Every finding on record at The Estates at Linden LLC

Based on observation, interview, and document review, the facility failed to ensure call lights were accessible for 1 of 1 resident (R11). Findings include:R11's modified significant change in status Minimum Data Set (MDS) dated [DATE], indicated R11 made himself understood and understood others, had moderate cognitive impairment, had impairment in range of motion to lower extremities, used a wheelchair, was dependent on staff for toileting hygiene, showering and bathing, and transfers. Further, R11 had multiple sclerosis, dementia, anxiety, and depression.R11's Kardex dated 1/8/26, indicated R11 was alert and oriented times two to three and lacked information R11 required his call light.R11's care plan revised 11/13/25, indicated R11 had an alteration in mood and behavior and interventions included to ensure the call light was visible and within reach. During observation on 1/5/26 at 2:19 p.m., R11 was in bed, and his call light was hanging off the foot of the bed between the foot board and the air mattress out of R11's reach.During observation on 1/7/26 between 7:30 a.m., and 8:11 a.m., R11 was in his room watching television in a reclining chair and his call light was located at the foot of the bed and draped between the foot board and the air mattress and out of R11's reach. At 8:11 a.m., two staff persons walked by R11's room and one staff person looked inside R11's room and went into another room down the hallway.During observation on 1/7/26 at 8:17 a.m., nursing assistant (NA)-B and NA-C brought R11 from his room to the dining room.During observation on 1/7/26 at 8:39 a.m., R11's call light was draped between the foot board and the air mattress. During interview and observation on 1/7/26 at 9:58 a.m., R11 was in his room in the reclining chair. NA-C stated R11 used his call light and verified R11's call light was between the foot of the bed and the mattress and was out of R11's reach. During interview on 1/7/26 at 10:40 a.m., registered nurse (RN)-C stated R11 used his call light and verified a call light intervention was not on the Kardex and expected staff to ensure R11's call light was within reach.During interview on 1/7/26 at 11:01 a.m., the director of nursing (DON) stated she expected staff to follow the care plan and stated it was important for R11 to have his call light in order to call for assistance. During interview on 1/7/26 at 1:02 p.m., the DON stated they did not have a policy on accessible call lights and stated it was general practice to have an accessible call light.

Based on observation, interview, and document review, the facility failed to implement pressure ulcer interventions for 1 of 1 resident (R11) reviewed for pressure ulcers.Findings include:R11's modified significant change in status Minimum Data Set (MDS) dated [DATE], indicated R11 had moderate cognitive impairment, had impairment in range of motion to lower extremities, used a wheelchair, was dependent on staff for most activities of daily living (ADLs) including putting on and taking off footwear and required substantial to maximal assistance with rolling left to right. Additionally, R11 did not reject care, had an indwelling catheter, was occasionally incontinent of bowels, had an unstageable pressure ulcer (pressure injury caused by prolonged pressure to a specific area of the skin that is completely obscured and cannot be staged) and was at risk of developing pressure ulcers. Furthermore, R11 had multiple sclerosis, dementia, diabetes, anxiety, and depression.R11's Physician's Orders form saved on 1/7/26 at 8:13 a.m., indicated the following orders:8/19/25, Wound, remove Prevalon boots (boots used to help protect heels from developing pressure injury) to inspect skin for any skin breakdown. Apply lotion and reapply boots every morning and at bedtime. Update hospice and provider with any changes. 9/17/25, Prevalon heel protector boots to be worn on bilateral feet at all times.10/23/25: wound to right great toe, cleanse with wound cleanser, pat dry. Apply a 2 by 2 saturated with quarter strength Dakin's solution to the wound base and cover with a small ABD pad twice a day. R11's Kardex saved on 1/7/26 at 10:17 a.m., directed staff to apply Prevalon boots to both feet at all times and to remove daily to inspect R11's skin for skin breakdown.R11's care plan saved on 1/7/26 at 8:23 a.m., indicated R11 had an alteration in mobility due to weakness from multiple sclerosis. R11's care plan saved on 1/7/26 at 8:23 a.m., indicated R11 had an alteration in skin integrity and had a pressure ulcer to his left buttocks and an abrasion to the right great toe. R11 had the following intervention, Prevalon boots to bilateral feet at all times remove daily to inspect skin for any skin breakdown. R11's Braden Scale for Predicting Pressure Sore Risk form dated 9/17/25 at 9:27 a.m., indicated R11 was at moderate risk for developing a pressure sore.R11's progress notes saved on 1/8/26 at 8:41 a.m., were reviewed from 1/1/26, and lacked documentation R11 refused to wear Prevalon boots. R11's nurse practitioner progress note dated 2/16/25 at 10:01 a.m., indicated R11 had an unstageable pressure ulcer to the right heel under a heading, Past Medical History. During observation on 1/7/26 at 7:30 a.m., R11 was in his room watching television in a reclining chair. R11's Prevalon boots were located on the counter in the room.During observation on 1/7/26 at 8:17 a.m., nursing assistant (NA)-B and NA-C brought R11 from his room to the dining room. R11 did not have the Prevalon boots on. During interview on 1/7/26 at 9:58 a.m., NA-C stated they received a sheet of paper with information when they started their shift to know what cares a resident required. NA-C stated R11 had a wound on his bottom and required a mechanical lift to get up and further stated R11 did not refuse cares. NA-C verified R11 was not wearing the Prevalon boots and stated she did not know whether R11 wore Prevalon boots while in his chair but wore the boots in bed. NA-C verified the sheet of paper lacked information R11 required boots. During interview on 1/7/26 at 10:07 a.m., nurse practitioner (NP)-A who conducted wound rounds at the facility stated she expected R11 to have the Prevalon boots on at all times and further stated everyone should know that. Licensed Practical Nurse (LPN)-A verified R11's boots were not on and stated he expected R11 to have the Prevalon boots on at all times. During interview on 1/7/26 at 10:16 a.m., LPN-A verified R11's care plan indicated R11 required the Prevalon boots at all times. During interview on 1/7/26 at 10:40 a.m., registered nurse (RN)-C stated she expected R11 have the Prevalon boots on at all times to protect R11's skin. RN-C stated residents had Kardex's in their closets, but the most accurate information was located in the computer. During interview on 1/7/26 at 11:01 a.m., the director of nursing (DON) stated she expected staff to follow the care plan and stated the boots should be on when resident was in bed and up in the chair. The DON further stated it was important R11 wear the boots for his skin integrity.A policy, Skin Assessment and Wound Management dated 2/2025, indicated the purpose of the policy was to provide guidelines for assessing and managing wounds and included implementing appropriate preventative skin measures. Additionally, for ongoing skin issues to follow ongoing treatments per provider orders.

Based on observation, interview, and record review the facility failed to ensure environmental services staff (EVS) followed infection control measures for handling potentially contaminated laundry and linens for 1 of 1 resident (R34) observed for TBP. Additionally, the facility failed to ensure infection control tracking and surveillance was completed for R25 who had symptoms of a respiratory infection. Findings include:R34 R34's discharge/readmit Minimum Data Set (MDS) dated [DATE], indicated R34 was unable to complete the cognitive assessment and required supervision to partial/moderate assistance for most activities of daily living (ADLs). R34's diagnoses included cellulitis of right lower limb and cutaneous (affecting skin) abscess of right lower limb. R34's care plan (CP) dated 11/5/25, indicated R34 had potential self-care deficit related to wound on right leg and required assistance of one person for bathing, personal cares, and dressing. The CP indicated R34 required staff to follow enhanced barrier precautions (EBP) due to the need for wound care on right leg. During an observation and interview on 1/5/26 at 4:33 p.m., environmental services (EVS)-A was in R34's bathroom cleaning the surfaces and toilet with cleaning rags with no gown or gloves on. When EVS-A was done, she held the cleaning cloths against her shirt and carried them out of the resident room into the hallway, where she obtained a plastic bag, put the used cleaning rags in the bag and brought the bag down to the soiled utility room. Upon return, when asked, EVS-A stated linen should be bagged before it touches staff clothing. During interview and observation on 1/7/26 at 7:57 a.m., environmental services (EVS)-B came out of a resident's room and down the hallway with unbagged white linens that were touching her body. EVS-B stated the linens were on the bathroom floor and stated they should have been placed in a bag. During an interview on 1/7/26 at 10:33 a.m., the director of nursing (DON)/infection preventionist (IP) stated soiled resident Linens and EVS cleaning towels should be bagged before taking out resident's rooms and not touch staff clothing to prevent the spread of potential infections. R25 R25's comprehensive Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, did not reject care, required substantial to maximum assist with toileting hygiene, bathing, and lower body dressing. Further, R25 had rheumatoid arthritis (an autoimmune disease), and an unspecified fracture of the skull. R25's Physician's Orders form indicated the following orders: 12/3/25, acetaminophen (a medication used for pain and for reducing fever) oral tablet, give 1000 milligrams (MG) three times a day for pain. 1/5/26, cough drops give 1 lozenge by mouth every hour as needed for cough/sore throat for 14 days. 1/5/26, Mucinex oral tablet Extended Release 12-hour 600 mg tablet every 12 hours as needed for congestion for 14 days. 1/5/26, geri-tussin oral liquid 100 mg/5 milliliters (ML) give 10 ml by mouth every 4 hours as needed for cough for 14 days. R25's medication administration record (MAR) and treatment administration record (TAR) dated January 2026, and saved on 1/8/26 at 9:35 a.m., indicated R25 utilized geri-tussin on 1/6/26, 1/7/26, and 1/8/26. Further, R25 utilized Mucinex on 1/5/26, 1/6/26, and 1/7/26. R25's progress notes dated 1/5/26 at 5:39 a.m., indicated R25 reported a sore throat. R25's progress notes dated 1/5/26 at 2:49 p.m., indicated R25 had cold symptoms and a sore throat and a message was sent to Aeris. R25's progress notes dated 1/5/26 at 8:49 p.m., 1/6/26 at 8:03 p.m., 1/7/26 at 1:44 a.m., 1/7/26 at 1:01 p.m., indicated Mucinex extended-release tablet was given and was effective for congestion. R25's progress notes dated 1/6/26 at 9:17 p.m., 1/7/26 at 2:31 p.m., 1/7/26 at 9:45 p.m., and 1/8/26 at 9:31 a.m., indicated that Geri-Tussin was effective for coughing. R25's care plan was reviewed and lacked information R25 had cold symptoms. R25's Kardex dated 1/8/26, was reviewed and lacked information R25 had cold symptoms. R25's Vital Signs form indicated R25's temperature was 99.7 on 1/7/26 at 1:44 p.m. Antibiotic logs provided by the facility for December and January year unspecified, indicated under a heading, Type of Infection R25 had rheumatoid arthritis upon admission and was on Hydroxychloroquine Sulfate (a medication used to treat autoimmune diseases) 200 mg twice daily that started on 12/1. Change in Condition logs provided by the facility for January 2026, indicated various residents with noted changes in condition on 1/5/26, and 1/7/26, however lacked information R25 had a change in condition. Resident Illness Tracker for January 2026, and provided on 1/8/26, lacked indication R25 had signs or symptoms of a respiratory infection. During interview and observation on 1/5/26 at 1:42 p.m., licensed practical nurse (LPN)-B entered R25's room and R25 stated her throat hurt and was on fire. R25 stated it started that morning. R25 had an occasional cough. During interview and observation on 1/5/26 at 1:49 p.m., LPN-B stated she spoke to the nurse practitioner and provided R25 ice chips for her sore throat. During interview on 1/7/26 at 2:14 p.m., R25 stated she started on three different drugs and stated she didn't have a sore throat but had a cough. During interview on 1/8/26 at 10:22 a.m., LPN-B stated staff wore masks when they had cold symptoms and if a resident had cold signs or symptoms, they report to the nurse practitioner and added R25 had a cough and will cover her cough and staff made sure R25's hands were washed. LPN-B stated they monitored residents' symptoms at first and residents did not go on any precautions, but their symptoms were monitored. During interview on 1/8/26 at 10:31 a.m., the DON/IP stated when residents had signs or symptoms of a respiratory infection, they were encouraged to wear a mask if leaving their room and they monitored to see if there were any patterns or trends and further stated residents did not go on precautions, they were kept in their rooms as they allowed and if staff had symptoms should wear a mask and were encouraged to wear masks but was not required when caring for a resident with cold signs and symptoms. The DON further stated they tracked dates of onset of signs and symptoms and specific symptoms and temps based on a resident's baseline and was documented on a tracker. The DON further stated they were made aware of new signs and symptoms through review of progress notes. The DON stated she had a tracker that was completed on a daily basis and one completed at the end of the month and included daily symptoms, and type of medications. The DON was asked how trends were tracked or how potential outbreaks were tracked and stated they were a small facility but did not have a tracking system for this. The DON verified the Illness tracker log had not been updated. The DON further stated for testing, staff would test based on working with the provider and types of symptoms such as fevers, oxygen levels and heart rates and they document in their Change of Condition log and verified the log was not updated and stated it was supposed to be updated every day and will clear the week prior unless a resident continued to show symptoms and verified R25 was not on the change in condition form and the morning meeting change of condition notes and stated they missed R25. The DON further stated scheduled acetaminophen could mask symptoms of an elevated fever and added she would talk with the provider today to see if R25 should be on any sort of testing and R25 would be encouraged to stay in her room and if testing was pending, R25 would be placed on respiratory precautions. A policy, Infection Prevention and Control Program (IPCP), dated 11/2024, indicated the IPCP's mission was to prevent the development and transmission of communicable disease and infections and addresses detection, prevention and control of infections among residents and personnel and major elements of the program included surveillance, data analysis, outbreak management, and prevention of infection. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections and detecting unusual pathogens with infection control implications. Data analysis gathered during surveillance is used to oversee infections and spot trends. Furthermore, the policy indicated to educate staff and ensure adherence to proper infection control techniques and to implement appropriate isolation precautions when necessary to prevent the spread of infection. The undated EVS policy titled Daily Cleaning Procedures identified place soiled rags in a plastic bag on cart, remove and discard gloves, and wash hands prior to leaving room. The policy lacked instruction on how staff must handle, store, process, and transport linen to prevent the spread of infection.

Based on interview and document review, the facility failed to manage pain consistent with the comprehensive assessment, plan of care, and physician's orders and to ensure potential acute opioid withdrawal symptoms were assessed to prevent avoidable, significant, pain for 1 of 1 resident (R23) reviewed for pain management. This deficient practice caused actual harm for R23, who experienced unmanaged pain and withdrawal symptoms. Findings include: R23's face sheet printed 10/31/24, indicated R23 had diagnosis of chronic pain syndrome with chronic opioid use related to a motor vehicle accident (MVA). R23's quarterly minimum data set (MDS) dated [DATE], indicated R23 was cognitively intact with no rejection of care. The MDS further indicated R23 had pain, however, did not receive any non-pharmacological interventions for pain. R23's pain Care Area Assessment (CAA) dated 5/7/24, indicated R23 reported pain which interfered with sleep and daily activities on an almost constant basis. Further, R23 reported constant pain rated at a 10 out of 10 on a 0-10 pain scale. Additionally, the CAA indicated R23 was at risk for pain not being adequately relieved or managed with interventions for nursing to monitor pain, administer pain medications as ordered, and nursing to update provider on pain as necessary and when pain was not adequately relieved/controlled. R23's care plan with revision date 5/17/24, indicated R23 had potential for alteration of comfort related to chronic pain syndrome, right humerus, and femur fractures, and left gluteal wound with the following interventions: pain medication as ordered by medical doctor (MD) and provide non-medicinal forms of pain relief including positioning, rest, and massage. R23's goal was to have adequate relief from pain as evidenced by verbalization, and freedom from signs/symptoms of non-verbal indications of pain. R23's physician visit note dated 10/10/24, indicated R23 had been on long-term opioid pain medications since 7/25/22 due to a motor vehicle accident and R23 reported pain intensity was an 8 on a 0-10 pain scale due to a recent fall during physical therapy which resulted in a fractured hip and shoulder. Further indicated, the physician ordered Belbuca (a strong prescription pain medicine that contains an opioid Buprenorphine. It is used to manage severe pain that requires long term treatment) 600 microgram (mcg) buccal film twice a day. R23's physician orders dated 10/31/24, indicated R23 had the following orders: -Lyrica 150 milligrams (mg) three times a day with a start date of 9/18/24 and a stop date of 10/11/24. -Lyrica 175 mg three times a day with a start date on 10/11/24. -Belbuca 900 mcg buccal film twice a day with a start date on 9/18/24 and a stop date of 10/11/24. -Belbuca 600 mcg buccal film twice a day with a start date on 10/11/24. R23's medication administration record (MAR) dated October 2024, indicated R23 did not receive the Belbuca 600 mcg buccal film from 10/11/24 at 8:00 p.m. through 10/15/24 at 8:00 p.m., a total of 9 doses missed. The MAR further indicated R23 did not receive the Lyrica 175 mg from 10/11/24 at 8:00 p.m. through 10/14/24 at 12:00 p.m., a total of 9 doses missed. R23's progress note dated 10/14/24 at 3:46 p.m., indicated R23 had increased anxiety, agitation, fidgeting, and pacing. R23's progress note dated 10/14/24 at 10:12 p.m., indicated R23's pain medication wasn't available and exhibited withdrawal symptoms such as restlessness and agitation. Review of R23's progress notes from 10/10/24 through 10/15/24, revealed no indication of physician notification of missed pain medications, R23's pain status, or R23's withdrawal symptoms. During review of R23's electronic medical record (EMR) from 10/10/24 through 10/16/24 on 10/31/24, lacked indication of non-pharmacological interventions provided, physician notification, or new pharmacological orders provided in substitution. During an interview on 10/31/24 at 10:59 a.m., registered nurse (RN)-A stated R23's Belbuca 600 mcg and Lyrica 175 mg pain medications were not available. Further, RN-A stated R23 was miserable and a mess during the days the pain medications weren't provided. Additionally, RN-A stated R23 exhibited withdrawal symptoms of shakiness, irritability, and restlessness during the days the pain medications weren't provided. Also, RN-A stated R23 was allowed to go smoke after hours throughout the night while he was unable to sleep. During an interview on 10/31/24 at 11:35 a.m. R23 stated, I felt awful, my pain was through the roof, my pain was completely out of control and they didn't do anything for my pain. Further, R23 verified the facility staff did not provide any non-pharmacological interventions during the time the pain medications weren't provided. During an interview on 10/31/24 at 11:43 a.m., registered nurse manager (RN-B) stated was informed by the nursing staff the pharmacy didn't send the new prescribed medications due to it was too early to fill the medications so, the medical provider was contacted on 10/16/24 regarding the missing pain medications. RN-B further stated the issue was the previous Belbuca and Lyrica medications were destroyed since R23 was given new prescriptions for the Belbuca and Lyrica. Additionally, the Belbuca prescription was sent to the wrong pharmacy and the facility had to call and have the pharmacy release the prescription so the facility pharmacy could fill and send the medication. During an interview on 10/31/24 at 1:26 p.m. the DON verified the nurses should have called the pharmacy when the medication wasn't received and should have updated the physician right away if the pharmacy couldn't send the medication. During an interview on 10/31/24 at 1:30 p.m., pain specialty physician stated the facility should have notified the office as soon as the medication wasn't received so an alternative could have been given. Further, the MD indicated if an opioid medication was stopped abruptly severe withdrawal symptoms could occur as well as increased pain. During an interview on 11/1/24 at 12:34 p.m. the administrator stated the facility administration was made aware on Monday 10/14/24 of R23 not receiving the new pain medications. Further, verified the medications were not received and given in a timely manner when the facility didn't receive the ordered medications. During an interview on 11/1/24 at 1:33 p.m., nurse practitioner (NP) verified they did not complete a comprehensive assessment of R23's pain or withdrawal symptoms on 10/14/24. During review of the prescribing information on Belbuca.com on 10/31/24, revealed a warning: Serious and Life-threatening risks from use of Belbuca indicated serious, life-threatening, or fatal respiratory depression may occur with use of Belbuca, especially during initiation or following a dosage increase. To reduce the risk of respiratory depression, proper dosing, and titration of Belbuca are essential. The Highlights of Prescribing Information obtained from Belbuca.com website indicated not to abruptly discontinue Belbuca in patients who may be physically dependent on opioids. Rapid discontinuation of opioid analgesics in patients who are physically dependent on opioids has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide. Rapid discontinuation has also been associated with attempts to find other sources of opioid analgesics, which may be confused with drug-seeking for abuse. Patients may also attempt to treat their pain or withdrawal symptoms with illicit opioids, such as heroin, and other substance. The Pain Management Protocol dated 3/23/23, indicated to ensure that residents with pain or at risk for pain, have an effective pain management plan in place with individualized interventions that are consistent with the resident's goals for comfort. Treatment/Management 1. With input from the resident and/or resident representative, the provider, and staff will establish goals of pain treatment, for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. 2. Nursing will evaluate for appropriate non-pharmacologic interventions to address the individual's pain. 3. Provider will order appropriate medication interventions to address individuals' pain. 4. The staff will evaluate and report how much and how often the resident utilizes PRN pain medication. a. Depending on severity and location of pain, the provider may start with PRN doses or supplement routine doses with PRN doses for breakthrough pain. b. If there are more than occasional PRN analgesic utilization (and depending on the success of nonpharmacological interventions), the provider may consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the routine dose of an existing analgesic, or switching to another analgesic. 5. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. 6. Resident's plan of care will reflect pain management needs. 7. For the individual who is receiving opioid analgesics, the provider may order a regimen of laxatives and other measures to prevent constipation. Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals; monitoring will occur to ensure pain is controlled, care plan goals are met, and pain management regimen is effective. Review should include frequency and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 2. The staff will discuss significant changes in levels of comfort with the provider who will consider adjusting interventions accordingly. This may include non-pharmacological measures and adjustments of regular and PRN analgesic doses to find the best combination of effectiveness and tolerable side effects. 3. The staff and physician will monitor for adverse effects of pain medications such as gastrointestinal bleeding from nonsteroidal anti-inflammatory drugs (NSAIDs), and anorexia, confusion, lethargy, severe constipation, or ileus related to opioids.

Based on observation, interview and record review the facility failed to ensure freedom of movement was not restricted for 1 of 1 residents (R15) whose wheelchair was locked during mealtime in the dining room. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had mild cognitive impairment and diagnoses of multiple sclerosis (a neurological disease that causes impaired walking and weakness the arms and legs), dementia with behavioral disturbance, and anxiety. R15 required total assistance with transfers, did not walk and was independent with wheelchair mobility. R15's nursing and provider orders lacked indication R15 had orders for restraints or to restrict movement when in the wheelchair. R15's care plan revised 8/12/24, indicated R15 had an alteration in socialization and at times can be disruptive during activities. Interventions included staff supervision when in an activity with R13 and encouragement to sit separately from R13. R13's annual MDS dated [DATE], indicated R13 had cognitive impairment and had diagnoses of dementia and diabetes. An observation on 10/28/24 at 5:09 p.m., R15 was sitting in their wheelchair in the dining room. Nursing assistant (NA)-A locked R15 wheelchair on the left side and stated I'm going to leave the wheelchair locked. NA-A then moved a bedside table in front of R15 in preparation for dinner. NA-A and NA-B were delivering trays and assisting residents in the dining room. R13 was seated at a table behind and to the left of R15. At 5:13 p.m., NA-A brought R15's dinner tray and placed it in front of him. R15's left wheel remained locked. R15 started eating dinner. At 5:40, registered nurse (RN)-C entered and cleared R15's dinner tray and R15 remained seated at the bedside table. AT 5:47 p.m., R15 attempted to wheel back away from the bedside table and only the right side of the wheelchair moved and R15 stopped trying to move. RN-C then moved the bedside table away from R15 however did not unlock the left wheel. R15 again attempted to self-propel the wheelchair and was only able to wheel the right side. R15 was only able to move in a circle pivoting on the left wheel, as that wheel was still locked. At 5:49 p.m. R15 started to self-propel the wheelchair and again rolled in part of a circle. AT 5:51 p.m., R15 again rolled in a circle pivoting on the left wheel. NA-A and NA-B were in the dining room removing trays of other residents and assisting some back to their rooms. At 6:12 p.m., NA-B went to move R15 out of the middle of the room and stated oh, not going anywhere with that locked as they unlocked R15's left wheel break. At 6:15 p.m., R15 started self-propelling out of the dining room. When interviewed on 10/28/24 at 6:19 p.m., NA-B verified R15's left wheelchair wheel was locked. NA-B further stated the break was placed to help keep R15 and R13 separated during dining. NA-B stated R15 and R13 had previous physical altercations and locking R15's wheelchair prevented R15 from rolling over to R13'stable . NA- further stated R15 wonders in his chair and locking the break made sure they were separated. When interviewed on 10/29/24 at 2:39 p.m., NA-C stated R15's wheelchair should not be locked. NA-C stated R15 wouldn't know how to unlock the breaks and having them locked would be a restraint. When interviewed on 10/29/24 at 2:47 p.m., RN- C stated R15 was alert to self and was independent with wheelchair mobility. R15 had a history of being intrusive to other residents and required redirection to stay away from R13. RN-C stated staff did not lock or unlock their chair as R15 liked to move throughout the building. RN-C believed R15 did not know how to lock or unlock his wheelchair due to dementia. When interviewed on 10/31/24 at 10:06 a.m., RN-B stated staff remained in the dining room to supervise meals and residents should be able to move around how they would like to. Furthermore, wheelchair breaks should not be locked if the residents could not unlock them. If locking them was to prevent movement, it would be considered a restraint. RN-C wasn't sure if R15 could unlock their wheelchair. R15 liked to self-propel around the facility in the wheelchair and locking the breaks would be a detriment to R15. When interviewed on 10/3124 at 10:23 a.m., the Director of Nursing (DON) stated wheelchair breaks should not be locked to prevent movement of residents. DON verified that would be considered a restraint if the resident was not able to lock and unlock the breaks themselves. The facility document titled Combined Federal and State [NAME] of rights dated 2019 , directed staff to treat the residents with respect and dignity to ensure freedom from physical restraints imposed for convenience and not required to treat a medical condition.

Based on observation, interview and document review, the facility failed to ensure a risk assessment and a water management program was developed and maintained to help reduce the risk of Legionnaire's Disease (Legionella) bacterial growth and subsequent contamination in the facility's water supply and/or storage. These findings had potential to affect all 34 residents, staff and visitors within the nursing home. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website titled Legionella.Prevention and Control, dated 03/25/21, revealed, The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella.Key Elements.Seven key elements of a Legionella water management program are to. Establish a water management program team. Describe the building water systems using text and flow diagrams. Identify areas where Legionella could grow and spread. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met. Make sure the program is running as designed (verification) and is effective (validation).Document and communicate all the activities.Principles. In general, the principles of effective water management include.Maintaining water temperatures outside the ideal range for Legionella growth.Preventing water stagnation.Ensuring adequate disinfection.Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella.Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. During interview on 11/1/23 at 11:50 a.m., the maintenance director (MD) stated since the first floor is empty, I flush the first-floor toilets and open the faucets once a week. MD stated this task was not documented and was not able to provide documentation of a water management program upon request. During interview on 11/2/23 at 12:34 p.m., the administrator stated a water management program was not developed and verified a Legionella risk assessment had not been completed prior to 10/30/23. A facility water management program and Legionella risk assessment was requested and was not provided. Review of the policy titled Legionella Water Management Program dated 6/13/23, indicated Monarch Healthcare Management had developed and implemented water management programs in large or complex building water systems to reduce the risk of legionellosis. The policy interpretation and implementation, identified three key elements: * Each facility must conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. * Implementation of a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. * Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.

Based on observation, interview and document review the facility failed to ensure food was labeled with an expiration date. The facility also failed to ensure food was prepared in a clean and sanitary environment. In addition, the facility failed to ensure the dishwasher temperatures were logged daily, and the chemical sanitization solution was at the correct concentration to ensure proper sanitization to prevent foodborne illness. This had the potential to affect all 34 residents in the facility. Findings include: Food Storage During an initial kitchen observation on [DATE] at 12:31 p.m., the following items were observed in the main kitchen: Refrigerator: -two half dozen bags of hard-boiled eggs, dated [DATE]. Dry Storage: -canned peaches in a 1-quart plastic tub with no label or date to indicate when they were opened. -multiple individual ranch and French dressing packets with no expiration date. Freezer: -frozen sausage links in a plastic bag with no date to indicate when they were opened or when they expire. During an observation [DATE] at 9:45 a.m., the following items were observed: Dry Storage: -Five 6-pound (lb) cans of crushed pineapple and six 6 lb cans of diced pears with no expiration date. -Two bags of dried cheddar cheese mix and three bags of dried cream soup mix with no expiration date. -Two bags of refried pinto beans with an expiration date of ,d+[DATE]. During an interview on [DATE] at 9:45 a.m., the dietary manager (DM) stated food removed from their original containers should be labeled with a date to indicate when they were opened and/or when they expire to avoid serving expired food to residents and potentially causing foodborne illnesses. Food Served/Prepped in a Sanitary Environment During an observation on [DATE] at 9:28 a.m., in the main kitchen food prep area by the stove, the ceiling was noted to have multiple cracks and flaking ceiling material and paint spanning the entire area above the food prep counter with two large chunks broken off and balancing and propped above the duct work over the stove area. A vent in the duct above the stove and near the food prep area was also coated around the edges and blades with black, fur-like dirt. The DM stated the vent should have been cleaned and the ceiling should be repaired to avoid contaminating food. During an observation on [DATE] at 9:28 a.m., six dozen muffins were cooling on the food prep counter. The ceiling above them remained cracked and peeling, with large pieces balanced on top of the duct work. During an interview on [DATE] at 10:09 a.m., the maintenance director (MTD) stated he was unaware of the pealing and cracked ceiling in the kitchen food prep area, and upon inspection agreed it would be a concern for possible food contamination. The MTD also stated the vents above the food prep area were supposed to be cleaned at least monthly to ensure they don't have dirt buildup and also contaminate food. Dishwasher Review of the facility dishwasher and sanitation solution log dated October indicated the dishwasher temperatures and sanitation solutions were tested 12 times out of the 52 times they should have been tested between [DATE] and [DATE] (two times per day). The log also indicated the following results: [DATE], PM -Dish PPM (sanitation parts per million) 0 -Wash temp:115 -Rinse temp:120 [DATE], PM -Dish PPM: 0 -Wash temp:110 -Rinse temp:115 [DATE], PM -Dish PPM: 0 -Wash temp:115 -Rinse temp:120 [DATE], PM -Dish PPM: 100 -Wash temp:110 -Rinse temp:115 [DATE], AM -Dish PPM: 100 -Wash temp:116 -Rinse temp:124 During an interview on [DATE] at 12:55 p.m., the cook (CK) stated the dishwasher was a low-temp dishwasher and they used test strips to test the sanitation solution for proper concentration. The test strips for the spray sanitation solution had an expiration date of [DATE], and the dishwasher test strips had an expiration date of [DATE]. During an interview and observation on [DATE] at 12:55 p.m., the DM stated the dishwasher and sanitation solutions should have been checked and logged twice each day. The DM also verified the test strips were expired and should not have been used. The DM further stated there was no temperature requirement for the low-temp dishwasher, but it was preferred if the wash temp was over 120 degrees Fahrenheit (F) and the rinse temp was at least 124 degrees F. The DM then tested the dishwasher sanitization level using an expired test strip and the reading was 60 ppm. The DM stated he was unsure what the required PPM should be to ensure proper sanitization of the dishes. During an interview and observation on [DATE] at 9:39 a.m., the DM used a new, unexpired test strip to test the dishwasher ppm: the result was 25ppm. The DM again stated he did not know what the ppm was supposed to be to ensure proper sanitization of the dishes. During an interview on [DATE] at 12:18 p.m., the dishwasher sanitization company representative (ELR) arrived at the facility to inspect the dishwasher and sanitization solutions. The ELR stated the test strip should have read between ,d+[DATE] ppm to ensure proper sanitization. The ELR further stated the wash temp should be over 115 degrees F and combined with the proper ppm, would ensure the dishes were sanitized properly. The ELR also stated he believed staff were not testing the sanitization solution at the proper intervals, causing low readings and educated them on how to test the solution accurately. During an interview on [DATE] at 1:55 p.m., the administrator stated she would have expected to have been notified if there were any concerns related to the dishwasher and/or sanitizing solution and was unaware of any problems. The facility Food Receiving and Storage policy dated ,d+[DATE], indicated staff were to maintain clean food storage areas at all times. Dry foods removed from their original packaging and stored in bins were to be labeled and dated with a use by date. All foods stored in the refrigerator and freezer were also to be labeled with a use by date. The facility Sanitization policy dated ,d+[DATE], indicated all kitchens were to be kept clean, free from litter and rubbish and all counters, shelves and equipment was to be kept clean, maintained in good repair and free from breaks, corrosions, open seams, cracks and chipped areas. Low-temperature dishwashers (chemical sanitization) was to have a wash temperature of 120 degrees F and a final rinse with 50ppm hypocholorite (chlorine) for at least 10 seconds.

Based on observation, interview and document review the facility failed to report to the provider timely, and appropriately respond to, significantly high blood pressure after a medication change for one of one resident (R2) reviewed for quality of care. Findings include: The Mayo Clinic article, What is a Hypertensive Crisis, dated 8/3/22, defined a hypertensive (high blood pressure) emergency as blood pressure higher than 180 millimeters of mercurcy (mm Hg)/120 mm Hg which requires emergency medical help. The Mayo Clinic further indicated untreated, high blood pressure increases the risk of heart attack, stroke and other serious health problems. The American Heart Association article, Why High Blood Pressure is a Silent Killer, dated 5/31/23, indicated that most of the time, there are no physical symptoms of high blood pressure, and it is known as the silent killer. The American Heart Association indicates ignoring high blood pressure and waiting for symptoms to alert that something is wrong is taking a dangerous chance with your life. R2's Minimum Data Set (MDS), dated [DATE], indicated R2 was cognitively intact and required extensive assist with most activities of daily living but was able to eat and use his wheelchair for locomotion independently. R2's Medical Diagnoses list, dated 1/18/23, indicated R2 was admitted to the facility with a primary diagnosis of acute on chronic kidney failure and had a secondary diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following a cerebral infarction (stroke). R2's physician orders indicated R2 had an order for amlodipine (used to treat high blood pressure) 10 milligrams (mg) daily, dated 1/20/23 and hydralazine (also used to treat high blood pressure) 25 mg three times a day, dated 10/23/23. The order lacked blood pressure parameters on when to notify the physcian. R2's care plan and treament record also lacked blood pressure parameters on when to notify the physcian. R2's blood pressure list in the electronic medical record (EMR) indicated R2 had the following blood pressures: 173/103 on 10/24/23, 165/104 on 10/27/23, 185/137 and 166/104 on 10/28/23, 183/119 on 10/29/23, 163/107 on 10/30/23, 194/106 on 10/31/23 and 177/107 on 11/1/23. During an interview on 10/23/23 at 6:02 p.m., R2 stated he was often dizzy when he stood up and went outside to smoke multiple times a day. During an interview on 11/1/23 at 10:35 a.m., registered nurse (RN)-A stated she would notify the provider if a resident's blood pressure was over 180. RN-A stated she did not notify the provider yesterday when R2 had a blood pressure of 194/106 but had notified the provider this morning for the first time due to R2's blood pressure of 177/107. During an interview on 11/1/23 at 12:27 p.m., nurse practitioner (NP)-A stated she had increased R2's Hydralazine from 25mg two times a day to 3 times a day on 10/23/23. The NP stated she was not concerned about R2's high blood pressure because he was not having any symptoms. NP-A failed to indicate what symptoms should be monitored for signs of hypertension. NP-A stated R2 was good at letting staff know if he wasn't feeling well but was unaware that he had been feeling dizzy. During an interview on 11/2/23 at 9:09 a.m., the consulting pharmacist (CP) confirmed that R2's blood pressure increased after increasing his Hydralazine, stating this concerned her because hydralazine could cause rebound hypertension. The CP stated she would have been concerned with R2's blood pressure readings and would have reached out to the provider right away regardless if R2 was experiencing physical symptoms or not. The CP stated she would definitely consider adding another blood pressure medication and would continue to closely monitor R2's blood pressure until it was stable to prevent it from impacting R2's renal function and cardiovascular status. The CP stated, the providers need to make some changes or closely monitor this patient (R2). During an interview on 11/2/23 at 12:25 p.m., the director of nursing DON stated she would have expected the staff to reach out to the provider with R2's high blood pressure reading or at least reach out to the provider to ask for parameters of when to be notified of abnormal blood pressure readings. The DON stated she had reached out to the medical director on 11/1/23 who had discontinued R2's blood pressure checks and had recommended no changes to his medication despite his ongoing elevated blood pressure. The DON further stated she had received a fax from the CP that morning (at approximately 10:00 a.m.) concerned about R2's high blood pressure, which suggested to taper off R2's hydralazine and start an angiotensin-converting-enzyme inhibitor (ACE inhibitors, a class of medication used primarily for the treatment of high blood pressure and heart failure) due to the CP's concerns of significantly high blood pressures. A facility policy on vital signs and provider notification was requested but not provided. A facility policy, undated titled Change in Resident Condition or Status indicated the facility will promptly notify the physician or healthcare provider of a change in the resident's medical condition or status.

Based on observation, interview and document review the facility failed to reassess a newly incontinent resident after foley catheter removal for a toileting program for one of one resident (R5) reviewed for bowel and bladder. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was admitted to the facility on [DATE], did not have a catheter in place and was not on a toileting program. R5's significant change MDS dated [DATE], indicated R5 was cognitively intact, now had a foley catheter and was not on a toileting program. R5's Bladder Evaluations on 8/18/23 and 9/6/23, both indicated R5 was continent on most occasions but rarely incontinent due to impaired mobility and that R5 was an assist of 1 with toileting. R5's Foley Catheter Evaluation, dated 9/6/23, indicated resident continues with need for a foley catheter. R5's Admission/Initial Data Collection, dated 8/11/23, indicated R5 was both always continent and occasionally incontinent of bladder. R5's progress note, dated 8/18/23, indicated R5 was sent to the emergency department for pain in his lower back, and bright red blood in his urine. A foley catheter was placed at the hospital on 8/20/23. A Urology After Visit Summary (AVS) note, dated 9/8/23, indicated R5's catheter was removed at the urology clinic 9/8/23. R5's care plan, dated 8/15/23, indicated R5 had an alteration in elimination as evidenced by indwelling foley catheter due to blood clot causing urinary retention. Resident has a history of hematuria and a diagnosis of benign prostatic hyperplasia (also called prostate enlargement, is a noncancerous increase in size of the prostate gland). Interventions included assist of 1 with toileting, monitoring foley output and change foley as ordered. R5's electronic medical record lacked evidence R5's bladder status was reassessed after foley catheter removal on 9/8/23. During an interview on 11/1/23 at 9:05 a.m., R5 stated his biggest concern was for his need for incontinent briefs, stating he was continent of bladder prior to admission to the facility. R5 stated he could sense the urge to urinate but felt he was always leaking urine and had to change his brief about five times a day. During an interview on 10/1/23 at 10:43 a.m., registered nurse (RN)-A stated there were no residents currently on a toileting program that she was aware of. However, RN-A stated staff were to check on R5 and ask if needed to use the toilet or have a brief change due to him being incontinent lately. During an interview on 11/2/23 at 8:50 a.m., nursing assistant (NA)-A stated staff checked on R5 to make sure he was clean and dry. NA stated R5 was not on a regimented toileting schedule and R5 would let staff know when he was wet. During an interview on 11/2/23 at 12:30 p.m., the director of nursing (DON) stated bowel and bladder assessments should be done within three days of admission and with significant changes. The DON confirmed R5 was not on a toileting program. The DON further stated it would be expected for a new bowel and bladder assessment to be completed when a foley catheter was removed. The DON stated R5 was recently started on a diuretic (also known as a water pill which increase the flow of urine) and could possibly benefit from a toileting program and should be assessed for a toileting program. A facility policy on bowel and bladder assessments was requested but not received.

Based on interview and document review the facility failed to ensure an allegation of resident-to-resident (R134,R135) abuse was reported to the state agency (SA) within two hours. Findings include: A Nursing Home Incident Report (NHIR) dated 7/14/23 at 12:13 p.m., indicated at 7:45 a.m., R135 entered the dining room using a four-wheeled walker. R135 approached R134 who was sitting at a table and drinking coffee and shouted, You're not suppose to be sitting here, get your ass up. R134 replied Yes, I am. R135 then intentionally pushed his walked into R134's leg. Review of facility Verification of Investigation undated, also indicated the incident occurred on 7/14/23 at 7:45 a.m. During an interview on 11/2/23 at 12:53 p.m., the director of nursing (DON) stated all allegations of abuse were to be reported to the SA within two hours but stated she was not involved in the investigation related to R134 and R135. During an interview on 11/2/23 at 1:52 p.m., the administrator stated allegations of abuse were to be reported to management immediately and then reported to the SA within two hours. The administrator stated she did not recall why the allegation of abuse between R134 and R135 was not reported within two hours but that we try to adhere to that as closely as we can. The facility Abuse Prevention/Vulnerable Adult policy dated 8/2023, indicated abuse was the willful infliction of injury and defined willful as an individual who acted deliberately, not that they intended to inflict injury or harm. The policy also indicated resident-to-resident abuse was to be reported to the SA. The policy further indicated suspected abuse shall be reported to the SA not later than two hours after forming the suspicion of abuse.

Based on observation, interview and document review the facility failed to provide a shower and accommodate a specific shower day for one of one resident (R6) who was refused showers. The facility further failed to assess why the resident was repeatedly refused his shower. Findings include: R6's quarterly Minimum Data Set (MDS), dated [DATE], indicated R6 was cognitively intact and admitted to the facility on [DATE]. R6's MDS further indicated he was independent with most activities of daily living (ADLs) and required moderate assistance with bathing. R6's Medical Diagnoses List, dated 12/9/21, indicated R6 had several medical diagnoses including dementia, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and squamous cell carcinoma of skin (cancer that occurs in the outermost part of the epidermis [skin surface] known as squamous cells.) R6's care plan, dated 12/10/21, indicated R6 had potential for alteration in skin integrity related not liking to bathe or shower. The care plan, dated 6/21/22, instructed staff to continue to encourage, reapproach and reeducate R6 on the importance of weekly showers. The care plan lacked approaches to encourage R6 to shower. R6's Interdisciplinary Team (IDT) Note, dated 9/21/23, indicated R6 was refusing showers but lacked approaches that have been used to encourage R6 to shower or approaches that have been successful. R6's electronic medical record (EMR) lacked an assessment of why R6 was continuing to refuse his showers and lacked evidence of documented approaches that work with R6 or have not work with R6 to encourage showers. R6's progress notes indicated R6 had refused his weekly shower six times in the past 10 weeks on 8/21/23, 9/4/23, 9/25/23, 10/2/23, 10/9/23, and 10/16/23. A progress note dated 10/2/23 indicated R6 had refused his shower because his shower day was Friday. During an interview and observation on 10/30/23 at 1:53 p.m., R6 stated he would rather have a shower on Fridays, so he is clean before the weekend. Multiple signs hanging in R6's room indicated his shower day was Mondays. R6 hair and clothes appeared disheveled and dirty. During an interview on 11/2/23 at 9:28 a.m., R6 stated he would take a shower if it was on Fridays and that he had told a few of the girls around here but it had not changed from Mondays. During an interview on 10/1/23 at 10:43 a.m., registered nurse (RN)-A confirmed R6 did refuse his shower most of the time and sometimes we just let him or we keep asking him. During an interview on 11/2/23 at 8:50 a.m., nursing assistant (NA)-A stated she heard from other staff that R6 refused his shower a lot. She was unsure if he had asked for a different day but stated staff should offer a different day to him if he was refusing. During an interview on 11/2/23 at 9:04 a.m., social services (SS)-A stated that the nurses usually assessed for shower day preferences with a resident upon admission. SS-A stated they had not attempted to change R6's shower day after his continued refusal but could try stating she was unsure if it would decrease his refusals as they had not yet tried to offer a different day, stating anything to help him get a shower. During an interview on 11/2/23 at 12:30 p.m., the director of nursing (DON) stated staff should reassess a resident for bathing preferences if they are frequently refusing showers and should be assessed for why they are refusing. The DON stated refusals should be discussed, and assessed, at care conferences and those discussions should be documented in an interdisciplinary team note (IDT) note. The DON further stated she would have expected staff to let her, or the assistant director of nursing know if a resident preferred a different shower day and the change would be made. The DON further stated she would expect the nurses to ensure the showers are getting offered and completed. A facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities Policy, dated 3/31/23, indicated staff across all shifts should provide person-centered care and services that honor and support each resident's preferences and choices to carry out ADLs.

Based on observation, interview and document review the facility failed to comprehensively assess, develop and implement activities for one of one resident (R10) reviewed who had a decline in condition. Finding include: R10's admission MDS dated [DATE], indicated R10 admitted to the facility on [DATE] with diagnoses of amputation (surgical removal of part of the body, such as an arm or leg), anemia (a condition in which the blood doesn't have enough healthy red blood cells), hypertension, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), diabetes, dementia, and anxiety. R10's significant change Minimum Data Set (MDS) dated [DATE], indicated R10 had moderate cognitive impairment and had enrolled in hospice. R10's Preference for Customary Routine and Activities indicated listening to music, keep up with the news, do things with groups of people, go outside to get fresh air, and participation in religious services was listed as very important to her. R10's quarterly MDS dated [DATE], indicated R10 had severe cognitive impairment, needed setup with transfers and needed assistance with oral hygiene and dressing. The MDS section Preference for Customary Routine and Activities was not completed. R10's activities care plan dated 4/27/23, indicated Resident is independent with activity choices. She enjoys dancing, singing, being with her siblings [she is a twin], quilting, talking on the phone, and going out for dinner. She is of Catholic faith. She is not interested in much being here. She is eager to leave. R10's care plan goal indicated, Resident will express satisfaction through positive statements. R10's activities care plan included two interventions. The first intervention dated 4/27/23 indicated, Invite her to Catholic services on Tuesdays and, the second intervention dated 7/20/23, indicated Issue monthly activity calendar. Offer to assist as needed. The activities care plan lacked documentation about R10's change in condition and being signed onto hospice. The care plan focus, goals and interventions were not revised to reflect R10's cognitive decline, medical condition, or her enrollment into a hospice program. During observation on 10/30/23 at 12:58 p.m. staff brought R10's lunch tray, set up the meal and R10 didn't sit up in bed. At 1:24 p.m., R10 was laying down in bed, the lunch tray remained at bed side and resident had not eaten any of her meal. During observation on 10/30/23 at 1:51 p.m., R10 was laying in bed, calling out for help, her call light was at the end of the bed, not within reach. Later, at 3:19 p.m., R10 was observed sleeping in bed. During observation on 10/31/23 at 8:19 a.m., R10 was laying in bed in a hospital gown without staff interaction,with no TV, or music on in her room. During observation on 10/31/23 at 12:13 p.m., R10 was sleeping in bed wearing a hospital gown, with no TV, or music on in her room. During observation on 10/31/23 at 12:42 p.m., R10 was in bed, wearing a hospital gown, with no TV, or music on in her room During observation on 10/31/23 at 12:50 p.m., R10 was in bed sleeping wearing a hospital gown. R10 woke up when her name was called a second time, answered yes/no questions. R10's side of her room didn't have a TV and the drape dividing the room was pulled obstructing R10 view of the roommate's TV or the room window. During observation on 11/1/23 at 7:23 a.m., R10 was awake in bed, disoriented to time and place, and was only able to answer yes or no to questions. During this observation, no newspaper, magazines, books, or radio were noted in R10's room. During interview on 11/01/23 at 12:41 p.m., R10's daughter stated R10 enjoyed being with other people, liked to listen to music, listened to the news, liked to attend religious services and played bingo. R10's daughter stated, R10 was no longer able to use her cellular phone as a distraction. During interview on 11/2/23 at 8:57 a.m., the therapeutic recreation director (TRD) stated, upon admission all residents are assessed, asked about their preferences, a MDS assessment is done, and a care plan is developed. TRD stated, the care plans were reviewed quarterly and changed accordingly to reflect changes in condition or changes in residents' interests. TRD stated for the last two months, R10 had spent more time in her room, hasn't attended Catholic services and hasn't participated in activities R10 enjoyed before, and most recently refused to go to music on Halloween day. TRD stated, the staff continued to invite R10 to attend activities, offered books, trivia questions and TV guide. TRD stated, R10's refusal to participate in activities was not documented, therefore there was not documentation R10 was invited to attend to activities. TRD verified R10's activities care plan had not been updated to include significant cognitive and physical decline, as well as the lack of documentation of R10's enrollment on hospice on June 2023. During interview on 11/2/23 at 12:10 p.m., the director of nursing (DON) stated she expected the activity director to assess residents quarterly, with significant changes and reevaluate their interests, activities and update their care plans. The DON also stated, the care plans should include a variety of interventions and if a resident was enrolled on hospice, the activities care plan should incorporate the services provided by the hospice program. A facility policy on recreational activities was requested; however, none was received.

Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 8% with 2 errors out of 25 opportunities involving 1 of 6 residents (R38) who were observed during medication administration. Findings include: R38's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Blood sugar results were 424 2. Order for insulin [MEDICATION(S)] solution pen-injector 100 units/mL (milliliters) inject four units subcutaneously in the morning 3. Order for insulin [MEDICATION(S)] 100 units/mL inject four units subcutaneously before meals. During an observation on 6/22/22, at 9:35 a.m. registered nurse (RN)-A cleaned the tip of the insulin [MEDICATION(S)] injector pen with an alcohol wipe, applied the needle and primed the dial with one unit of insulin. RN-A then dialed up four units of insulin [MEDICATION(S)] as prescribed. RN-A then repeated the same process for the second type of insulin this time from the [MEDICATION(S)] injector pen: she cleaned the tip of the insulin pen with an alcohol wipe, applied the needle, dialed up one unit to prime the needle. RN-A then turned the dial to draw up four units as prescribed. RN-A then administered the insulin to R38. During an interview on 6/22/22, at 10:02 a.m. RN-A stated she was not aware the insulin pen needles to be primed with two units of insulin and then the prescribed dosage, so she only primed the needles with one unit. RN-A stated she had not seen insulin come out of the needle during priming to indicate it was primed fully. During an interview on 6/22/22, at 10:19 a.m. the consultant pharmacist (CP) stated insulin pen needles need to be primed with two to three units of insulin and then dial up the prescribed dosage of insulin. During an interview on 6/22/22, at 1:22 p.m. the director of nursing (DON) stated insulin pen needles need to be primed with two units of insulin and then dial up the insulin to ensure the resident received the correct insulin dose. Polaris Pharmacy Services document titled How to Give a Shot: Insulin Pens, undated, indicated to first dial up two units to prime the needle, and ensure at least a drop of insulin appears. Then dial up the prescribed dose of insulin.

Based on observation, interview, and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 residents (R38) reviewed for insulin administration using an insulin pen. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], was in progress. MHM (Monarch Health Management) Brief Interview for Mental Status (BIMS) form dated 6/20/2022, indicated R38 had severely impaired cognition. R38's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's care plan dated 6/23/22, indicated R38 had higher blood sugars since admission, and staff were directed to provide diabetes medication as ordered by the doctor. R38's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Blood sugar results were 424 2. Order for insulin [MEDICATION(S)] solution pen-injector 100 units/mL (milliliters) inject four units subcutaneously in the morning 3. Order for insulin [MEDICATION(S)] 100 units/mL inject four units subcutaneously before meals. During an observation on 6/22/22, at 9:35 a.m. registered nurse (RN)-A cleaned the tip of the insulin [MEDICATION(S)] injector pen with an alcohol wipe, applied the needle and primed the dial with one unit of insulin. RN-A then dialed up four units of insulin [MEDICATION(S)] as prescribed. RN-A repeated the same process for the second type of insulin from the [MEDICATION(S)] injector pen; she cleaned the tip of the insulin pen with an alcohol wipe, applied the needle and dialed up one unit to prime the needle. RN-A then turned the dial to draw up four units as prescribed. RN-A administered the insulin to R38. By priming the insulin pen needles with only one unit of insulin each, R38 was potentially shorted two units of insulin in total. During an interview on 6/22/22, at 10:02 a.m. RN-A stated she was not aware the insulin pen needles to be primed with two units of insulin and then the prescribed dosage, so she only primed the needles with one unit. RN-A stated she had not seen insulin come out of the needle during priming to indicate it was primed fully. During an interview on 6/22/22, at 10:05 a.m. RN-C stated insulin pen needles required two units of insulin to prime and then dial up the prescribed dosage to ensure the needle was primed fully. During an interview on 6/22/22, at 10:09 a.m. the nurse practitioner (NP) stated R38 had some high blood sugars, and she was in the process of adjusting the medication orders today. The NP stated she would expect the prescribed dosage of insulin to be administered. During an interview on 6/22/22, at 10:19 a.m. the consultant pharmacist (CP) stated insulin pen needles need to be primed with two to three units of insulin and then dial up the prescribed dosage of insulin. During an interview on 6/22/22, at 1:22 p.m. the director of nursing (DON) stated insulin pen needles need to be primed with two units of insulin and then dial up the prescribed insulin to ensure the resident received the correct insulin dose. Polaris Pharmacy Services document titled How to Give a Shot: Insulin Pens, undated, indicated to first dial up two units to prime the needle, and ensure at least a drop of insulin appears. Then dial up the prescribed dose of insulin.

Based on interview and document review, the facility failed to provide equipment necessary to accommodate a resident's individualized needs for 1 of 1 resident (R1) reviewed for bariatric needs. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 required extensive to total assistance with activities of daily living. Further, the MDS identified R1 had a functional limitation in range of motion to both sides of his upper and lower extremities. R1 used a wheelchair. R1's care plan dated 3/10/21, identified R1 had an alteration in mobility related to [CONDITION(S)]. Interventions included transfer R1 via a Maxi-Lift (fulf-body mechanical lift) with assistance of two staff. During an interview on 4/7/21, at 2:19 p.m. family member (FM)-A stated there was not proper equipment for nursing or therapy staff to assist R1 because he was a big man. FM-A stated the facility had not informed her they did not have the proper equipment to care for R1 and family would had transferred R1 out of the facility had they known. FM-A stated R1 was perfectly capable of using the toilet and R1 struggled because he had to lay in bed to have a bowel movement, in a pad, and staff did not come right away to clean him. FM-A stated prior to admission to the facility R1 was able to get to the toilet, was continent of bowel and used a condom catheter. FM-A stated as R1 was unable to sit on the toilet at the facility due to lack of equipment and R1 had started to have problems with his bowels. FM-A stated facility's lack of proper equipment was a concern and lead to R1 not getting the walking and tolerance she had expected him to achieve during the short-stay. Review of R1's medical record revealed: --A Physical Therapy Treatment Encounter Note dated 3/11/21, at 3:23 p.m. indicated the maintenance director was to find a Sara lift (sit-to-stand mechanical lift) with appropriate weight support from another facility so R1 may begin standing with assist. -A Physical Therapy Treatment Encounter Note dated 3/16/21, at 2:00 p.m. indicated staff attempted to get R1 into a power wheelchair with a Hoyer lift, however, they were unable to locate appropriate sling for safety. -A Physical Therapy Treatment Encounter Note dated 3/17/21, at 2:38 p.m. indicated a physical therapy assistant (PTA) and certified occupational therapy assistant (COTA) provided co treatment and the bariatric Sara lift was not holding a charge, per maintenance notes. -A late entry nursing note dated 4/3/21, at 11:30 a.m. indicated R1 had requested to get up into his wheelchair using a Hoyer lift (mechanical lift) so he could have lunch with FM-A. R1 was updated he had not been up in a wheelchair throughout his stay. R1 was made aware it was a safety issue and the writer would speak with therapy regarding getting R1 up in his chair in the morning. During interview, on 4/7/21, at 11:21 a.m. licensed practical nurse (LPN)-A stated R1 required total staff assistance with all activities of daily living. During interview on 4/7/21, at 11:34 a.m. NA-B stated she worked with R1 a few times, and R1 required total assistance with all the cares and was incontinent of bowel. NA-B stated she never saw R1 out of the bed, even with a Hoyer lift. NA-B stated R1 did not like how the Hoyer lift made him feel. NA-B stated R1 verbalized he was angry as he wanted to get out of bed on 4/4/21, when FM-A came to the facility. NA-B confirmed R1 was told by staff they were unable get him out of bed because therapy had not approved due to safety. During interview on 4/8/21, at 8:27 a.m. when asked how R1's toileting was completed, RN-A stated nursing depended on therapy to set the pace on how to transfer R1. RN-A stated after therapy assessed R1 they would let nursing know how to transfer him to the commode. RN-A stated R1 would let staff know when he needed to be changed after he had a bowel movement. RN-A stated the facility had a Hoyer lift, however, R1 experienced spasms which was a safety issue. RN-A stated therapy was not comfortable using a Hoyer lift and did not want to put nursing or therapy in danger. When asked if proper equipment had been obtained to accommodate R1's condition, RN-A stated the last communication she had with maintenance staff they were unable to get a Sara lift. During interview on 4/7/21, at 3:08 p.m. the director of therapy (DOT) stated initially when R1 was admitted to the facility an available Sara lift did not match R1's weight safely. The DOT stated he thought the facility rented a bariatric Sara lift which supported R1's weight. The DOT stated there was also a Hoyer lift which supported R1's weight and safe for R1 to use. The DOT stated R1 believed all facility lifts were not supportive of his weight and it was demoralizing. The DOT stated R1 refused getting out of bed on many occasions because he did not want to use a Hoyer lift. The DOT stated challenges of working with R1 included not having parallel bars in the therapy room which supported R1. The DOT stated therapy had a conversation with the social service director that R1 was getting to a point they needed to do a referral to another facility with state-of-the-art equipment. The DOT acknowledged he was not aware the Sara lift had battery issues as documented by a therapy staff. During interview on 4/7/21, at 1:45 p.m. PT stated R1 used a Hoyer lift to get up but did not like it because he was scrunched up. PT stated when a Hoyer lift was not used to assist R1 sitting up, four staff were required for safety. PT stated there was a Hoyer lift available which accommodated R1's weight, but R1 refused to use it. During a follow up interview on 4/8/21, at 9:14 a.m. PT stated they never used the Sara Lift to transfer R1 out of the bed, but instead used a walker. PT stated prior to admission, R1 was not using a lift for transfers which was probably a good thing. PT stated the biggest problem with R1 was getting him to sit on the edge of his bed, hence, they requested R1 to use the Hoyer. PT stated R1 did not like the Hoyer lift as it made him feel uncomfortable. PT confirmed, If there would have been a Sara lift, it would have been used to practice standing longer with two people instead of us pulling extra people to do the sit to stand with walker. During interview on 4/8/21, at 8:06 a.m. the director of social services (DSS) stated a referral to another facility who had proper equipment did not occur because R1 and FM-A did not request it. The DSS stated My understanding was we had the equipment [Sara lift]. I was not aware the battery was dying, and this would not be something they would have discussed with me. During interview on 4/8/21, at 8:48 a.m. the DON stated she thought facility maintenance staff rented a Sara lift as the facility's Sara lift needed battery replaced. The DON stated she was not aware there was not proper equipment at the facility to provide care for R1. The DON stated a Sara lift was available at the facility, but she was not able to respond when asked why the lift was not being used for therapy and while toileting R1. During interview on 4/8/21, at 10:30 a.m. a former maintenance employee, stated on 3/12/21, he went to work for a sister facility. He stated he brought a Sara lift from a sister facility to the facility R1 resided in. He stated he checked the Sara lift battery function when he brought it to the facility and verbalized it was working at that time. He stated no one from therapy or nursing communicated there was a concern with the Sara lift he had delivered. He stated assumed the equipment was properly functioning. Facility policy titled Activities of Daily Living (ADLs), Supporting revised 3/18, directed, Residents will provided with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Based on interview and document review, the facility failed to offer and/or provide bathing, as preferred, for 1 of 1 resident (R1), who was dependent upon staff for bathing assistance, reviewed for choices. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified it was somewhat important for R1 to choose between a tub bath, shower, bed bath or sponge bath. R1 required extensive to total assistance with bathing. R1's care plan dated 4/5/21, identified R1 had a self-care deficit related to incomplete [CONDITION(S)] and nerve damage. Interventions included providing extensive assistance with bathing. Review of R1's medical record revealed: -An undated facility bath schedule revealed R1 was scheduled baths on Tuesday mornings. -Review of the interdisciplinary notes and Weekly Skin Inspections indicated R1 had not received, or been offered, a tub bath, shower, bed bath or sponge bath on 3/9/21, and 3/23/21. R1 received bed baths on 3/16/21, and 3/30/21. R1 recieved a shower on 4/6/21. During an interview on 4/7/21, at 2:19 p.m. family member (FM)-A stated throughout R1's stay at the facility from 3/4/21, through 4/6/21, he only received a shower on 4/6/21, which was a few hours before he discharged from the facility. FM-A stated R1 told her staff gave him bed baths because he was exposed to COVID-19 and was quarantined. FM-A stated R1 told her he did not feel clean, and smelled like himself. FM-A stated she visited the facility and R1 smelled. FM-A stated she brought forward concerns to staff related to R1's skin, ears and nails not being kept clean. FM-A stated she assisted R1 trim his nails During interview on 4/7/21, at 11:05 a.m. nursing assistant (NA)-A stated she assisted R1 with cares during his short-stay. NA-A stated R1 required assistance with all activities of daily living. During interview, on 4/7/21, at 11:21 a.m. licensed practical nurse (LPN)-A stated R1 required total assistance with all activities of daily living. During interview on 4/7/21, at 11:34 a.m. NA-B stated she worked with R1 a few times and R1 required total assistance with all cares and was incontinent of bowel. During interview on 4/7/21, at 12:14 p.m. RN-A stated R1 was given bed baths because he was on back-to-back quarantines due to COVID-19 exposure. RN-A stated R1's quarentine ended on 3/23/21, and R1's scheduled bath day were on Tuesday mornings. RN-A verified R1 was not offered, nor received, a tub bath, shower, or bed bath on 3/9/21 and 3/23/21. RN-A stated R1 received bed baths on 3/16/21 and 3/30/21. RN-A confirmed R1 should had received a showers on 3/23/21 and 3/30/21. During interview on 4/8/21, at 8:48 a.m. the DON stated she had started educating staff on making sure they provided residents with showers once they were done with COVID-19 quarantine the next day. Facility policy title Activities of Daily Living (ADLs), dated 3/18, directed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and document review, the facility failed to ensure timely incontinence cares were provided for 1 of 2 residents (R4) whom were incontinent and dependent upon staff for incontinence care. Findings include: R4's face sheet printed 3/18/21, indicated R4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had a severe cognitive impairment, required extensive - total assistance for most activities of daily living (ADLs), and was always incontinent of bladder and bowel. R4's ADL Care Area Assessment (CAA) dated 5/12/20, indicated R4 required extensive assistance for toileting and personal hygiene. R4's urinary incontinence CAA dated 5/12/20, indicated R4 was at risk for skin breakdown, had urinary incontinence and should be toileted every two - three hours and as needed. R4 had a goal of remaining clean, dry, and free of incontinence related skin breakdown. R4's care plan dated 5/6/20, indicated R4 was at risk for alteration in skin integrity related to functional incontinence and needed turn and reposition every two hours and while lying & while sitting. R4's care plan did not indicate R4 needed to be checked and changed every two hours and as needed. R4's nursing assistant (NA) task sheet provided 3/17/21, indicated R4 utilized a brief, and directed staff to check and change R4's brief every two hours and as needed. R4 was observed during personal care on 3/18/21, at 6:45 a.m. and was incontinent. R4 was dressed and repositioned in bed by NA-E. R4 was transferred to her Broda chair at 7:30 a.m. and remained in her Broda chair without being checked and changed for incontinence until 11:35 a.m., a total of 4 hours and 50 minutes. When interviewed on 3/18/21, at 11:10 a.m. NA-B verified R4 should be checked every two hours and changed if needed. NA-B stated she thought R4 was changed by NA-C and DON at 8:30 a.m. because she overheard, they were going into R4's room. NA-B stated they typically check and change her every 3 hours maybe. When interviewed on 3/18/21, at 11:19 a.m. NA-D verified R4 was supposed to be checked and toileted every two hours. NA-D stated she thought NA-B had toileted R4 and stated, it should have been at 10:30 a.m., I haven't changed her though. At 11:22 a.m. NA-D asked NA-B if she had checked or changed R4. NA-B stated she had not. NA-D and NA-B stated in order to know when residents have or have not received cares, Basically we just talk to each other. When interviewed on 3/18/21, at 11:30 a.m. licensed practical nurse (LPN)-B verified R4 was supposed to be toileted every two hours and stated, It's on their care sheets, they should know, they should be checking and changing her every 2 hours. LPN-B stated, it's hard and further stated she was training a new nurse today but normally she was on the floor checking to make sure toileting for R4 and other residents was being completed. At 11:35 a.m. NA-D and NA-B laid R4 down in her bed and changed her brief. R4 had been incontinent of urine and had dried feces on her perineal area. When interviewed on 3/18/21, at 12:00 p.m. RN-C verified R4 should be changed every two hours due to skin impairment. RN-C stated the NA's do not have room assignments and rely on verbal communication about resident cares. When interviewed on 3/18/21, at 3:16 p.m. the DON verified R4 was supposed to be checked and changed every 2 hours and as needed and stated, there is no reason she wasn't toileted, she should have been. The facilities activities of daily living (ADL) policy dated 2018, indicated appropriate care will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care.

Based on interview and document review, the facility failed to ensure the administrator and State agency (SA) were notified within 24 hours of allegations of neglect, for 1 of 3 residents (R2) reviewed for allegations of abuse, neglect and injuries of unknown origin. Findings include: R2's face sheet printed 3/19/21 indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan dated 1/16/19, indicated R2 required a maxi lift and assist of two for transfers. R2's progress note dated 8/8/20, at 6:59 p.m. indicated, CNA summoned writer to resident's room. Maxi lift tipped over during res transfers. Hoyer tipped over after res was lowered to wheelchair, no injuries observed. Maxi lift did not hit resident. Resident denies pain as result of incident. will continue to monitor. R2's progress note dated 8/10/20, at 3:42 p.m. indicated, Resident had maxi lift tip over during a transfer from bed to wheelchair. Staff and agency aide were working together on the transfer and thought the legs of the lift were left closed while the resident was push/pulled into place over his wheelchair causing it to tip onto the ground with him attached to it. Neither resident nor staff were injured in the incident. DON, MD, and resident's sister informed of the incident. Staff will be reeducated on use of the maxi lift. Incident Review and Analysis dated 8/11/20, indicated, Staff misused lift equipment (not opening the legs of the Invacare maxi lift during a transfer) and pulled on resident while suspended in sling causing center of gravity to shift and machine to tip onto the ground. Resident was lowered to wheelchair without injury despite still being connected to the lift as it fell . Staff responsible for correct use of equipment, resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Education provided for all nursing department staff. Aides who failed to operate equipment correctly reassessed for competency in use of mechanical lift skill. R2's Pain Evaluation dated 8/11/20, indicated R2 reported occasional, moderate pain within last 5 days and was given Tylenol 1000 mg (milligrams) each morning which was effective. When interviewed on 3/18/21, at 8:15 a.m. the director of nursing (DON) verified the incident had occurred and stated, there was an issue with the legs of the lifts. DON stated they facility had considered reporting the incident but did not as R2 did not sustain an injury. Even though R2 had received tylenol daily for five days after the incident occurred. When interviewed on 3/18/21, at 12:23 p.m. nursing assistant (NA)-E verified on 8/8/20, while she and NA-G transferred R2, the hoyer lift tipped over onto R2. NA-E stated she believed the incident was caused by an operator error and she felt NA-G didn't really know how to maneuver [R2] so she explained the use of the lift to NA-G during the transfer. NA-E stated NA-G was operating the lift and failed to open the legs of the lift, causing R2's weight to shift and the lift 'tipped over towards R2, causing him to fall into his wheelchair. NA-E stated she did not think the lift landed on R2 and she did not believe R2 hit anything hard. NA-E stated NA-G went to get licensed practical nurse (LPN)-C to assess R2 who was not complaining of pain at that time and appeared to be in shock. NA-E stated the facility assessed us every so often for lift use before the incident. NA-E verified she received post-incident reeducation on lift use. When interviewed on 3/18/21, at 1:34 p.m. LPN-C verified the incident had occurred and stated he did not remember any further details other than what he had written in the progress notes. When interviewed on 3/18/21, at 3:16 p.m. DON asked to verify if the concerns with R2 surrounded the incident not being reported and verified she understood the lack of education and operational error on behalf of staff precipitating the incident. A facility form titled, Mechanical Lifts, indicated NA-E received education on use of lifts including a demonstration on 12/17/19, and education on Mechanical Lifts/Sit-to Stand lifts including a demonstration on 8/7/20, one day before the event occurred. There was no indication that NA-G had received any education on lifts prior to the incident occurring. Facility document titled Mechanical Lifts, dated 8/9/20, indicated NA-E and NA-G were reeducated on the use of lifts on this date. Facility policy titled Abuse Prohibition/Vulnerable Adult Plan, dated 7/5/19, directed Incidents that must be reported to MDH include: Avoidable Accidents: Means that an accident occurred because the facility failed to includes, but not limited to, incidents in which the facility or facility staff failed to identify hazards, properly assess and evaluate for the risk of an accident; facility failed to eliminate hazards, if possible, and implement interventions to reduce risk, including adequate supervision; and/or monitor for effectiveness of interventions and modify when necessary.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure ulcer (PU) interventions for 2 of 4 resident (R4 and R1) identified whom had current pressure ulcers. Findings include: R4's face sheet printed 3/18/21, indicated R4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had a severe cognitive impairment, used a wheelchair, required extensive assistance for bed mobility and was dependent for transfers. The MDS further indicated R4 had one unstageable pressure ulcer and at risk for pressure ulcers. R4's pressure ulcer and injury Care Area Assessment (CAA) dated 5/12/20, indicated R4 was at increased risk of skin breakdown. The CAA called for toileting and repositioning every two - three hours, skin checks and peri-care with morning and evening caress, and weekly skin audit. R4's had a Braden Scale (scale to determine risk level for PU development) dated, 2/4/20 that indicated no risk for pressure ulcers, and on 2/10/20 the scale was updated and identified R4 was at mild risk and required assistance with turning and repositioning. R4 remained at mild risk and pressure relieving mattress, wheelchair cushion and Broda chair (tilt-in-space positioning chair) was identified as interventions. The Braden Scale on 1/21/21 identified R2 had increased to moderate risk for PU. There were no additional interventions were identified. The Treatment Administration Record (TAR), based on physicians orders, identified on 12/15/20, R4 had left heel skin prep twice a day and float heels in bed, twice a day for wound care. The TAR was updated on 12/29/20, clean wound with wound cleanser and skin prep, and cover with [MEDICATION(S)] (a breathable soft cloth) dressing. change as needed, donn (place on) [NAME] boots. TAR was updated on 1/13/21, administer oxycodone, 30 minutes before dressing change, and clean with wound cleanser or saline, pat dry and apply skin prep to peri wound skin, medi honey (honey-based gel wound dressing) to wound bed and cover with foam dressing. Change daily and as needed. R4's care plan was last updated 2/22/21, indicated R4 was at risk for alteration in skin integrity and directed staff to turn and reposition every two hours while lying and while sitting and as needed. R4's care plan did not indicate R4 had a current pressure ulcer or include interventions for the pressure ulcers, even though they had developed a PU on 11/14/2020. R4's nursing assistant (NA) task sheet provided 3/17/21, indicated R4 had a pressure wound on her left heel, needed a pillow under her calves while in her wheelchair, needed to wear Prevalon booties (boot used to keep pressure off the heel), float her heels (heel positioned so they do not have contact with a surface) and staff turned and reposition R4 every two hours. The Weekly Skin Inspection form, indicates skin evaluation to identify any abnormalities observed, and define site and description along with a comment section. The Weekly Skin Inspection form identified the following: 11/14/20, first identified a Pressure area to left heel. There was no description or characteristics identified as part of the weekly skin inspection form. 11/22/20, There was not any skin issue noted. 11/29/20, Left heel pressure area measuring approx. 2.5 centimeters (cm.) There was no indication if this area was open or other characteristics of the PU. 12/6/20, was blank with nothing written. 12/13/20, indicated no new skin issues. 12/20/20, indicated bruise on arms and hands, delicate skin, bruises featly. There was no mention of the PU. 1/3/21, indicated pressure ulcer on left heel, treatment is ongoing. 1/10/21, indicated left heel no drainage, no s/s of infection no redness no foul odor. 1/17/21, indicated pressure ulcer on left heel, old bruises on arms, legs, skin easily bruises. Open areas on rear lower right leg. 1/24/21, indicated pressure ulcer measuring approx 1.5 length 1.5 width with scant tan colored drainage no odor, no s/s of infection dressing applied, heel protector in place. 1/31/21, indicated wound on right heel, treatment ongoing. 2/7/21, indicated redness noted underneath the right breast 2/14/21, indicated dry scaly skin on BLE (bilateral lower extremities), old bruises on arms bilaterally, wound on left heel, treatment ongoing. 2/21/21, indicated wound to left heel, periwound with no drainage, odor, no redness surrounding wound, to skin, area cleansed with wound cleanser, skin prep to periwound, medi-honey foam dressing. boots maintained for reduction of pressure. 2/28/21, indicated pressure ulcer on left heel, treatment ongoing. scaly dry skin easily bruises. 3/7/21, indicated left heel dressing dry and intact. 3/14/21, indicated skin tear on right thigh healed, pressure ulcer on left heel healing. The facility Weekly Pressure Wound Evaluation Forms identified the following: 1/6/21, indicated wound length 1.5 cm - width 1.8 cm - no depth indicated. There was no wound stage identified. 2/2/21, indicated length 1.0 cm- width 1.5 cm- depth 0.2 cm. The wound was unstageable. 2/9/21, indicated length 1.5 cm - width 1.5 cm - no depth indicated. The wound was unstageable. 2/16/21, indicated length 1.0 cm - width 1.5 cm - Depth 1.0 cm. The wound was unstageable. 2/23/21, indicated length 1.0 cm- width 2.0 cm- depth 1.5 cm. The wound was unstageable. 3/2/21, indicated length 1.0 cm- width 1.0 cm - depth 0.5 cm- The wound was unstageable. 3/9/21, indicated length 1.0 cm- width 1.0 cm- depth 0.5 cm. The wound was unstageable. 3/16/21, indicated length 1.0 cm- width 1.5 cm- depth 1.0 cm. The wound was unstageable with 25% granulation (fibrous connective tissue and blood vessels), 75% slough (dead skin tissue), and scant (minimal) serosanguinous (thin) drainage. and noted to have increased in size and depth today and was painful to R4. There is no indication the facility completed consistent monitoring of R4's PU that included pressure ulcer staging, characteristics of the PU that included skin color, moisture, temperature, integrity, progress toward healing, and if infection or pain were present. These characteristics and monitoring were not identified consistently even though R4's developed their PU on 11/14/2020. When interviewed on 3/18/21, at 3:16 p.m. the director of nursing DON verified wound evaluations should be done weekly and RN-C should have been documenting R4's weekly wound notes. In addition: R4 was observed on 3/18/21, at 6:45 a.m. nursing assistant (NA)-E removed positioning pillows from below R4's feet, changed R4's brief, dressed, and repositioned R4. NA-E did not replace the pillows below R4's feet and R4's heels were resting on the mattress. On 3/18/21, at 7:30 a.m. DON and NA-C transferred R4 out of bed and into her Broda chair and wheeled R4 into the dining room for breakfast. Staff did not place pillows under R4's calves to float heels per the direction in the NAR task sheet. R4's Lt heel pressure ulcer was resting directly on the foot rest of the Broda chair. On 3/18/21, at 7:47 a.m. R4 was sitting in dining room and had not been repositioned. R4 had no pillows under calves while in her wheelchair. When interviewed on 3/18/21, at 8:00 a.m. NA-C verified R4 was supposed to have pillows under her feet to float heels. NA-C verified pillows were not there when she and the DON transferred R4 at 7:30 a.m. NA-C stated she was not aware R4 was to have pillows under calves when she was in her wheelchair. During continuous observation R4 was observed on 3/18/21 from 8:23 a.m. sitting in the dining room, with her Lt heel pressure ulcer that was resting directly on the padding of the Broda chair. She continued to remain in this same positron with her heels touching the chair until 11:35 a.m. when R4 was flayed down in bed, a total of 3 hours and 12 minutes without relieving pressure on her buttock or PU on her heel. When interviewed on 3/18/21, at 11:10 a.m. NA-B verified R4 had a pressure ulcer on her heel. R4 verified pillows were not in place under R4's calves and that R4 was supposed to be repositioned every two hours. When interviewed on 3/18/21, at 11:19 a.m. NA-D verified R4 had a pressure ulcer on her heel. R4 verified pillows were not in place under R4's calves and that R4 was supposed to be repositioned every two hours but she had not done that for her. When interviewed on 3/18/21, at 11:30 a.m. licensed practical nurse (LPN)-B verified R4 was to be repositioned every two hours and stated, they can reposition her in the Broda chair or lay her down in the bed. LPN-B further stated, it's hard and further stated she was training a new nurse today but normally she was on the floor checking to make sure care for R4 and other residents was being completed. At 11:35 a.m. NA-D and NA-B laid R4 down in her bed and changed her brief. No pillows were placed under R4's feel when laid in bed. At 11:46 a.m. RN-C examined R4's skin and measured the wound on her left heel. During care, R4 stated her heel hurt and was quite painful at times. RN-C completed wound care and lowered R4's bed. NA-D and NA-B asked RN-C if R4 could get up for lunch. RN-C stated, no, I think she needs to offload for a while. Even though R4 had a PU on her heel, her heels remained in contact with the bed and were not placed on a pillow to alleviate pressure to her heels. When interviewed on 3/18/21, at 12:00 p.m. RN-C verified R4 was not able to reposition herself and should be repositioned every two hours. RN-C verified R4 should have her heels floated and stated she would expect a pillow under her calves when she is in her wheelchair and while in bed. At 12:10 p.m. and 2:49 p.m. R4 was lying in bed and had no pillow in place to float her heel, and her heels were resting directly on the bed. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R2 had spinal stenosis (narrowing of the spinal column), fusion of the spine, and moderately impaired cognition. R1 was totally dependent upon staff for transfers and required extensive assistance with bed mobility. R1's pressure ulcer/injury Care Area Assessment (CAA) dated 3/8/21, indicated R1 was at risk for skin breakdown due to incontinence and reduced mobility. The CAA further indicated R1 needed to be repositioned every two to three hours. R1's care plan dated 3/1/21, indicated R1 was at risk for skin breakdown due to fragile skin. R1's care plan lacked interventions related to repositioning. R1's Nursing Assistant Task Sheet dated 3/1/21, indicated R1 needed assistance with bed mobility once per shift and as needed. R1's physical therapy note dated 3/2/21, indicated R1 was dependent on staff for all mobility. R1's Braden score (skin assessment) dated 3/2/21, was 19-23 which indicated R1 was at no risk for pressure injury and was able to make major and frequent position changes independently, even though R1's MDS indicated on 3/6/21 he was total dependence. R1's tissue tolerance observation (laying) dated 3/2/21, indicated R1 turned and repositioned himself in bed, at night, although R1 was noted to need extensive assistance with bed mobility in the MDS. R1's tissue tolerance observation (sitting) dated 3/3/21, indicated R1 had dry and intact skin, was not independently mobile, was high risk for pressure injury, and needed to be turned and repositioned frequently. R1's tissue tolerance evaluation and skin risk factors dated 3/3/21, indicated R1's Braden score was actually 10-14 which indicated a moderate/high risk for pressure injury and frequently sat. R1 needed be adjusted and moved frequently to avoid a pressure ulcers. R1's weekly skin assessment dated [DATE], indicated R1's skin integrity was noted as clean, dry, and intact and did not indicate any pressure injuries were present. R1's integrated wound care note dated 3/9/21, indicated a consultation was requested for skin concerns which included a coccyx wound. R1's treatment recommendations included the application of dressings to bony prominence's, application of [MEDICATION(S)] cream daily and as needed, monitoring pressure/offloading to the elbows and heels, and turning and repositioning was to be conducted, per facility protocol. R1's Treatment Assessment Record (TAR) dated 3/10/21, did not identify the dressing or application of [MEDICATION(S)] cream. R1's face sheet printed 3/18/21, indicated R1 was discharged to the hospital on 3/11/21 at 2:30 p.m. R1's hospital admission note dated 3/11/21, indicated R1 had presented to the emergency room from the facility with had stage 1 pressure areas to bilateral heels and coccyx present on admission. There was no mention of bilateral heel PU at the nursing home. R1's hospital note dated 3/11/21, indicated left buttocks pressure ulcer POA (present on admission). R1's hospital note dated 3/15/21, indicated R1 had a stage 1 pressure ulcer present which the hospital was treating with barrier cream and offloading weight with repositioning. During an interview on 3/17/21, at 1:32 p.m. family member (FM)-B verified R1 had some redness on coccyx upon admission to the facility and was unsure how it was being treated. During an interview on 3/17/21, at 1:50 p.m. a hospital registered nurse, (RN)-A stated R1 was alert to himself, but did not know he was in the hospital. RN-A stated R1's coccyx and heels were red, however, had intact skin. During an interview on 3/17/21, at 2:28 p.m. FM-C stated when she visited R1 in the emergency room , his heels appeared extremely red and inflamed. During an interview on 3/18/21, at 11:00 a.m. licensed practical nurse (LPN)-A initially stated R1 had a repositioning plan, however, subsequently verbalized R1 may not be on a repositioning plan. LPN-A explained R1 shifted around when in bed. LPN-A was unable to recall if R1 had any skin issues. During an interview on 3/18/21, at 12:15 p.m. NA-A stated she had not noticed any issues with R1's skin. NA-A stated everyone is on a reposition plan, and believed R1 was as well. NA-A stated R1 liked to be in a recliner most of the day. NA-A stated staff reclined R1, or helped him shift and adjust but did not specify a frequency. During an interview on 3/18/21, at 1:06 p.m. registered nurse (RN)-B stated R1 needed to be repositioned every two hours. RN-A verified R1 did not have the strength to reposition independently. RN-B stated R1 could slide around some, but was unable to independently off-load pressure. RN-B verified she previously checked R1's sacral area (lower back) as R1 sat most of the time. RN-B stated a barrier cream was used with incontinence cares, but did not recall a coccyx dressing. RN-B was unable to recall any skin issues with R1's heels. During an interview on 3/18/21, at 4:45 p.m. the director of nursing (DON) stated once an assessment was completed, or once something happened that indicated a need for interventions, the care plan should be updated immediately. The DON stated she or the nurse managers were responsible to update care plans. The DON stated the Nursing Assessment Task Sheet was populated from the care plan. The DON stated she did not understand why R1 did not have repositioning interventions in-place as identified through assessments. The Pressure Ulcer/Injury Risk assessment dated 2017, directed a resident-centered care plan and interventions must be based on recognized standards of care and the care plan must be modified as the resident condition changes or if current interventions are deemed inadequate.

Based on observation, interview and document review, the facility failed to monitor, re-evaluate, modify interventions/treatment and notify the physician of a worsening pressure ulcer for 1 of 2 residents (R1) who developed a stage III pressure ulcer (Full thickness skin 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. May include undermining and tunneling) at the facility. The failure resulted in actual harm for R1 who required hospitalization [MEDICAL CONDITION] related to an infected pressure ulcer and debridement (a procedure that involves thoroughly cleaning the wound and removing infected, and necrotic or dead tissue) reviewed for pressure ulcers. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment and required extensive to total assistance for all activities of daily living including transfers, bed mobility, getting dressed, toilet use and eating. The MDS identified R1 was always incontinent of bladder and bowel. The MDS identified R1 did not have a pressure ulcer, but had a surgical wound, was at risk to develop pressure ulcers, did not reject cares but had physical behavioral symptoms towards others including hitting. Pressure reducing devices had been applied for the chair and the bed. Further, the MDS identified R1 [DIAGNOSES REDACTED]. R1's pressure ulcer/injury Care Area assessment dated [DATE], identified R1 was at risk for skin breakdown due to but not limited to: recent admission to facility, incontinent of bowel et bladder, cognitive impairments, dependent on staff for all repositioning and bed mobility. The CAA directed staff to reposition R1 every two to three hours and as needed, to complete weekly skin assessments by nurse and the nurses were to update the physician with any signs and symptoms of skin breakdown R1's care plan dated 11/24/20, identified R1 admitted to the facility 11/24/20, had a deficit in self-care and mobility and directed staff to assist. The care plan did not identify R1 was at risk for pressure ulcers, however on the undated nursing assistant care sheet staff were directed to turn and reposition, R1 every two hours. R1's medical record was reviewed and included the following entries related to skin: -Braden Scale Score Risks (a tool used to predict pressure ulcer risk), conducted on 11/25/20, 12/2/20 and 12/9/20, all identified a score of 18 (15-18: mild risk for breakdown). -MHM Weekly Skin Inspection, Admission assessment, dated 11/29/20, identified no new skin issues noted. Documentation lacked information to identify what the skin had looked like to determine what, no new issues referenced. -Progress Note dated 12/3/20, indicated Resident has a wound on his coccyx that writer found today, cleansed and dried and wound dressings applied. There was no indication an assessment of the PU had been completed, to identify PU stage, size, depth, drainage, odor or pain. -MHM Weekly Pressure Wound Evaluation, dated 12/4/20, identified R1 had a stage III wound in the sacrum area which measured 3.0 centimeters (cm) by 3.5 cm by 1.0 cm. and the description of wound was it had an ample amount of slough (Non-viable yellow, tan, gray, green or brown tissues, usually moist, can be soft, stringy, and mucinous in texture) and eschar (Dead or devitalized tissue that is hard or soft in texture, usually black, brown, or tan in color and may appear like a scab). The interventions implemented included air mattress to be delivered and per the assessment. The physician was contacted and treatment orders to cleanse, skin prep peri wound, silver alginate and apply a large foam dressing. The evaluation also identified, referral to dietary, referral to therapies, notifying the nurse manager/wound nurse and initiate weekly pressure wound evaluation. -MHM Weekly Skin Inspection dated 12/6/20, identified R1 had wound around his coccyx, however no description of the status of the wound was noted on the assessment. -December treatment administration record (TAR) revealed an order with start date 12/5/20, directed staff to Cleanse, skin prep periwound, silver Alginate, large foam dressing in the morning wound care. During further review of the TAR it was revealed from 12/5/20, through 12/10/20, R1's wound treatment had been signed off as completed however, the medical record lacked documentation of the status of the wound, whether drainage was present, status of the area surrounding the pressure ulcer, possible complications such as signs of increasing area or soft tissue infection and pain. -MHM Weekly Pressure Wound Evaluation, dated 12/11/20, identified R1 had a wound in the coccyx which measured 3.0 cm by 5.5 cm by 4.2 cm stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). The wound bed description was noted to have yellow slough, with edge of blacked eschar; the amount of drainage was heavy brown, odor present, tunneling at deepest was (4.2 cm at 12:00); (2.0 cm at 1:00); (2.3 cm at 9:00); (3.0 cm at 11:00). In addition the wound edges were black, rolled, intact and there was pain associated with wound. -A nurse practitioner (NP) note dated 12/11/20, indicated R1 had been evaluated for an unspecified open wound in the buttock for a worsening wound on the sacrum. NP noted Today large amount of serosanguinous drainage which has foul odor to it. Tunneling today. Patient feels warm today to touch. The treatment plan by the NP was [MEDICATION NAME] 875/125 milligram (mg) give 1 tablet by mouth every 12 hours for 7 days and dressing for the coccyx wound was cleansed, skin prep to periwound, silver alginate and a large dressing. -A nursing change of condition progress note dated 12/12/20 at 9:38 a.m. identified R1 had decreased blood pressure, increased heart rate and increased respirations. Vital signs were listed as B/P 88/48, Pulse 107, and respirations 22. Background: Resident has coccyx wound that is infected. NP assessed wound yesterday and new order for [MEDICATION NAME] initiated yesterday evening. The note also indicated the abnormal vital signs had been identified at 8:30 a.m. and the on-call provider was notified and gave an order to send R1 to the hospital. -A nursing note dated 12/14/20, at 10:34 a.m. indicated R1 had been admitted to the hospital related [MEDICAL CONDITION] from his coccyx wound and was undergoing surgical irrigation and debridement. On 12/21/20, at 8:57 a.m. R1 was observed lying in bed with the head of the bed at least 80 degrees. R1 was noted to be asleep and the breakfast tray was right in front of R1. -At 9:04 a.m. to 10:22 a.m. nursing assistant (NA)-A was observed go in and out of R1's room to encourage R1 to eat and also provided assistance to R1 with eating. -At 10:26 a.m. NA-A and NA-B were observed to provide R1 with incontinence cares and then turned and repositioned R1. During the observation, R1 was observed with a large clean dry and intact dressing on the coccyx area when NA's rolled R1 side to side. On 12/21/20, at 11:40 a.m. registered nurse (RN)-C (nurse manager) stated the wound assessment dated [DATE], had been completed by RN-B (nurse manager). RN-C stated she was not aware R1 had a pressure ulcer until 12/7/20. RN-C stated RN-B covered her floor while she had been out of the facility from 11/29-12/7/20. RN-C also stated R1 required total assistance and staff were supposed to report any skin concerns to the nurse to be assessed or anything that was not normal with the residents. On 12/21/20, at 11:37 a.m. nursing assistant (NA)-A stated she was not certain when the wound had started however, she had assisted the nurses, to patch it up a few times. NA-A also stated the wound got worse and (R1) was sent to the hospital. The nurse knew he had the wound because they were doing the patching up. We thought they were looking at it. On 12/21/20, at 12:08 p.m. RN-B nurse manager stated she first became aware of pressure ulcer on 12/4/20, when NA-B came and got her and stated they wanted her to see the wound. She measured the wound and got doctors orders and when she went to look at the admission form she noticed there was no wound noted. She then entered the measurements into the form because she assumed RN-A did not do a skin assessment and she had not asked the nurse who had done the assessment if resident had any wounds. At the time she assessed the wound, it was significant and she then got a treatment order for the wound to be done by the nurses daily. RN-B also stated the nurses were to monitor the wound progress and report to her or RN-C if there was concerns because they assess wounds weekly. RN-B then stated she had followed up with NA-B to find out if the skin concern had been reported to a nurse, and NA-B had stated he had reported to RN-A two other times prior to reporting the concern to her because she was next in line to report the concern to. RN-B stated it was possible R1 had developed the pressure wound in the facility care. RN-B then stated she had not asked when NA-B when he had seen the pressure wound first and when she spoke to him as their conversation was in passing during break and that's when NA-B told her he had told RN-A. RN-B stated as soon as she had assessed the wound she got the orders and the nurses were supposed to do the dressing change daily and during the wound treatment they were supposed to monitor the state of the wound and if there were any concerns they were to let her know or call the nurse practitioner. RN-B stated she did not hear any concerns about the wound until on 12/11/20, when she and the nurse practitioner had assessed the wound and found the wound had tunneling, had a foul smell, a lot of drainage and R1 felt warm. RN-B stated at that time the nurse practitioner started R1 on an antibiotic and treatment for [REDACTED]. RN-B acknowledged the nurses failed to monitor and update the provider to re-evaluate the treatment plan. -At 12:37 p.m. RN-B stated following the incident the facility was providing education to RN-A and all the other nurses. RN-A stated the NA's had not been trained also. During the interview the consultant nurse, RN-D stated all the rest of the training was going to be started and was not going to be delayed. The consultant RN stated the pressure ulcer should have been caught earlier because R1 required total assistance and this was going to be addressed immediately. On 12/21/20, at 1:08 p.m. the DON stated she had spoken to RN-A about some of the concerns with wound assessment, on going monitoring, re-evaluating interventions and updating the provider on the worsening of the wound. The DON stated she had started to provide education to the nurses and some had been completed on 12/17/20 and 12/18/20, however not all the nurses had received the training at the time. The DON also stated NA's training was not happening until 12/23/20. The consultant RN stated training for the NA's was going to be started then and was not going to wait. We will teach them as they come and the session will capture who is left. At 1:35 p.m. the DON stated her first recollection of the pressure ulcer was when RN-A had documented the wound had been found on 12/3/20. The DON stated she was made aware of the severity of the pressure ulcer after R1 was readmitted to the hospital by the hospital coordinator. The DON said, we dropped the ball on this one for sure. On 12/22/20, at 2:17 p.m. RN-A stated he was not aware of the pressure ulcer and did not remember anything being reported to him until 12/3/20. RN-A stated after he had seen the wound he had written a progress note and thought the nurse managers would follow up with the provider. RN-A acknowledged he did not know he was supposed to assess the wound at the time however he had cleaned the wound and applied a dressing on it. RN-A stated when he was doing the wound care on 12/3/20, after NA-B had reported to him, R1 did show signs and symptoms of pain as R1 was screaming but he was not sure if the pain was from the surgical hip or the pressure ulcer. RN-A also stated the wound looked reddish and pink at the time, no tunneling and was not that deep. The drainage was not smelling. RN-A stated since the incident he had received training from the DON. On 12/22/20, at 3:02 p.m. via telephone the NP stated she had been informed the nurse on the floor RN-D was concerned about the wound getting worse and wanted her to see it. The NP stated We went into the room myself and (RN-B) to assess the wound and I found on that Friday the wound had been tunneling for the past couple days. They had first noticed it on 12/4/20. At that time I wrote orders to start the packed dressing and an antibiotic for (R1). The NP stated she would have expected the staff to have called her in between the time the wound was identified and the date she saw it. The NP also stated If the nurses were seeing signs of an infection they were supposed to let her know to avoid worsening the wound which was the case and the wound now needed a different level of care. The NP further stated it was hard to say but there was a potential if R1 had been started on antibiotic sooner than 12/11/20, it would have prevented R1 being septic. The facility Skin Assessment and Wound Management dated July 2018, directed staff to perform routine skin inspections (with daily care), Nurses were to be notified if skin changes are identified and weekly skin inspection were to be completed by licensed staff. In addition, the policy directed staff when a new pressure ulcer was identified the following actions were to be taken: 1) Notify MD/Treatment Ordered 2) Notify resident representative 3) Complete education with resident/resident representative including risks & benefits 4) Initiate Weekly Pressure Wound Evaluation 5) Notify Nurse Manager/Wound Nurse 6) Complete Braden Scale 7) Complete Tissue Tolerance Observation (lying and sitting) 8) Complete Tissue Tolerance Evaluation 9) Referral to dietary, if appropriate 10) Referral to therapies, appropriate 11) Update Care Plan 12) Update resident care lists