressure relieving mattress on admission. Reviewed orders with the Director of Nursing. No evidence that Resident #2 had orders for a pressure relieving / reducing device on his bed until 11/18/2019. When asked what her expectations are of nurses concerning wound care and prevention of skin breakdown, Director of nursing stated, Got to fix the system. Moving forward current wound nurse is training replacement. Audits are in place, report is due today. On 02/28/2020 at approximately 2:30 p.m. reviewed complaint with Administrator, Director of Nursing and Corporate Nurse Consultant at pre-exit meeting and made them aware of the concerns. On 02/28/2020 at approximately 3:00 p.m., the Director of Nursing was asked if she could provide any further information concerning Resident #2's wound and what was done to prevent the wound from declining. On 02/28/2020 at approximately 4:15 p.m., the Director of Nursing brought the facility Wound Nurse in to meet with Surveyor. An interview was conducted with Licensed Practical Nurse (LPN) #4, Wound Nurse. LPN #4 stated, Resident #2 did not have any skin breakdown on sacrum on admission, [DATE], he only had arterial wounds on the feet. LPN #4 stated, About a week or two later he stopped eating well and was non-compliant with wound care, complained of pain as he had [MEDICAL CONDITION], terrible pain in his legs. LPN #4 stated, Once he started declining the Stage 2 showed up on his buttocks, around 09/17/2019. LPN #4 stated, I provided treatment, Xeroform. When asked was the treatment documented, LPN #4 stated, No, I have an issue with documenting in the chart and I have been reprimanded. LPN #4 stated, I do treatments and I have been working as a medication nurse. When asked if there was an treatment order for the Xeroform, LPN #4 stated, No. LPN #4 stated, I did the wound treatments on Monday through Friday. When asked how would the nurses know to do the treatment on the weekend with it not being documented on the TAR, LPN #4 stated, They wouldn't. LPN #4 stated that she reported identifying the wound on the Sacrum at the Standards of Care Review on 09/18/2019. When asked if weekly measurements were completed, LPN #4 stated, Weekly wound observations and assessments were inconsistent and were not entered into the system. When asked if Resident #2 was on a pressure relieving mattress, LPN #4 stated, He was on a air mattress for the Stage 2. When asked if there was a order for the air mattress, the Director of Nursing stated, No. On 02/28/2020 at approximately 5:00 p.m., the Director of Nursing and the facility Medical Director came to the conference room to meet with the Surveyor. The Medical Director stated, The wounds on (Resident Name) were improving. When asked if he was made aware of the unstageable wound on the residents sacrum, Medical Director stated, Eventually found out, yes ma'am. The Medical Director stated, The resident went to (Hospital Name) then returned and started declining. Reviewed dates of discharge with the Medical Director. Reviewed that Resident #2 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE] and the unstageable wound on the sacrum was identified by Integrated Wound Care nurse on 10/08/2019 which was before discharge to the hospital. The Medical Director stated, The resident had weight loss and pocketing his food. The Medical Director said that the resident had co-morbidities that would prevent the would from healing. Reviewed that the area of concern was the pressure ulcer on Resident #2's sacrum. Reviewed with the Medical Director that the resident was admitted on [DATE] and the facility stated that the resident did not have any open areas on his sacrum when admitted . On 08/28/2019 the staff stated that Resident #2 developed a Stage 2 on the Sacrum. On 10/08/2019 the Integrated Wound Care nurse identified the areas on Resident #2's sacrum as unstageable. Reviewed with the Medical Director that there was no documented evidence that a treatment was provided to the sacral wound until 10/17/2019. The Medical Director provided the Surveyor with copies of his progress notes, labs, dietary notes to review. On 02/28/2020 at approximately 5:30 p.m. the Administrator and Director of Nursing were informed of the findings at the exit meeting. No further information was provided by the facility staff.

Based on information obtained from the local Adult Protection Service (APS) representative, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure the necessary care and services were provided to prevent pressure injury development for 1 of 46 residents in the survey sample, Resident #103. The facility staff failed to identify Resident #103 had developed a left buttock pressure injury until it had advanced to a stage 3 pressure injury and presented with non-viable tissue, which constitutes harm. The findings included: Resident #103 was originally admitted to the facility 7/9/13 and was discharged to a local acute care hospital on [DATE] but had not return to the nursing facility at the time of the survey. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/4/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. This indicated Resident #103's cognitive abilities for daily decision making were severely impaired. The resident was coded for no mood or behavior problems. In section G(Physical functioning) the resident was coded as requiring extensive assistance of 2 people with bed mobility and transfers, total care of 1 person with locomotion, personal hygiene, bathing, dressing and eating and total care of 2 people with toileting. In section K (Swallowing/Nutritional Status) of the 4/4/18 MDS assessment the resident was coded at K0200B weight, 86 pounds. K0300; resident coded for no weight loss of 5% or more in the last month or loss of 10% or more in 6 months. An interview was conducted with the APS representative on 5/2/18 at approximately 3:30 p.m. The APS representative stated the daughter of Resident # 103 contacted their office on 4/30/17 concerning the resident's food and fluid consumption while in the nursing facility as well as the status of the resident's pressure injuries. Review of the clinical record revealed a nurses' note dated 4/27/18 at 12:21 p.m. It stated; Resident #103 was observed with changes in her breathing, sounding wet and an elevated temperature of 100.5 axillary (under the armpit). The physician was notified and ordered a chest x-ray. The x-ray company was made aware and the daughter was in informed, for she was in the facility. Another nurses' note dated 4/27/18 at 13:30 p.m., stated the resident was transferred to a local hospital per request of the daughter. Further review of the clinical record revealed Resident #103 had 2 pressure injuries present. Pressure injury #1, was to the right buttock was identified as shearing 3/29/18 and progressed by 4/12/18, to a stage 3 pressure injury, measuring 3.0 x 2.0 x 1 centimeters and presented with white/grey non-viable tissue. During an interview with the new wound care nurse on 5/3/18 at approximately 10 a.m., the wound care nurse stated pressure injury #2, was identified 4/5/18, by herself and the wound care nurse who was training her. The new wound care nurse stated the two of then turned Resident #103 after completing the dressing change to the right buttock, revealing the first observation of the pressure injury to the left buttock. The newly identified left buttock pressure injury, upon initial observation and assessment measured 3.5 x 4.5 x 0.2 centimeters. It also presented with 10% white/grey non-viable tissue in the center of the wound bed and was surrounded by pink scar tissue from a previously healed pressure ulcer. The left buttock pressure injury was staged by the two wound care nurses as a stage 3 pressure injury. An order was obtained to treat the left buttock pressure injury with Calcium Alginate (a highly absorbent dressing), every other day. During the 10 a.m., interview with the new wound care nurse 5/3/18, she stated it is the facility's expectation for pressure injuries to be identified at an early stage, not a stage 3 or 4. She further stated skin integrity education is ongoing to ensure the nursing staff is well informed. She also stated the first line of detecting skin impairment should be from direct care observations during daily care and skin checks/assessments. On 5/4/18 at approximately 10:45 a.m., the Director of Nursing (DON) was asked if an investigation of the in-house acquired left buttock stage 3 pressure injury identified 4/5/18 was conducted and if she cared to share the findings. She stated it was investigated and presented the investigation document. The document stated the resident's risk status were impaired transfer or bed mobility only. Comatose, malnutrition and end stage disease were also options but not chosen as Resident #103's risk factors. Under clinical status the following were selected; chronic urinary incontinence, poor food/fluid intake. Under Lab Data no information was selected. The heading clinical signs of inadequate nutrition/hydration cachexia or muscle wasting was noted. The investigation also noted the following under facility interventions; preventive skin care - clean, protect and moisture, utilization of appropriate pressure reduction support surfaces, evidence of consistently monitoring skin/body, Registered Dietitian consult to address nutrition needs, prevention addressed on care plan to manage identified risk factors. The facility's determination stated facility interventions are checked- area unavoidable. An interview was conducted with Registered Nurse (RN) #1 on 5/3/18 at approximately 11:00 a.m. RN #1 stated Resident #103 required total care with incontinence care, showers/bathing and dressing and meal consumption. RN #1 also stated the resident was out of bed daily in a recliner chair with a basic cushion and sometimes accepted meals in the dining room. RN #1 further stated Resident #103 was doing better with meal consumption up until the week prior to transferring to the hospital. The most recent Braden Scale for Predicting Pressure Sore Risk dated 2/5/18 revealed Resident #103's score of 10. This indicated the resident had a high risk for pressure ulcer development because of a limited ability to feel pain over most of her body surface, constant moisture to the skin, chair-fastness, and complete immobility. Resident #103 Nutrition Therapy Review dated 4/6/18 revealed there was a change in the diet order since the last nutritional review. The current diet consistency was pureed and fortified foods were ordered, all liquids were served spoon/pudding thick. The nutritional review read the resident averaged intake was more than 50% in the past 7 days. The resident's weight have ranged from 2/20/18 (92 pounds) to 4/16/18 (83.5 pounds) 4/23/18 (85.3 pounds). The active care plan with a revision dated of 4/7/16 had a problem which read; potential for impaired skin integrity related to generalized weakness, [MEDICAL CONDITION], poor appetite, weight loss, dementia, failure to thrive and incontinence. The goal read; skin will remain intact through next review. The interventions were; Assess resident's skin weekly and as needed. Dietary consult as needed. Encourage resident to get up and attend activities. Obtain rehab consult as needed. Offload heels as tolerated when in bed. Provide fortified cereal at breakfast. Provide house supplements as ordered. Provide skin care per physician's orders [REDACTED]. Stat two mattress as ordered. Turn and reposition as needed. Another active care plan problem was initiated 4/5/18 and revised 4/25/18 to reflect Resident #103's newly identified pressure ulcer. The problem read (name of resident) has a pressure ulcer to the left buttock. The goals read; (name of resident) pressure ulcer will show signs of healing and remain free from infection through next review and (name of resident) will have interventions in place to prevent altered skin integrity through next review. The interventions were; Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing per protocol. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Monitor dressing per protocol to ensure it is intact and adhering. Report lose dressing to the treatment nurse. Monitor/document/report to physician as needed changes in skin status, appearance, color, wound healing, signs/symptoms of infection, wound size and stage. Offload heels while in bed. Treat pain as per orders prior to treatment/turning, etc., to ensure resident's comfort. Also an active care plan problem dated 4/5/18 and revised 4/25/18. The problem read; (name of resident) has pressure ulcer to the right buttock. The goal read; (name of resident) pressure ulcer will show signs of healing and remain free from infection through review date. (name of resident) will have interventions in place to prevent altered skin integrity. (name of resident) will not develop any new skin breakdown through next review. The interventions were the same as in care plan problem above with a revision date of 4/25/18. The above information was shared with the Administrator and Director of Nursing during the pre-exit meeting at 3:00 p.m., on 5/4/18. The Director of Nursing stated the facility staff had identified the above information also and a Quality Assurance Performance Improvement (QAPI) plan was developed and on 2/28/18 and assessment for compliance was ongoing. The QAPI tool presented by the DON stated 20 residents were identified with a high risk for skin breakdown based on their Braden scores. The 20 identified residents would receive twice weekly skin assessments to ensure no new or worsen skin breakdown and to verify accuracy of weekly skin assessments. The QAPI plan stated during (MONTH) (YEAR), three in-house wounds were acquired, 1 resident with a previously vascular wound reopened and 2 high risk residents developed wounds. An interview was conducted with the Primary care physician 5/4/18 at approximately 5:35 p.m. The physician stated it was his expectation for pressure injuries to be identified at an early stage as 1 or 2 but he has known pressure injuries to develop within a few hours. The physician also stated a person in the emergency room has no one to turn and reposition them on a gurney and may be left for many hours without repositioning. The physician was reminded that we were reviewing Resident #103's care while she was a resident in the nursing facility for it was within the nursing facility she was identified with a stage 3 pressure ulcer of the left buttock on 4/5/18. The physician further stated the resident was with poor nutritional intake and a low weight and for her to develop a pressure injury within 2 hours was a possibility. The physician was asked if he felt since the resident was frail and could develop a pressure injury so quickly were every 1 hour turning and repositioning prudent interventions. The physician replied (name of physician) looked at the resident's pressure injuries and agreed with the treatment plan. The National Pressure Ulcer Advisory Panel (NPUAP) NOTE: Based on current reported data, Stage I PrU likely began 12-24 hours prior Stage II PrU likely began 24 hours prior Stage III - IV PrU likely began at least 72 hours prior sDTI PrU purple tissue without [MEDICATION NAME] loss likely began 48 hours prior (file:///C:/Users/eyz /AppData/Local/Microsoft/Windows/INetCache/IE/NTPQV9PP/UPDATED-3-9-2014-RCA-Template.pdf) The facility policy with a revision date of 11/28/17 titled Prevention and treatment of [REDACTED]. Prevention steps: 1. A risk assessment is completed upon admission and at designated intervals throughout the resident's stay. a. Residents at risk for developing pressure ulcers are identified by using the Braden scale. b. Residents are identified as at risk for skin related issues such as;: moisture associated skin damage, skin tears, or other non-pressure skin related issues upon admission and at designated intervals throughout the resident's stay. c. Pressure ulcer and other wound and skin related interventions are created in collaboration with the interdisciplinary team and implemented in other to identify, prevent or reduce the risk of acquiring pressure and/or non-pressure related wounds or skin issues: 2. treatment of [REDACTED]. 3. Nutritional status is addressed upon admission or when there is a change in the resident's skin status. 4. The interdisciplinary team, resident/family collaborates to establish goals and interventions to address resident specific risk factors for the prevention of skin alteration. 5. The Interdisciplinary team and resident/family collaborates to establish goals and interventions to promote the healing of wounds and/or prevent further breakdown. Multiple request were make to the DON for the twice skin assessments or weekly skin assessments but they were not provided. Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Debridement - Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process.

Based on a complaint investigations, observations, clinical record review, staff and family interview, and facility documentation interview the facility staff failed to provide adequate supervision to prevent avoidable accidents for 1 of 46 residents (Resident #475) in the survey sample. The facility staff failed to adequately supervise Resident #475, leaving her alone at the nurse's station. The resident fell and sustained an acute subpial [MEDICAL CONDITION] with a left periorbital and left frontal hematoma. The findings include: Resident #475 was initially admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to the local hospital on [DATE] after a fall in the facility and was admitted with a [DIAGNOSES REDACTED]. Resident #475 was readmitted to the nursing facility on [DATE] and expired on [DATE], thus a closed record review was conducted. *Subpial tissue is situated beneath the pia mater (https://www.merriam-webster.com/medical/subpial). Pia mater is the delicate and highly vascular membrane of connective tissue investing the brain and spinal cord (https://www.merriam-webster.com/dictionary/pia%20mater). [MEDICAL CONDITION] is a type of bleeding that occurs inside the skull (cranium) (https://my.clevelandclinic.org/ ./ -intracranial-hemorrhage-cerebral-hemorrhage). A hematoma is a mass of clotted or coagulated blood. It differs from a simple bruise or contusion because the area becomes swollen, raised, or painful. Hematomas may occur after an injury or impact to the skin (https://my.clevelandclinic.org/health/diseases/ -bruises). The Minimum Data Set (MDS) assessment dated [DATE] instrumental at the time of the [DATE] fall was a quarterly and coded the resident with a score of 1 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was severely impaired in the cognitive skills necessary for daily decision making. The resident required extensive assistance from two staff for transfers and toileting. She was totally dependent on one staff for bathing. The resident required set up and supervision for eating. She was assessed to have balance problems and not steady without the assistance of staff to move from a seated to a standing position, move on and off the toilet, and surface to surface transfers. Resident #475 was coded with range of motion limitations of the lower extremity on one side. The MDS coded the resident to have fallen, without injury, once since admission. The MDS assessment dated [DATE] was a discharge and coded the resident to have fallen two or more times since admission with one of the falls resulting in non-major injury. The MDS assessment dated [DATE] was a quarterly and did not code the resident for any falls. A curser symbol was in the blocks for falls with no injury, non major falls and falls with major injury. The resident had been in the facility four days at the time of this assessment and there were no MDS corrections made to this assessment. The admission fall risk assessment dated [DATE] indicated Resident #475 was at high risk for falls based on fall history, functional status and dementia. The care plan dated initiated on [DATE] and revised on [DATE] identified Resident #475 was at risk for falls related to confusion, gait/balance problems, history of falls and actual falls. The goals set by the staff for the resident remained the same, the resident would not sustain serious injury related to falls. Some of the approaches to accomplish this goal included continue to assess risk for falls, bring to nurse's station for short periods when restless, close observation and supervision while at nurse's station, use chair pressure pad alarm when in chair/wheelchair, and review information on past falls and attempt to determine cause of falls and follow fall protocol which is inherent in the facility's policy and procedures to prevent falls, fall response and management. Record possible root causes. After remove any potential causes if possible. Educate resident, family, caregivers and interdisciplinary team members as to causes. Resident #475 had multiple falls since her admission to the nursing facility without injury where she was found either on the floor mat beside her bed or attempting to rise and walk while in her room sitting in the wheelchair. The care plan indicated when restless keep at the nurse's station for close supervision and observation to redirect when attempting to stand in order to prevent fall with subsequent injury. The resident also had a chair sensor pad that would alarm to alert staff of her movement, thus abort a fall that could subsequently result in injury. The nurse's notes dated [DATE] at 7:21 p.m. indicated the following: Resident fell from wheelchair at nurse's station, have a large hematoma on the left side of her head. Resident says she is in no pain. Area cleaned and dressing applied. She also has a skin tear to her left elbow. Area cleaned and [MEDICATION NAME] ointment applied and wrapped with dressing. POA (power of attorney) notified. (Attending physician's name) notified, ordered her to be sent out to ER to be evaluated and treated. 911 arrived at 6:20 p.m. and left at 6:30 p.m. Resident was alert and nonverbal, but confused when left the facility, was transported to (local hospital name). The fall investigation report dated [DATE], filled out by Licensed Practical Nurse (LPN) #7 indicated the resident had a witnessed fall that occurred at 6:30 p.m. from the wheelchair at the nurse's station, but the circumstances of the fall were unknown. Injuries included a hematoma of the left side of the head. First aid was applied to the left side of the head and left eye. The documented measures implemented included to continue 1:1 care in that patient does not comprehend due to dementia. The post fall investigation dated [DATE] at 6:33 p.m., filled out by LPN #7, evidenced the same information as the fall investigation report with the addition that the resident was standing up and lost her balance and vital signs were obtained, all within normal range. Neither the fall investigation report or the post fall investigation report indicated whether the chair sensory alarm sounded to alert the staff at the nurse's station of the resident's movement in the wheelchair in her attempts to stand. The local hospital admission information dated [DATE] indicated the resident's primary [DIAGNOSES REDACTED]. The resident also sustained a left periorbital and left frontal hematoma. Based on a follow-up CT, the resident was stable enough to transfer back to the nursing facility on [DATE]. The following interviews were conducted some of the facility's IDT members: On [DATE] at 5:00 p.m., an interview was conducted with the Director of Rehabilitation (Rehab) department. He presented screening, evaluation and treatment records that were applicable to physical functioning status of the resident, Physical Therapy (PT) and Occupational Therapy (OT). He stated PT concentrated on gait/balance and therapeutic strengthening exercises and OT's concentration was on activity tolerance, strength and safety in order to maximize activities of daily living (ADL). He said the resident was screened and provided the aforementioned therapies based on her repeated falls and basically did not meet the long term goals, thus she was discharged from OT and PT. He stated the resident was picked up again for PT on [DATE] and discharged again on [DATE] for therapy exercises to improve strength, endurance and gait. He stated the resident was evaluated for therapies again after she returned from the hospital on [DATE]. He further said, they provided a hip abductor pillow between her legs, but it irritated the resident and she frequently removed it. He also stated it was not traditional to implement a helmet to protect her from head injuries as a result of falls because that would be an added irritant to the resident. The Director of Rehab stated the best course of action for the resident was to closely supervise her when out of bed 1:1 with nursing staff and or to keep her in activities. He stated Dycem (a non-slip mat) was also placed in her seat to prevent sliding, as well as bed and chair alarms to alert staff of resident movement. He stated if the resident happened to fall out of bed, she was protected from injury due to the fall mat on the floor beside the bed, with the other side of the bed positioned against the wall. On [DATE] at 5:20 p.m., an interview was conducted with LPN #8, who stated Resident #475 had to be closely supervised by nursing staff and was mostly kept at the nurse's station when out of bed so staff could provide 1:1 supervision otherwise she would try to stand. She added the chair alarm would sound when the resident attempted to stand, and by her positioned with staff at the nurse's station you would be able to reposition her back in the chair. On [DATE] at 5:30 p.m., an interview was conducted with LPN #7 who filled out the investigation report as well as the post fall report related to the [DATE] fall. The LPN stated she left the resident with LPN #6 when she went around the corner to get a bag of potato chips and when she came back to the nurse's station LPN #6 was coming out of another patient's room and they met each other in the hallway. Once back at the nurse's station they found the resident in the floor, turned her over to see a large goose egg on the left side of her head. She said the alarm was not sounding. She stated she immediately called the physician and the resident was sent to the ER for evaluation. When asked why didn't she record this information on the incident report, she was silent, became tearful and asked, Are we going to be in trouble for this? On [DATE] at 5:45 p.m., an interview was conducted with LPN #6 regarding Resident #475's fall on [DATE]. He took this surveyor to the nurse's station where the fall occurred. This nurse's station floor area was not carpeted and was a concrete linoleum type floor. He stated he was sitting at the computer and the resident was sitting sort of behind him, when LPN #7 stated she was leaving the nurse's station to get a bag of potato chips. The LPN stated he stayed at the nurse's station with Resident #475. This surveyor asked since he was with her; how did she fall, did he hear the chair alarm sound, did he hear her moving, did he hear her hit the floor and did he see her hit the floor. LPN #7 responded to all the aforementioned questions, I cannot recall. On [DATE] at 5:55 p.m., an interview was conducted with both LPN#6 and #7. LPN #7 shared with LPN #6 that on her way back to the nurse's station they met each other in the hall and he was coming out of a resident's room. They looked over into the nurse's station and found Resident #475 on the floor. It was at this time LPN #6 stated he had left the resident unsupervised and did not have anyone replace him to provide the necessary supervision for Resident #475 when he left the nurse's station. On [DATE] at 11:15 a.m., and interview was conducted with the Homer unit's Registered Nurse (RN) #1. RN#1 stated the resident resided on the Homer unit and was best supervised when out of bed at the nurse's station desk with staff at the desk. She stated, I would call it 1:1, but other staff observed and supervised her. We needed to keep her in eyesight if she attempted to stand up we could intervene quickly before an accident could occur. We would see her get up or hear the alarm sound. The unit manager added they would give her magazines at the nurse's station or give her wash cloths to fold to keep her occupied. She stated from her understanding the resident fell at the nurse's station and hit her head, but she did not know the circumstances surrounding the fall. She stated all falls are discussed at the morning meeting and during the weekly standards of care meeting. She stated if there are any further recommendations to prevent falls they are discussed during those times and interventions updated on the care plan. She said the nurse who filled out the fall investigation should have thorough and complete information about the fall and that information would be brought forward to the aforementioned meetings. On [DATE] at 10:57 p.m., interviews were conducted with the Director of Nursing and the Assistant Director of Nursing. They both stated although they did not hire a nurse or aide to be 1:1 with Resident #475 or had a policy for 1:1, the staff established 1:1 supervision for the resident among themselves in order to keep the resident safe. The DON stated different nursing staff provided 1:1 supervision for Resident #475 because she would try to rise from her wheelchair which could result in a fall. They stated the resident had a bed and chair sensor pad to alert staff of her movement in order to redirect and position her back in the chair. The DON also stated the staff would offer picture magazines and drinks as interventions to divert her from trying to stand. The DON stated she reviewed the fall investigation report and the post fall investigation report of the fall incident on [DATE] and concluded that the resident stood from her wheelchair and fell . Both the fall investigation report and post fall investigation report indicated the fall was unwitnessed. She stated she did not interview any of the staff on duty that night to include the ones at the desk when the resident fell , but took the information as documented by Licensed Practical Nurse (LPN) #7 and saw it as an unfortunate accident and everything had been done to avoid the fall. The DON stated she was aware that the resident had a closed head injury and an intracranial bleed as a result of the fall on [DATE]. She presented a Root Cause Analysis (RCA) of the fall and stated the information to generate the RCA came from the investigation report that was filled out by LPN #7 and saw no need to investigate further or conduct any further interviews. The RCA (no date) that the DON referred to indicated the resident fell and sustained a hematoma and skin tear at the nurse's station on the evening shift and that the human factors relevant to the outcome involved supervision. The RCA indicated supervision was missing and the cause of the incident, and documented the staff had the resident in supervised area at the time of the incident and it was questionable as to how the incident happened. It was documented there were no uncontrollable external factors and her physical environment was appropriate. The RCA did not include whether the chair alarm sounded at the time of the fall or any interviews specific to who saw the fall and if it was questionable about the supervision aspect, why weren't further inquires and staff interviews conducted. This surveyor chose not go over the findings from the interviews that were conducted with LPN #6 and #7 at this time. On [DATE] at 12:48 p.m., an interview was conducted with Certified Nursing Assistant (CNA) #4. The CNA stated the resident loved to coordinate her clothes everyday and would be excited every morning to pick her clothes out. She stated she and other CNAs would trade off to provide 1:1 supervision because she would try to stand from her wheelchair and walk. The CNA stated they also placed the resident at the nurse's station's desk to be 1:1 with them when they were at the desk. She added the sensor pad alarm in the resident's chair alerted the staff if she was trying to stand and they would catch her before she attempted to try to walk. The CNA stated, When she came back after that last fall with the head injury, she no longer was her lively self and was not interested in coordinating her clothes. She was different. On [DATE] at 1:15 p.m., the activities assistant presented activity logs from (MONTH) (YEAR) through (MONTH) (YEAR), where the resident participated in many activities on a daily basis. The activities assistant stated the resident's sister visited everyday and came to activities with her. She stated when she was pulled up to the table participating in activities, especially Bingo, and was with her sister, she did not attempt to stand up from her wheelchair. On [DATE] at 11:30 a.m., an interview was conducted with Resident #475's Resident Representative (RR). She stated, because she did not drive, she visited mostly on Sunday afternoons when a friend could offer transportation. She said she made telephone calls to the nurse's station and asked to talk to the resident. The RR stated although the resident had [DIAGNOSES REDACTED]with confusion, the resident knew who she was and was full of lively chatter, and never left a conversation without calling her little girl and asking where's your daddy, did you bring your daddy. She said when she went to the hospital on [DATE], she was shocked to see the huge bump on the resident's head and her left eye swollen shut. She continued to say, when she visited the following weekend after the fall, the resident did not participate in lively chatter nor did she call her little girl or where's your daddy, did you bring your daddy. During the debriefing with the Administrator and the DON on [DATE] at 2:50 p.m., the above information from LPN #6 and #7 was shared with them. The DON stated she expected the resident to have been supervised per the plan when she was up and out of bed with either CNA staff or licensed staff. She stated although it was not an ordered 1:1, the staff provided it in order to keep her safe. The DON said she thought there was only one nurse involvement in the incident of [DATE] and could not answer why the one nurse left the resident alone. Other unanswered questions, during this interview, were the same ones this surveyor posed to LPN #6 (if she was with a nurse), how did she fall, did you hear the chair alarm sound, did you hear her moving, did you hear her hit the floor and did you see her hit the floor? On [DATE] at 6:00 p.m., the DON brought in the attending physician and asked the survey team if we had any questions. The attending physician asked, I understand there may be concerns about (Resident #475's name) fall on [DATE]. This survey shared the aforementioned details about the staff's failure to properly supervise the resident on [DATE]. The attending physician was not aware of all of the circumstances surrounding the fall and was in agreement that the resident sustained [REDACTED]. No further information was brought forth prior to survey exit.

Based on observations, clinical record review, staff interviews and review of the facility's policy, the facility staff failed to provide the necessary treatment, care and services, consistent with professional standards of practice, to prevent a new avoidable pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue) from developing for 1 of 26 residents (Resident 6), in the survey sample. The facility's staff did not identify Resident #6 had developed a sacral (the part of the spinal column which sits between the two hip bones) pressure ulcer until it had advanced to a stage three (3)* resulting in harm. The findings included; Resident #6 was originally admitted to the facility 07/13/16 and has never been discharged . The resident's current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/19/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were intact. The 1/19/17 MDS assessment also revealed the resident was without mood or behavior problems. The MDS assessment further revealed the resident required limited assistance one person with eating, extensive assistance of two or more persons with bed mobility, total care of one person with personal hygiene, bathing, dressing and toileting. The resident was coded as incontinent of bowels and bladder. The clinical record revealed a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE]. The score of 16 indicated the resident was at risk for pressure ulcer development. The Braden Scale for Predicting Pressure Sore Risk dated 1/17/17 score was 11 indicating the resident was at high risk for pressure ulcer development. The Pressure Ulcer Weekly Log for 1/28/17 - 2/3/17 revealed Resident #6 acquired a stage 3 pressure ulcer to the sacrum on 1/17/17. A pressure ulcer dressing change observation of Resident #6's sacrum was conducted on 2/8/17 at 10:50 a.m. The wound care nurse was assisted by a Certified Nursing Assistant (CNA) #8. The sacral wound was approximately 2.5 cm in length 1.5 cm wide 0.1 cm deep. The entire wound was pink and moist with no slough and drainage. The wound was cleaned with normal saline, Santyl ointment, and a foam dressing was applied. The resident had no complaint of pain or discomfort during the dressing change. Resident #6's Weekly Skin Check dated 1/5/17, stated the resident had no skin conditions, changes, ulcers or injuries. On the body diagram the following sites were documented; at site 23, the coccyx (tailbone) was with a red area, at site 31, the right buttock was with old scratches, at site 37, the front of the right knee had [MEDICAL CONDITION] and old scratch marks and at site 4, the face was with red areas around the mouth. There was a note in the comments/summary section of the Weekly Skin Check which read; right hand peripheral intravenous therapy dressing. Peripherally inserted central catheter (PICC) line to right inner arm antecubital. Resident #6's Weekly Skin Check documentation dated 1/12/17 read at section B1; Are there any skin conditions or changes, ulcers or injuries? The response was NO. The note in the comments/summary section of the Weekly Skin Check read; continue treatments. During the 2/9/17 interview at approximately 1:50 p.m., with the wound care nurse, she stated the treatment remained Triad cream as a preventative measure since the resident had previously been with a stage I pressure ulcer. Resident #6's Weekly Skin Check documentation dated 1/20/17 read at section B1; Are there any skin conditions or changes, ulcers or injuries? The response was yes. Section B2 asked if; is this new since the last documentation? The answer was NO The note in the comments/summary section of the Weekly Skin Check read; no new open areas, treatment continue to sacrum and right heel. Resident #6's Weekly Skin Check documentation dated 1/26/17 read at section B1: Are there any skin conditions or changes, ulcers or injuries? The response was No. The note in the comments/summary section of the Weekly Skin Check read; no new open areas, treatment continue to sacrum and right heel. Midline site left arm dry and intact. The clinical record contained a Weekly Pressure Ulcer BWAT Report dated 1/17/17. The report stated Resident #6 was with a new onset pressure ulcer at site 53, the sacrum. The stage 3 pressure ulcer of the sacrum measured 5 centimeters by 4 centimeters by 0.1 centimeters. The report revealed the pressure ulcer was irregular in shape, was initially observed on 1/17/17, was a full thickness skin loss involving damage or necrosis of subcutaneous tissue, may extend down to but not through underlying fascia; and/or tissue layers obscured by granulation tissue. The Weekly Pressure Ulcer BWAT Report dated 1/17/17, also stated the stage 3 pressure ulcer of the sacrum had distinct, outline edges, undermining less than 2 centimeters in any area and necrotic tissue type; white/grey non-viable tissue and/or non-adherent yellow. The report revealed there was 25 - 50 percent of necrotic tissue present. The wound produced a small amount of thin watery, pale red/pink drainage. The skin surrounding the wound was bright red and/or blanched to touch. The wound also contained granulation and [MEDICATION NAME] tissue. The treatment/evaluation section of the Weekly Pressure Ulcer BWAT (Bates-Jensen Wound Assessment Tool) Report dated 1/17/17 read; area to sacrum noted. Area noted with yellow tissue to wound bed. Medical Doctor (MD) notified and new orders received for Santyl (an ointment to remove dead tissue from wounds) daily. Responsible Party notified of new area. Will re-evaluate in 1 week. An interview was conducted with the wound care nurse on 2/9/17 at approximately 1:50 p.m. The wound care nurse stated Resident #6 was stable prior to development of the stage 3 pressure ulcer and the only behavior exhibited was his resistance to meals in the dining room. She further stated the staff provided turning and repositioning, incontinence care and applied Triad cream (a zinc oxide based paste) to the resident's bottom every shift. During the 2/9/17 interview at approximately 1:50 p.m., with the wound care nurse, the Pressure Ulcer Investigation was reviewed. The Pressure Ulcer Investigation revealed Resident #6 was identified with a stage 3 pressure ulcer acquired in house on 1/17/17. The wound care nurse stated the investigation revealed the resident had the following risk factors; impaired transfer and bed mobility, chronic urinary incontinence, chronic bowel incontinence, diabetes, immobility, and inadequate nutrition/hydration therefore; the pressure ulcer was unavoidable. The wound care nurse stated it is not ideal for pressure ulcers to be discovered at a stage 3, early on when there is only redness is optimal. The wound care nurse also stated the Certified Nurse Assistants (CNA)s are the first line of defense for early detection as they provide routine bathing and incontinent care. The wound care nurse futher stated the facility interventions were consistently implemented and they included; preventative skin care (clean protect, moisture), consistently turn and reposition, utilization of appropriate reduction surface, evidence of consistently monitoring skin/body, incontinence management program, Rehabilitation consult for positioning if indicated. Registered Dietitian consult to address nutrition needs, Preventions addressed on most recent MDS and prevention addressed on care plan to manage identified risk factors. Review of the care plan dated 7/25/16 and active at the time the stage 3 pressure ulcer was discovered on 1/17/17 read; Potential for skin/tissue integrity due to [DIAGNOSES REDACTED]. The interventions were; assess (name of resident) skin weekly and as needed, provide dietary supplements as ordered, provide incontinence care as needed, When (name of resident) is out of bed, change position by shifting weight or return to bed for rest. The above findings were shared with the Executive Director and the Director of Nursing on 2/9/17 at approximately 3:10 p.m. The Staff Development Coordinator (SDC) was interviewed on 2/9/17 at approximately 4:45 p.m. The SDC presented a Quality Assurance Performance Improvement Action Plan (QAPIAP) dated previously dated 11/15/16 and updated to read 11/17/16. The SDC stated the facility staff recognized an increase in pressure ulcer at that time and developed a plan on 11/17/16 to identify trends and institute interventions to reduce the opportunities for new pressure ulcer development. Review of the QAPIAP revealed the data was not accurate. The document stated there were 5 residents with acquired pressure ulcers the week of 9/5/16 - 9/11/16 , but the Pressure Ulcer weekly log revealed no pressure ulcers were in house acquired 9/5/16 - 9/11/16 and on 11/12/16 -11/18/16 the Pressure Ulcer weekly log revealed two pressure ulcers were in house acquired. The SDC stated the measures/trends are not accurate but the interventions were instituted and continues to be implemented. They included Validate resident with acquired pressure ulcer have appropriate treatment, care plan interventions, pain assessment with new change in pressure ulcer, Braden scales, responsible party and registered dietitian notification, evaluation of treatment every 14 days. The Pressure Ulcer Investigation form was implemented for any new pressure ulcers, review of the weekly body checks for 1 month prior to pressure ulcer development to validate completion. Educate licensed nurses as needed, weekly skin assessments/body checks by licensed nurses. Re-implement turning schedule. Provide to nursing staff. In-service licensed nurses related to pressure prevention and treatment. The SDC stated the during the interviewed on 2/9/17 at approximately 4:45 p.m., that all of interventions from the action plan developed 11/17/16 remained in effect. The SDC did not attach or provide copies of the staff which had been in-serviced on the QAPIAP dated 11/17/16. The facility's policy titled Prevention and treatment of [REDACTED]. Under prevention steps the procedure reads; A at risk assessment is completed on admission and at designated intervals throughout the patient's stay. Patients at risk for developing pressure ulcers are identified by using the Braden Scale. Patients are identified as at risk for skin related issues such as moisture associated skin damage, skin tears, or other non-pressure skin related issues upon admission and at designated intervals throughout the patient's stay. Another facility policy titled Pressure Ulcer dated 12/20/16 stated; pressure ulcers prevention requires an interdisciplinary approach to care. Some parts of pressure ulcers prevention are highly routinized, but care must be tailored to the specific risk profile of each patient . Risk assessment is a key component of clinical practice aimed at identifying individuals vulnerable to the development of pressure injuries. In order to target appropriate interventions and prevent pressure ulcer development, characteristic that increase probability of pressure injuries must be identified. Individuals who are at high risk are those portrayed by multiple risk factors affecting both the mechanical boundary conditions (i.e., the type shear, pressure, friction, magnitude, time and duration of the mechanical load and the susceptibility and tolerance of the individual) . *A Stage 3 pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. A stage 3 pressure ulcer may include undermining or tunneling. (National Pressure Ulcer Advisory Panel)

Based on observations, clinical record reviews and staff interviews the facility staff failed to ensure that a resident who entered the facility without pressure ulcers (bed sores) to the Left elbow, did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 24 Residents in the survey sample (Resident #8). The facility staff failed to identify a left elbow pressure ulcer prior to it developing to advanced stage (unstageable) on 2/22/16. This constituted harm for Resident #8. In addition, the facility failed to initiate and ensure the appropriate wound protocol was in place. The findings included: Resident #8 was admitted to the facility on [DATE] after a hospital stay for treatment after a motorcycle accident. [DIAGNOSES REDACTED]. in a wound). The admission MDS (minimum data set - an assessment protocol) with an ARD (assessment reference date) of 12/30/15 coded Resident #8: At Risk for Pressure Ulcers and as having: Zero, Stage I pressure ulcers (intact skin with non-blanchable redness of a localized area usually over a bony prominence); Three, Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough); Zero, stage III pressure ulcers (full thickness tissue loss, Subcutaneous fat may be visible but bone, tendon or muscle is not exposed); and Zero stage IV (Full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcers. Resident #8 was coded on the annual MDS with an ARD date of 12/30/15 as having short term and long term memory problems. In addition, Resident #8 was coded as requiring maximum assistance with one staff person support for hygiene, bathing, and bed mobility. Range of Motion for upper and lower extremities was coded as impaired. Resident #8 was observed during the facility's initial tour on 3/1/16 at approximately 2:45 p.m. lying on his back in bed. When spoken to, Resident #8 made no changes in his facial expression or eye movement. The right and left elbows were observed to not be offloaded in any way. A sheet covered the lower body. The CNA (Certified Nursing Assistant) #1 stated: I believe physical therapy is coming to his room. He was injured in a motorcycle accident. Resident #8 was observed on 3/2/16 at approximately 9:15 a.m., out of bed sitting in a geri chair facing the television. A blanket was across his body from upper chest down over his feet. His head was elevated approximately 45 degrees. Resident #8 was observed on 3/2/16 at approximately 12:15 p.m., sitting up in the geri chair with his head elevated approximately 45 degrees. On 3/3/16 at approximately 9:08 a.m., wound care was observed on Resident #8's left elbow performed by the Staff Development Coordinator (SDC) RN (Registered Nurse) #1. The Left elbow was observed to be off loaded with a pillow under the upper arm. The left elbow dressing was removed and the pressure ulcer was cleansed with seaclenz wound cleanser, Santyl (a debridement agent) ointment applied on wound base with Biatin Alginate dressing applied, then covered with a [MEDICATION NAME] dressing and secured with Kling dressing. SDC RN #1 stated: The Kling helps keep the dressing in place. SDC RN #1 stated the Left Elbow pressure ulcer was acquired in house (in the nursing facility). When asked to describe the Left elbow when it was first identified she stated, It was found as unstageable. We're working on offloading with pillows. When asked to describe the left elbow pressure ulcer as observed presently, she stated, It's currently presenting as a Stage III. It has 10% slough in the center and the edges have granulation. SDC RN# 1 was asked about a turn sheet observed in Resident #8's room on 3/3/16 which was not observed on 3/1 and 3/2/16. SDC RN #1 stated, family wanted it done after they visited yesterday. *Unstageable/Unclassified: Full thickness skin or tissue loss-depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown necrotic tissue) and/or eschar (tan, brown or black necrotic) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a *Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance (fluctuating/unstable), eschar on the heels serves as the body's natural (biological) cover and should not be removed (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). Review of the 12/23/15 Admission Nursing assessment dated [DATE], was reviewed. It documented the following two open wounds: Right knee (front) and Right shoulder (front). In addition, the 12/23/15 Admission Nursing Assessment documented that Resident #8 required staff assist to move to relieve pressure over any one site, was bed/chair bound, and required a special mattress/chair cushion. The 12/23/15 Admission Nursing Assessment Summary documented the following: Has wound to right shoulder that is pink in color and has mixture of some yellowish tissue to wound bed.Pink colored wound to right knee. Also BLE (bilateral lower extremities) are stiff and has bilateral foot drop. Incontinent of B/B (bowel/bladder), total care. Part 2 of the 12/23/15 Admission Nursing Assessment documented that Resident #8 was non-ambulatory and documented Resident #8 was totally immobile in bed. The facility's weekly skin check was reviewed and documented the following: 2/1/16 No new area noted 2/15/16 No new area noted 2/22/16 Yes: are there any skin conditions or changes, ulcers, or injuries? Summary: Resident noted with unstageable area to left elbow. MD (physician) notified and new treatment order in place. Area to R (right) knee and R shoulder remains with treatment in place. Shearing noted to buttock. 2/22/16 Weekly Skin Check documented site Left Elbow unstageable pressure ulcer 2/29/16 Summary: Resident continues with area to L (left) elbow, R knee and R shoulder, R buttock with treatments in progress. No other skin issues noted. The Weekly Pressure Ulcer BWAT (Bates Wound Assessment Tool) Report dated 2/29/16 documented the following measurements: Length 3.5; Width 3; Depth 0.1 Stage Unstageable Shape Round/Oval Date of Initial Observation 02/22/2016. Resident #8's Care Plan was reviewed and documented the following Focus areas: Initiated on 12/24/15 Potential for impaired skin integrity r/t (related to) [MEDICAL CONDITION], TBI ([MEDICAL CONDITION]) with right craniectomy (removal of cranium bone over brain), impaired communication, incontinence,[MEDICAL CONDITION](tube into windpipe) status, altered nutritional intake, history of [MEDICAL CONDITION] ([MEDICAL CONDITION] -blood clot) The following interventions were documented: Assess skin weekly and PRN (as needed) Preventative dressing/treatment to left elbow prn, turn and position as needed Initiated 1/11/16, Resident has ADL (Activity of Daily Living) Care Performance Deficit r/t TBI with documented following interventions: Turn and reposition as needed; Resident is total care in all ADL's Initiated on 2/22/16, Actual alteration in skin integrity r/t (related to) Stg. (Stage) II to Right Shoulder and Right Knee and unstageable to left elbow. The following interventions were documented: Follow physician orders [REDACTED]. The 2/22/16, progress Note documented by LPN # 20 at 16:53 (4:53 p.m.) Resident noted with area to Left elbow. Yellow slough (dead tissue) noted in wound bed. MD notified and new order obtained to clean wound with w/c (wound cleanser) apply santyl with gauze and cover with secondary dressing daily. POA (Power of Attorney) notified of new area and new order. No signs of infection noted. No signs or symptoms of pain or discomfort noted. No signs or symptoms of distress. In an interview conducted with LPN (licensed practical nurse) #2 on 3/3/16 at approximately 12:35 p.m. she stated, I saw blood on the sheets when turning and when I looked, the blood was from the Left elbow. An interview was conducted with CNA #2 on 3/3/16 at approximately 12:37 p.m. CNA #2 when asked about Resident #8's Left elbow, she stated: it was pink and had seen dressing on it somedays and off somedays. I thought it was getting aired out. As a dressing was on it, I figured the nurse already knew. Review of Physician orders [REDACTED].#8's Left elbow documented the following: Santyl Ointment 250 Unit/Gram ([MEDICATION NAME]) Apply to L (Left) elbow topically every day shift for Wound Care. Clean area to L elbow with w/c (wound cleanser). Apply with fluffed gauze and cover with secondary dressing The order date was documented as 2/22/16 and start date was documented as 2/23/16. Review of a facility document entitled: ' Performance Improvement Form ' dated 2/26/16 for LPN #21 documented: Reason for Counseling Corrective Action: Failure to report change in condition. Applying treatment with no MD order. Failure to notify MD/RP of change in skin condition. The form further documented Expected Level of Performance: To notify MD/RP of all changes in condition and obtain appropriate orders as warranted. LPN #21 was suspended for 2 days. The DON (Director of Nursing) stated on 3/3/16 at approximately 3:30 p.m., She was suspended for not notifying MD of changes to left elbow and for not getting orders for preventative treatment. The facility policy and procedure titled ' Prevention and treatment of [REDACTED]. The policy documented, in part the following: The facility has a system and procedures in place to promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible), and prevent development of additional pressure ulcers unless clinically unavoidable. Prevention Components 1. A risk assessment is completed upon admission and at designated intervals throughout the patients stay. c. Pressure ulcer and other wound and skin related interventions are created in collaboration with the interdisciplinary team and implemented in order to identify, prevent or reduce the risk of acquiring pressure and/or non-pressure related wounds or skin issues: 1) Reduce pressure, friction and shear such as turning and repositioning determined per patient's risk level and 2) Condition or offloading with elevation of extremity, wedges, pillows, etc. as indicated 2. treatment of [REDACTED]. 3. Nutritional status is addressed upon admission or when there is a change in the patient's skin status requiring re-evaluation of the patient's nutrition status. 4. The facility individualizes and maintains care plan interventions as appropriate to address identified risk factors. Resident #8 entered the facility with no pressure ulcer on his Left Elbow on 12/23/15 and staff first identified it and began treatment on 2/22/16 at an advanced stage (Unstageable) Pressure Ulcer. The administration consisting of the Administrator and the DON were updated of the findings during a briefing on 3/3/16 at approximately 3:30 p.m. No further information was presented.