Every finding on record at The Villas at Roseville

Based on interview and document review, the facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since January of 2020, which had the potential to affect all 54 residents who resided in the facility. Findings include: Qualifications for the Culinary Services Director (CSD) was requested however was not received. During the initial kitchen tour on 4/27/26 at 10:45 a.m., CSD stated she worked full time at the facility and there was also a registered dietician (RD) who worked one day a week but was available by phone for questions whenever needed. During a follow up interview on 4/30/26 at 10:40 a.m., the surveyor asked the CSD to see her certification and she stated she had recently enrolled in the certified dietary manager (CDM) program about a month ago and didn't have any other certification or training for food services. She had originally enrolled during COVID but didn't finish. During interview on 4/30/26 at 1:00 p.m., the administrator stated they have a registered dietician who worked at the facility once a week and was on call if they needed anything. They also have a CSD, who started working as the kitchen manager in January of 2020 and was currently enrolled in school for her CDM license. The administrator further stated she thought the CSD just had to be enrolled in the program in order for her to be qualified as the CSD. A facility policy regarding qualifications for dietary staff was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure freedom of movement was not restricted when a pillow was placed adjacent to the resident's body, underneath the fitted sheet which could not be removed easily by the resident for 1 of 1 resident (R44) reviewed for potential restraints.Findings include:R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 was dependent on staff for all activities of daily living (ADLs), transfers and mobility. R44's diagnoses included dementia and acquired absence of right leg below the knee.R44's care plan revised 4/30/26, identified R44 had impaired cognitive function/dementia or impaired thought processes, and was at risk for falls. The care plan further indicated R44 had alteration in mood and behavior and would put self on floor and crawl. The care plan instructed staff to keep bed in a low position and place a mat on the floor to allow resident to safely crawl.During observation on 4/27/26 at 12:56 p.m., nursing assistant (NA)-A and NA-B entered R44's room to transfer R44 into bed using a mechanical lift. Incontinent care was performed and a new brief placed. R44 was positioned in the middle of the bed, with the right side of the bed against the wall. NA-A lowered R44's bed to the lowest position, provided the call light, and placed a pillow along the left side of R44's torso underneath the fitted bottom sheet.During observation on 4/28/26 at 3:48 p.m., R44 was taken to his room to be transferred back to bed. After the transfer, NA-C placed a pillow along the left side of R44 under the fitted bottom sheet, bed lowered, and mat placed on floor.During interview on 4/28/26 at 3:59 p.m., NA-C stated R44's pillow was placed under the fitted sheet to prevent the pillow from falling out if R44 became agitated. NA-C did not think R44 could remove the pillow from under the sheet.During interview on 4/28/26 at 4:05 p.m., registered nurse (RN)-A stated R44 had fall intervention in place such as call light in reach, bed in the lowest position, and a mat on the floor. The mat was in place to prevent injury in case R44 would roll out of bed. RN-A stated pillows were used as positioning aids and should never be placed under the fitted sheet since that could restrain R44's movement.During interview on 4/29/26 at 11:49 a.m., RN-B stated pillows were used for position and should never be placed under the fitted sheet. RN-B stated if a resident could not easily remove a pillow and it prevented them from getting out of bed, it would be considered a restraint.During interview on 4/29/26 at 1:07 p.m., director of nursing (DON) expected resident pillows would not be placed under fitted sheets as that could be considered a restraint.A facility policy regarding restraints was requested but not provided.

Based on interview and document review, the facility failed to provide care conferences for 1 of 1 resident (R53) reviewed for care conferences. Findings include:R53's quarterly Minimum Data Set (MDS) dated [DATE], identified R53 was cognitively intact with diagnoses of traumatic brain injury (TBI) and seizure disorder.R53's electronic health record (EHR) lacked indication of care conferences since admission dated 8/20/25.R53's care plan dated 11/25/25, indicated R53 was a vulnerable adult, at risk for decreased cognitive and physical abilities related to diagnoses of TBI, depression, opioid dependence, legal blindness and dizziness.When interviewed on 4/27/26 at 1:07 p.m., R53 stated she didn't remember being invited or involved in any meetings about her care at the facility.When interviewed on 4/29/26 at 11:11 a.m., social service director (SS)-A confirmed the EMR lacked documentation of care conferences for R53. SS-A and social service designee (SS)-B were responsible for scheduling conferences. Information was sent to the inter-disciplinary team (IDT), resident, and their family/representatives. Furthermore, the expectation for care conferences was to have one within 48 hours of admission, quarterly and as needed.When interviewed on 4/30/26 at 9:49a.m., registered nurse (RN)-B stated care conferences were coordinated with the interdisciplinary team (IDT), resident and their family occurred within the first 48 hours of admission, quarterly and with any significant change in the resident's condition. This ensured individual needs of the resident were met. When interviewed on 4/30/26 at 2:45 p.m., the director of nursing (DON) stated resident care conferences were expected to be done within 48 hours of admission, quarterly, with significant changes and as needed. The importance of care conferences was to align cares with resident's needs, revisit concerns and follow up with the plan of care. An undated policy titled Care Planning-Interdisciplinary Team dated indicated comprehensive care plan was to be developed within 7 days. The IDT would make every effort would be made to have the resident and their family attend the care conferences.

Based on interview and document review, the facility failed to ensure recommended provider referral for ophthalmology care was followed up on for 1 of 1 resident (R21) reviewed for missed appointments. Findings include:R21's quarterly Minimum Data Set, dated [DATE], indicated R21 was cognitively intact, required setup or clean-up assistance to total dependence with most activities of daily living (ADLs), and substantial to maximal assistance with transfers and mobility. R21did not display rejection of care behaviors. R21's diagnoses included ataxia (a neurological condition causing lack of muscle coordination) and need for assistance with personal care.R21's provider visit note dated 1/20/26, indicated, Patient requested to speak to me regarding a small left [sic] tag underneath his left eye. The visit notes further indicated under orders placed today, Ophthalmology appt for skin tag under L eye and follow up summary, Yellowish colored skin tag below left eye. Will put in a referral for ophthalmology.R21's provider order dated 1/20/26, instructed, Ophthalmology appt for skin tag under L eye.During observation and interview on 4/29/26 at 11:06 a.m., R21 stated he remembered talking to the doctor about this (pointing to the approximately 1cm flesh colored raised area just under his left eye) and was told it was a skin tag and that they would look into getting it removed. R21 continued, But that never happened.During interview on 4/29/26 at 11:40 a.m., licensed practical nurse (LPN)-A stated all appointment referrals were handled by the medical records director (MRD).During interview on 4/30/26 at 10:45 a.m., registered nurse (RN)-B stated would expect all appointments to be scheduled timely for routine referrals within 30 days and within 24 hours if an urgent matter. RN-B stated the facility used) for in-house routine dental care and would find an external dental clinic for urgent care.During interview on 4/29/26 at 1:07 p.m., director of nursing (DON) stated MRD would be the one to make arrangements routine and non-routine appointment scheduling either through Health Drive (HD - an outside source for medical and dental support for long term care facilities) or an outside clinic. DON stated HD was used for routine dental, podiatry, and audiology appointments and any other services needed would be made through an outside clinic.During interview on 4/30/26 at 8:43 a.m., MRD stated she was responsible for making all arrangements for referrals to include scheduling the appointment and transportation to an external clinic if needed. MRD stated she had just seen R21's ophthalmology referral last week and had not made any arrangements yet. MRD could not explain why the ophthalmology referral was not seen back in January when originally ordered other than it must have been lost in the folders of paperwork around her office while she was attempting to reorganize.During follow up interview on 4/30/26 at 10:49 a.m., DON stated would expect appointment referrals to be made timely as ordered. DON stated R21should have had arrangements for ophthalmology appointment by now.During interview on 4/30/26 at 11:40 a.m., nurse practitioner (NP) stated would have expected appointment referrals to be followed up on timely. NP stated would expect staff to act on provider orders as soon as possible and would have expected R21 to have been seen by ophthalmology by now since that referral was placed in January.A facility policy on appointment scheduling or provider orders was requested but not provided.

Based on interview and document review, the facility failed to ensure coordination of mental health care services for 1 of 1 residents (R4) who had a referral to obtain psychiatrist services. Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact with diagnoses of borderline personality disorder, post-traumatic stress disorder and major depressive disorder.R4's provider order dated 3/11/26, indicated psychiatry to see R4 next week, social work to get in touch with case manager to expedite transfer to a setting that would support her mental health, also seeking changes to her psychiatric medications due to her increased anxiety, and R4 requested female caregivers. R4's care plan dated 4/21/26, indicated R4 was at risk for altered behavior related to trauma. R4 required a referral for psychiatry services, collaboration with social services and psychiatry improved social connections and minimize symptomology.R4's psychiatry provider notes were requested however were not provided. When interviewed on 4/27/26 at 2:50 p.m., R4 stated her post-traumatic stress disorder, anxiety and depression made her feel that she wasn't heard and understood by staff. R4 used an IPAD to speak with a grief therapist but was not offered any additional therapy or mental health support. When interviewed on 4/29/26 at 11:26 a.m., nursing assistant (NA)-C stated if a resident was having behaviors, stress-based outbursts, the care was to use therapeutic communication, acknowledge their concerns, respond calmly, and explain the situation without judgement, meet the resident where they are at.When interviewed on 4/30/26 at 9:46 a.m., registered nurse (RN)-B stated provider orders were to be followed. If referrals made, it was important, so all caregivers were on the same page and were able to provide cohesive care. RN-B stated she was unaware of the referral for psychiatrist for R4.When interviewed on 4/30/26 at 9:63a.m., service director (SS)-A stated the process to obtain an appointment for psychiatric services were offered on admission, as ordered and as needed. The social services department was responsible for scheduling appointments with the outside psychiatrist team. SS-A stated R4's order was not completed because social services was unaware of the order. When interviewed on 4/30/26 at 1:46 p.m., director of nursing (DON) The DON staff were expected to place provider orders into the medical record as soon as possible. The expectation was to have outside psychiatric appointments set up per orders. It was important to provide/arrange psychological counselling services to meet the needs of the resident, what was driving behaviors, provide proper care, it was a collaborative approach to the behaviors. DON further stated they were not sure why R4's order was missed and it was unknown if the R4 accepted or declined the additional services and would look into it. No further information was provided. A policy titled Trauma Care dated 2/24/23 indicated the inter-disciplinary team monitor effects of approaches to ensure they are implemented and care plans updated.

Based on interview and document review, the facility failed to ensure emergency dental referral for infected tooth was followed up on for 1 of 1 resident (R21) reviewed for dental services.Findings include:R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated R21 was cognitively intact, required setup or clean-up assistance with oral hygiene, and substantial to maximal assistance with transfers and mobility. R21did not display rejection of care behaviors. R21's diagnoses included ataxia (a neurological condition causing lack of muscle coordination) and need for assistance with personal care.R21's provider visit note dated 11/11/25, Patient currently reports severe toothache described as horrible, with examination revealing left upper molar decay with partial breakage and erythema around gum line. The visit notes further indicated under orders placed today, Referral to dentist for definitive treatment of infected left upper tooth and follow up summary, Escalate priority for dental appointment scheduling.R21's provider orders dated 11/12/25, instructed, Referral to dentist for treatment of infected left upper tooth.During interview on 4/29/26 at 11:06 a.m., R21 stated he had a tooth infection a while ago and was supposed to see a dentist but never did. R21 stated he was using a special mouthwash which seemed to help.During interview on 4/29/26 at 11:40 a.m., licensed practical nurse (LPN)-A stated all appointment referrals were handled by the medical records director (MRD).During interview on 4/30/26 at 10:45 a.m., registered nurse (RN)-B stated would expect all appointments to be scheduled timely for routine referrals within 30 days and within 24 hours if an urgent matter. RN-B stated the facility used an outside provider source for medical and dental support for in-house routine dental care and would find an external dental clinic for urgent care. During interview on 4/29/26 at 1:07 p.m., director of nursing (DON) stated MRD would be the one to make arrangements routine and non-routine appoint scheduling either through outside provider source for medical and dental support for in-house routine dental care or an outside clinic. DON stated the outside provider source for medical and dental support for in-house routine dental care was used for routine dental, podiatry, and audiology appointments.During interview on 4/30/26 at 8:43 a.m., MRD stated she was responsible for making all arrangements for referrals that included scheduling the appointment and transportation to an external clinic if needed. MRD stated residents would be seen as needed when the outside provider source for medical and dental support came to the facility or for routine appointments such as annual or bi-annual dental care. MRD stated she thought she had set up an appointment for R21 to see them, but R21 refused the care. MRD was unable to locate any evidence that R21 was ever seen by outside provider source for medical and dental support or was on a list to be seen them, or any documented refusal of care. MRD stated if there was an emergency need, she would try to get them sent out to an outside clinic for treatment. MRD stated had worked at this facility for four years and could not recall ever making urgent dental arrangements and did not know if there was a specific procedure to do so. MRD stated the outside provider source for dental support was at the facility on 11/11/25, 2/17/26, 3/17/26, and 4/14/26. MRD confirmed R21 was not listed as being seen at any of those visits. During phone interview on 4/30/26 at 9:32 a.m., the appointment coordinator for the outside provider source for dental support stated R21 was not enrolled in for dental care and had only elected podiatry services with them.During follow up interview on 4/30/26 at 9:47 a.m., MRD stated she was mixed up earlier and that R21 was only signed up for podiatry care and would not have been scheduled for dental care. MRD stated R21 needed an external dental clinic of his choice and an appointment should have been arranged back in November when originally scheduled and could not explain why it was missed.During follow up interview on 4/30/26 at 10:49 a.m., DON stated would expect appointment referrals to be made timely as ordered. DON stated R21should have been seen by a dentist by now. During interview on 4/30/26 at 11:40 a.m., nurse practitioner (NP) expected appointment referrals to be followed up on timely. NP stated they would expect staff to act on provider orders as soon as possible and would have expected R21 to have been seen by a dentist back in November as ordered.A facility policy on appointment scheduling or provider orders was requested but not provided.

Based on interview and record review the facility failed to develop a comprehensive care plan for one of four residents (R1) reviewed when R1's care plan did not include her foley catheter daily care needs. Findings include: R1's admission record indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery. R1's additional diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity due to excess calories, peripheral vascular disease, difficulty walking, and cognitive communication deficit. R1 was discharged from the facility on 9/18/25. R1's bladder evaluation completed on 7/23/25 indicated R1 had urge incontinence of her bladder. R1's care plan initiated on 7/24/25 indicated R1 had alterations in elimination due to impaired mobility and metabolic acidosis but did not indicate in the interventions that R1 had a foley catheter. R1's minimum data set (MDS) completed on 7/30/25 indicated R1 was frequently incontinent of her bowel and bladder, triggering a care area assessment (CAH). R1's provider note dated 8/1/25 indicated R1 was to start an indwelling 16 French foley catheter with a 10-cc balloon would be started to promote wound healing with a diagnosis of Decubitus Ulcer Bilateral Buttocks. R1's CAH dated 8/2/25 indicated R1 had urinary incontinence and an indwelling catheter. R1's provider order dated 8/6/25 indicated R1 would start an indwelling catheter with a 10-cc balloon to promote further healing of her wounds. R1's provider order dated 8/7/25 indicated R1 would change the foley catheter to a 16 French foley catheter with a 10-cc balloon would be started to promote further healing of her wounds. R1's brief interview for mental status (BIMS) assessment completed on 9/3/25 indicated a score of 14, which indicated R1 was cognitively intact. R1's discharge MDS completed on 9/18/25 indicated R1 was frequently incontinent of her bladder. R1's urinary continence was not rated due to R1 having a catheter. During an interview on 10/14/25 at 8:45 a.m., registered nurse (RN)-B stated the director of nursing (DON), and the nurse manager will create a resident's care plan. If the DON or nurse manager was not in the building, nurses can make change to a resident's care plan. During an interview on 10/14/25 at 10:01 a.m., scheduling coordinator (SC)-A stated the assistant director of nursing (ADON), and the DON is responsible for creating and maintaining a resident's care plan. During an interview on 10/14/25 at 10:37 a.m., licensed practical nurse (LPN)-I stated the nurse manager is responsible for creating and maintaining a resident's care plan. During an interview on 10/14/25 at 10:40 a.m., RN-J stated the DON is responsible for creating and maintaining a resident's care plan. During an interview on 10/14/25 at 11:01 a.m., LPN-H stated the nurse manager is responsible for creating and maintaining a resident's care plan. During an interview on 10/14/25 at 11:25 a.m., DON-A stated the nurse manager initiates the care plan. DON-A stated she would expect a resident's foley catheter to be documented in a resident's care plan. During an email correspondence on 10/14/25 at 1:38 p.m., the administrator stated the facility did not have a policy on foley catheters. The facility's Care Planning policy revised on 11/2024 indicated the care plan would be used in developing a resident's daily care routines and would be utilized by staff personnel for the purposes of providing care or services to the resident.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 2 of 2 residents (R40) reviewed for pressure ulcers, and (R15) reviewed for psychotropic medications. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated 10/2024, identified the intent of section M, Skin Conditions, documented the risk, presence, appearance, and change of pressure ulcers and injuries. Further, it was important to recognize and evaluate each resident's risk factors and identify and evaluate all areas at risk of constant pressure and a complete assessment of skin was essential to an effective pressure ulcer prevention and skin treatment program. The RAI manual directed staff to review the medical record including skin care flow sheets, or other skin tracking forms, nurses' notes, and pressure ulcer injury risk assessments, speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident, examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings, devices were present. Additionally, pressure ulcer staging was determined by the deepest anatomical stage and if a stageable pressure ulcer had been classified at a higher numerical stage than what was observed it should continue to be classified at the higher numerical stage and pressure ulcers do not heal in a reverse sequence. Stage three and four pressure ulcers fill with granulation tissue that is never as strong as the tissue that was lost and hence is more prone to future breakdown. Clinical standards do not support reverse staging or back staging as a way to document healing as it does not accurately characterize what is occurring physiologically as the ulcer heals. Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest numerical stage and a previously closed pressure ulcer that opens again should be reported at its worst stage, unless currently presenting at a higher stage or unstageable. The State Operations Manual (SOM) provided guidance on pressure ulcer staging that defined the following pressure ulcers/injuries: Stage 1 Pressure Injury is intact skin with localized redness. Stage 2 Pressure ulcer is partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open or ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (new connective tissue), slough, (non-viable tissue) and eschar (dead tissue) are not present. Stage 3 Pressure Ulcer is a full thickness loss of skin in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and or eschar may be visible but does not obscure the depth of tissue loss. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/injury. Stage 4 Pressure Ulcer is a full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/pressure injury. Unstageable Pressure Ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. Deep Tissue Pressure Injury (DTPI) is intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. R40's annual MDS dated [DATE], indicated R40 had one or more unhealed pressure ulcers/injuries, 0 stage 1 pressure injuries, one stage 2 pressure ulcer/injury, 0 stage 3 pressure ulcers, 0 stage 4 pressure ulcers, 0 unstageable pressure ulcers with slough or eschar, and 0 unstageable DTPI's. The MDS directed staff to report based on the highest stage of existing ulcers/injuries at their worst; and do not reverse stage. R40's progress notes dated 1/1/25, indicated, R40's pressure ulcer 2 right Achilles-improving. R40's Skin and Wound Evaluation form dated 12/26/24, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 2.9 centimeters (CM) long by 2.1 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 70% granulation tissue, 10% slough, and 20% eschar. R40's Skin and Wound Evaluation form dated 1/1/25, indicated R40 had an in-house acquired stage two pressure ulcer to the right Achilles that had been present for one week measuring 4.1 (cm) long by 2.7 cm wide. Further, the note indicated the wound bed contained 80% granulation tissue, 20% slough, and no eschar. R40's Integrated Wound Care note dated 12/26/24, indicated R40 had a right heel unstageable pressure ulcer. Further, the wound was 2 cm long by 4.7 cm wide, by 0.4 cm deep and contained 10% slough, 20% necrotic tissue, and 70% granulation tissue. R40's Integrated Wound Care note dated 1/2/24, indicated R40 had a right heel unstageable pressure ulcer. Further, the wound was 2.5 cm long, by 4 cm wide by 0.4 cm deep and contained 20% slough, and 80% granulation. During interview on 3/10/25 at 5:18 p.m., R40 stated her heel was painful and pointed to her right heel and stated that was why it was elevated. R40's wheelchair foot rest on the right was pulled down and R40 had a sock on with her right heel resting directly on the foot rest. R40 stated she had a sore on her heel and stated staff usually changed the dressing in the morning, but stated it was changed mid morning on 3/10/25. During interview on 3/12/25 at 12:14 p.m., registered nurse (RN)-A stated he was the MDS coordinator and scheduled the MDS assessments, completed assessments, and made sure everyone completed their sections. RN-A stated he completed sections A, E, G, H, GG, I, J, K, L, M, N, O, P, and S. RN-A stated they were supposed to schedule skin assessments each week and when looking for skin assessments, looked at the Forms in the electronic medical record (EMR). RN-A stated R40 had an Annual MDS on 1/3/25, and when completing the MDS, looked for a skin assessment for 1/3/25, or around that date. RN-A stated they used to have a wound care manager who documented notes directly into progress notes but did not locate notes related to staging during the window for the MDS after reviewing the progress notes. RN-A stated he could not recall where he went to find the stage of the wound and knew it had been a stage two pressure ulcer and stated he used the RAI manual for guidance. RN-A stated according to the RAI manual, a stage two pressure ulcer was the first layer of skin removed and could also be a blister. RN-A further stated a stage two pressure ulcer did not contain slough, eschar, or granulation tissue. RN-A stated he viewed the Wound Evaluation form 1/1/25, for the MDS and stated the form indicated R40 had a stage two pressure ulcer but was staged incorrectly because a stage two pressure ulcer did not have granulation tissue, or slough and stated the MDS would need to be modified. RN-A stated he had been stating that staging of wounds was not being completed correctly and has completed education on staging of wounds. RN-A further stated he looked at wound pictures, but had to be more critical in what he saw and had not been doing that and further added it was important to have correct staging in order to know whether there has been a decline in the pressure ulcer which could indicate the wound was not being managed correctly. During interview on 3/12/25 at 2:14 p.m., the director of nursing (DON) stated she expected documentation align with the provider documentation and the documentation should be accurate. The DON verified the wound documentation note was not accurate for the wound staging according to the wound staging definitions. A policy was requested, however an email from the DON dated 3/12/25 at 3:01 p.m., indicated they utilized the RAI manual dated October 2024 for accuracy of assessments. 49617 R15's quarterly Minimum Data Set (MDS) dated [DATE] indicated he had intact cognition and identified his diagnoses of anxiety, depression, and bipolar disorder (a mental health condition characterized by extreme periods of elevated mood, or mania, and low mood, or depression). The MDS reported he was taking an antipsychotic medication on a routine basis and indicated a gradual dose reduction (GDR) had not been attempted and there was no physician documentation the GDR was clinically contraindicated. Furthermore, the MDS reported he was not taking an antianxiety medication. R15's active pharmacy orders were reviewed on dated 3/12/25 at 8:12 a.m., and revealed the following orders: - hydroxyzine hydrochloride (HCl) oral tablet 50 milligrams (mg), Give 50mg by mouth two times a day for anxiety, dated 12/15/23. - quetiapine fumarate oral tablet 100mg, Give 100mg by mouth three times a day for depression, dated 7/25/23. R15's medication administration record (MAR) dated 1/25 was reviewed 3/12/25 and reflected the following administered medication orders: - hydroxyzine hydrochloride (HCl) oral tablet 50 milligrams (mg), Give 50mg by mouth two times a day for anxiety, dated 12/15/23. - Seroquel oral tablet (quetiapine fumarate), Give 300mg by mouth at bedtime, dated 10/30/24. R15's care plan dated 7/26/23, identified his use of psychotropic drug medications and his alteration in psychosocial well-being related to his diagnoses of schizophrenia (chronic mental health condition characterized by disruption in thought processes, perceptions, emotions, and social interactions), agoraphobia with panic (anxiety disorder characterized by intense fear of being in situations that might cause panic, or being trapped), and anxiety. A pharmacist's recommendation to prescriber dated 9/16/24, recommended a GDR to R15's psychotropic medications. The prescriber ordered a reduction of his evening Seroquel (quetiapine). A provider progress note dated 11/12/24 indicated under the treatment and plan: no medication changes at this time. GDR attempts are not recommend[sic] at this time due to failed GDR and mental decompensation. Per interview on 3/12/25 at 9:19 a.m., licensed practical nurse (LPN)-A, confirmed R15 was taking hydroxyzine and verified this was an antianxiety medication. Per interview on 3/12/25 at 2:37 p.m., the director of nursing (DON) confirmed R15 was taking an antianxiety medication and had a failed GDR. The DON expected the MDS data to be accurate based on a review of a resident's recent medication list, progress notes, and provider notes. Per interview on 3/12/25 at 2:46 p.m., registered nurse (RN)-A confirmed accountability for completing R15's quarterly MDS dated [DATE]. RN-A verified answering no him taking an antianxiety on the MDS and reviewed his MAR dated 1/25 and stated, I missed the hydroxyzine. Furthermore, RN-A reviewed the provider progress note dated 11/12/24 and the pharmacist's recommendation to prescriber dated 9/16/24 and verified there had been a GDR performed as well as a clinical contraindication to GDR provided. RN-A stated the facility's procedure was to make a modification to erroneous MDS and submit the corrected one. A policy pertaining to MDS accuracy was requested but not received.

Based on interview and document review, the facility failed to ensure a Level 1 Pre-Admission Screening (PAS) and, if needed, a a Level II Pre-Admission Screening and Resident Review (PASARR) were completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 resident (R1) reviewed for PASARR. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was not considered by the state level II PASRR process to have a serious mental illness and or intellectual disability or a related condition, had intact cognition, and had the following active diagnoses: bipolar disorder and schizophrenia. R1's physician's orders indicated the following order: 12/30/24, aripiprazole (an antipsychotic medication) 2 milligrams (MG) daily, take along with 5 mg for a total dose of 7 mg every day for schizoaffective disorder. 12/30/24, aripiprazole 5 mg daily, take 5 mg along with 2 mg for a total of 7 mg per day. 2/21/25, resident targeted behaviors of yelling, refusal of cares, isolation and interventions to redirect, remove from environment, and see notes, monitor resident for signs and symptoms of medication side effects and notify the physician if noted. R1's History and Physical dated 12/24/24, indicated R1 had active diagnoses of schizoaffective disorder and bipolar 1 disorder. R1's care plan, no date identified, indicated R1 had an alteration in mood and behavior due to bipolar and schizoaffective diagnoses and R1's goals included a stable mood and behavioral state, and R1 would respond to interventions. R1's medical record was reviewed and under a Miscellaneous form in the electronic medical record (EMR), indicated under the heading, PASRR included a document titled, ER [DATE] PAS.pdf The document, was opened and included a Preadmission Screening Referral form. The reason for the referral included two checked boxes indicating managed care, and waiver/AC/ECS. The form indicated the preadmission screen (PAS) was not completed by Senior LinkAge Line and the PAS required action. Further, the form indicated an OBRA Level II and level of care face to face assessment must be completed before nursing home admission. R1's medical record lacked evidence a Level 1 or, if needed, a Level II PASARR had been completed for R1 despite admitting to the nursing home a few months prior and having mental health-related diagnoses (i.e., schizophrenia and bipolar disorder) which could require active treatment. Further, the form lacked a determination of the PAS. During interview on 3/11/25 at 2:01 p.m., the admission coordinator (AC)-E stated she worked at the facility for over two years and her role included requesting preadmission screens through the Senior LinkAge Line. AC-E stated the PAS described what a resident was admitted for and showed the resident's medical and living situation. AC-E viewed R1's chart and initially stated R1 had a PAS, but after opening the form, stated R1 had a referral and the form was not the PAS. AC-E stated no other staff worked on preadmission screenings and verified the PAS were located in the EMR and a PAS would let staff know if a resident needed more than a level one and possibly a level II. AC-E stated R1 would stay at the nursing facility until they could find placement and further stated she would add R1 to her list to find out why she didn't have a PAS and stated it was probably overlooked and R1 should have had a PAS completed before being admitted to the facility. During interview on 3/11/25 at 2:11 p.m., the social services director (SSD) stated she was not a licensed social worker. SSD stated AC-E followed up on the PAS screens and further stated the purpose of the PAS was to help determine services and level II PAS included mental illness diagnoses like schizoaffective disorders would trigger a resident to need a level two PASARR. SSD stated the PAS screenings were supposed to be completed prior to admission and were uploaded into the miscellaneous tab. SSD viewed R1's miscellaneous tab and verified no PAS was uploaded and stated it was important to be completed for the whole team to assess and assist the resident and stated R1 could trigger for a level II PASARR and viewed the form and stated she thought AC-E uploaded the form at this time. SSD viewed a PAS scanned that indicated under a heading, Does the person have a current diagnosis of a mental illness that indicated R1 did not have a mental illness and stated she would ask their consultant if the answer for the question should be documented as yes. During interview on 3/11/25 at 2:22 p.m., AC-E stated she contacted Senior LinkAge right away and stated they never attached the PAS and had just sent the PAS. During interview on 3/11/25 at 2:58 p.m., SSD stated she reviewed the PAS with the consultant and was directed to submit a new PAS with the diagnosis of R1 having mental illness to further determine if R1 needed a Level II PASARR. During interview on 3/12/25 at 11:04 a.m., the director of nursing (DON) stated she expected the PAS to be completed and stated it was important to have the PAS in order to know how to take care of residents and create an individualized care plan. During interview and observation on 3/12/25 at 11:14 a.m., registered nurse (RN)-C viewed R1's paper chart and verified there was no PAS in the paper chart. A care plan with revision history was requested, but was not provided. A policy, Pre-Admission Screening (PASSR), dated 6/2023, indicated social services would check for preadmission screening and OBRA Level II requirements and would ensure the initial Pre-Admission Screening results state that the resident meets level of care for purposes of medical assistance payment prior to the resident being admitted to the facility. The initial Pre-Admission Screening must be completed by a medical professional. If the requirements from the initial Pre-Admission Screening cannot be determined, the admission will need to be postponed until the county can complete a face to face assessment and the county can confirm the consumer meets requirements for nursing facility level of care under Medicaid. Upon receipt of the hard copy of the preadmission form(s) from the Senior Linkage Line and or Lead Agency, social services or designated staff person will upload documentation to the resident's medical record. For residents discharging to a nursing facility from the hospital, assisted living, clinic and out of state, before accepting the admission you must receive a copy of the initial PAS from the referring agency which notes that consumer meets criteria for placement.

Based on interview and document review the facility failed to ensure care conferences were completed in a timely manner for 1 of 1 resident (R14) reviewed for care planning. Findings include: R14's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnosis of chronic kidney disease. If further indicated R14 required staff assistance with most activities of daily living (ADL) and mobility. During interview on 3/10/25 at 2:53 p.m. R14 stated he couldn't remember if he'd had a care conference or not. R14's progress note dated 8/27/2024, indicated the following: care conference held today with resident. Resident was in a good mood and willing to participate. Interdiciplinary team (IDT) went over cares, nursing needs, therapy, and other questions as needed. Resident had no questions. IDT will continue to assist resident as needed. R14's medical record lacked documentation of a care conference since 8/27/24. During interview on 3/12/25 at 2:53 p.m., the director of social services stated the MDS nurse provided a list of who needed a care conference each month based off of the MDS assessments' schedule. When it was time for a resident to have a care conference she would talk to the team and then schedule it. The director of social services stated they were working on developing a better system in regards to care conferences and they're probably things that have been missed. She also verified the last time R14 had a care conference was on 8/27/25. A facilty policy on care conferences was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure and identify accurate wound care assessments for 1 of 1 resident (R40) reviewed for pressure ulcers. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated 10/2024, identified the intent of section M, Skin Conditions, documented the risk, presence, appearance, and change of pressure ulcers and injuries. Further, it was important to recognize and evaluate each resident's risk factors and identify and evaluate all areas at risk of constant pressure and a complete assessment of skin was essential to an effective pressure ulcer prevention and skin treatment program. The RAI manual directed staff to review the medical record including skin care flow sheets, or other skin tracking forms, nurses' notes, and pressure ulcer injury risk assessments, speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident, examine the resident and determine whether any ulcers, injuries, scars, or non-removable dressings, devices were present. Additionally, pressure ulcer staging was determined by the deepest anatomical stage and if a stageable pressure ulcer had been classified at a higher numerical stage than what was observed it should continue to be classified at the higher numerical stage and pressure ulcers do not heal in a reverse sequence. Stage three and four pressure ulcers fill with granulation tissue that is never as strong as the tissue that was lost and hence is more prone to future breakdown. Clinical standards do not support reverse staging or back staging as a way to document healing as it does not accurately characterize what is occurring physiologically as the ulcer heals. Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest numerical stage and a previously closed pressure ulcer that opens again should be reported at its worst stage, unless currently presenting at a higher stage or unstageable. The State Operations Manual (SOM) provided guidance on pressure ulcer staging that defined the following pressure ulcers/injuries: Stage 1 Pressure Injury is intact skin with localized redness. Stage 2 Pressure ulcer is partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open or ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (new connective tissue), slough, (non-viable tissue) and eschar (dead tissue) are not present. Stage 3 Pressure Ulcer is a full thickness loss of skin in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and or eschar may be visible but does not obscure the depth of tissue loss. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/injury. Stage 4 Pressure Ulcer is a full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/pressure injury. Unstageable Pressure Ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. Deep Tissue Pressure Injury (DTPI) is intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. R40's 5 day Minimum Data Set (MDS) assessment dated [DATE], indicated diagnoses of anemia, heart failure, peripheral vascular disease, diabetes mellitus, was at risk of developing pressure ulcers, had one stage 2 pressure ulcer that was not present upon admission. Additionally, R40 did not have any stage 1, 3, 4, pressure ulcers or unstageable, or deep tissue injuries. R40's annual MDS dated [DATE], indicated R40 had intact cognition, did not reject care, had anemia, coronary artery disease, heart failure, peripheral vascular disease, diabetes mellitus, one or more unhealed pressure ulcers/injuries, 0 stage 1 pressure injuries, one stage 2 pressure ulcer/injury, 0 stage 3 pressure ulcers, 0 stage 4 pressure ulcers, 0 unstageable pressure ulcers with slough or eschar, and 0 unstageable DTPI's. The MDS directed staff to report based on the highest stage of existing ulcers/injuries at their worst; and do not reverse stage. R40's Optional State Assessment (OSA) dated 1/3/25, indicated R40 required extensive assist with bed mobility, transfers, and toileting. R40's Care Area Assessment (CAA) for pressure ulcers indicated R40 had a stage two pressure ulcer and required partial assistance with lying to sitting, had a foley catheter which could increase the risk for pressure due to the tubing and the pressure ulcer would be addressed in the care plan. R40's care plan undated, indicated R40 had limited physical mobility related to non weight bearing to right lower extremity and interventions included to turn and reposition every 3-4 hours, uses wheelchair and ensure foot peddles are in place. R40's care plan indicated a self care deficit and required assist of one with grooming, bathing, and was encouraged to participate in dressing by placing arms and legs into clothing and staff were to assist with placing and removing socks and shoes. Further, R40's care plan indicated R40 was admitted with a right heel surgical wound and diabetic ulcer and on 3/9/23, had a right heel blister/suspected deep tissue injury and a pressure injury on the right Achilles and interventions included evaluating and treating per physician's orders, evaluate for signs and symptoms of possible infections, was followed by the wound care team weekly, took prostat (a protein supplement), was to be turned and repositioned every 3 to 4 hours, monitor skin during cares, provide a pressure reducing mattress. R40's physician's orders included the following order: 1/29/25, cleanse right heel wound with generic wound cleanser or Vashe, apply collagen until Santyl arrives, cover with foam dressing, change dressing daily and as needed, inform the provider with any signs or symptoms of infection. Dressings need dates and initials and change daily for wound care. R40's Re-Admission History and Physical note dated 6/11/24, located in the progress notes indicated R40 had an unstageable pressure ulcer to the right heel. R40's Re-Admission History and Physical note dated 6/25/24, located in the progress notes indicated R40 had an unstageable pressure ulcer of the right heel. R40's progress notes dated 1/1/25, indicated, R40's pressure ulcer 2 right Achilles-improving. R40's Skin and Wound Evaluation form dated 11/21/24, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 2.9 centimeters (CM) long by 2.6 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 30% granulation tissue, 20% slough, and 50% eschar. R40's Skin and Wound Evaluation form dated 12/3/24, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 3.6 cm long by 2 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 60% granulation tissue, and 40% eschar. R40's Skin and Wound Evaluation form dated 12/10/24, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 3.9 centimeters (CM) long by 2.6 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 30% granulation tissue, 60% slough, and 10% eschar. R40's Skin and Wound Evaluation form dated 12/17/24, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 3.1 centimeters (CM) long by 2.0 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 30% granulation tissue, 60% slough, and 10% eschar. R40's Skin and Wound Evaluation form dated 12/26/24, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 2.9 centimeters (CM) long by 2.1 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 70% granulation tissue, 10% slough, and 20% eschar. R40's Skin and Wound Evaluation form dated 1/1/25, indicated R40 had an in-house acquired stage two pressure ulcer to the right Achilles that had been present for one week measuring 4.1 (cm) long by 2.7 cm wide. Further, the note indicated the wound bed contained 80% granulation tissue, 20% slough, and no eschar. R40's Skin and Wound Evaluation form dated 1/7/25, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 4.1 centimeters (CM) long by 2.5 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 90% granulation tissue, and 10% slough. R40's Skin and Wound Evaluation form dated 1/14/25, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 7.4 cm long by 2.8 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 90% granulation tissue, 10% slough, and no eschar. R40's Skin and Wound Evaluation form dated 1/21/25, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 2.4 cm long by 1.3 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 50% granulation tissue, no slough, and no eschar. R40's Skin and Wound Evaluation form dated 1/28/25, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 5.5 cm long by 2.4 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 70% granulation tissue, no slough, and no eschar. R40's Skin and Wound Evaluation form dated 2/6/25, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 5 cm long by 3.9 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 70% granulation tissue, 10% slough, and no eschar. R40's Skin and Wound Evaluation form dated 2/13/25, indicated R40 had a stage two pressure ulcer to the right Achilles that had been present for one week measuring 4.5 cm long by 2.7 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 70% granulation tissue, 10% slough, and 20% eschar. R40's Skin and Wound Evaluation form dated 2/20/25, indicated R40 had an unstageable pressure ulcer to the right Achilles that had been present for one week measuring 4.5 cm long by 2.7 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 70% granulation tissue, 10% slough, and no eschar. R40's Skin and Wound Evaluation form dated 2/25/25, indicated R40 had an unstageable pressure ulcer to the right Achilles that had been present for one week measuring 4.3 cm long by 2.4 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 20% granulation tissue, 20% slough, and no eschar. R40's Skin and Wound Evaluation form dated 3/7/25, indicated R40 had an unstageable pressure ulcer to the right Achilles that had been present for one week measuring 4.4 cm long by 2.8 cm wide. Further, and contrary to the definition of a stage two pressure ulcer, the note indicated the wound bed contained 20% granulation tissue, 20% slough, and no eschar. R40's Integrated Wound Care note dated 12/3/24, indicated a right lateral heel unstageable pressure ulcer measuring 3.8 cm long by 2.7 cm wide by 0.3 cm deep with 30% necrotic tissue, 20% eschar, and 50% granulation tissue. R40's Integrated Wound Care Note dated 12/17/24, indicated a right lateral heel unstageable pressure ulcer measuring 3 cm long by 3.5 cm wide by 0.5 cm deep with 10% necrotic tissue, 30% granulation tissue, and 60% slough. R40's Integrated Wound Care note dated 12/26/24, indicated R40 had a right heel unstageable pressure ulcer. Further, the wound was 2 cm long by 4.7 cm wide, by 0.4 cm deep and contained 10% slough, 20% necrotic tissue, and 70% granulation tissue. R40's Integrated Wound Care note dated 1/2/24, indicated R40 had a right heel unstageable pressure ulcer. Further, the wound was 2.5 cm long, by 4 cm wide by 0.4 cm deep and contained 20% slough, and 80% granulation. R40's Integrated Wound Care note dated 1/2/25, indicated a right lateral heel unstageable pressure ulcer measuring 4 cm long by 2.5 cm wide by 0.5 cm deep with 10% slough and 90% granulation tissue. R40's Integrated Wound Care note dated 1/14/25, indicated a right lateral heel unstageable pressure ulcer measuring 7.3 cm long by 2.8 cm wide by 0.4 cm deep with 10% slough and 90% granulation tissue. R40's Integrated Wound Care note dated 1/21/25, indicated a right lateral heel unstageable pressure ulcer measuring 2.3 cm long by 1.3 cm wide by 0.3 cm deep with 50% necrotic tissue, and 50% granulation tissue. R40's Integrated Wound Care note dated 1/28/25, indicated a right lateral heel unstageable pressure ulcer measuring 5.5 cm by 2.4 cm by 0.3 cm with 30% necrotic tissue and 70% granulation tissue. R40's Integrated Wound Care note dated 2/6/25, indicated a right lateral heel unstageable pressure ulcer measuring 5 cm long by 3.9 cm wide by 0.2 cm deep with 20% necrotic tissue, 70% granulation tissue, and 10% slough. R40's Integrated Wound Care note dated 2/13/25, indicated a right lateral heel unstageable pressure ulcer measuring 4.5 cm long by 2.7 cm wide by 0.2 cm deep with 20% necrotic tissue, 70% granulation tissue and 10% slough. R40's Integrated Wound Care note dated 2/20/25, indicated a right lateral heel unstageable pressure ulcer measuring 4.5 cm long by 2.7 cm wide by 0.2 cm deep with 20% necrotic tissue, 70% granulation tissue and 10% slough. R40's Integrated Wound Care note dated 2/25/25, indicated a right lateral heel unstageable pressure ulcer measuring 4.3 cm long by 2.4 cm wide by 0.2 cm deep with 30% necrotic tissue, 20% granulation, and 20% slough. R40's Integrated Wound Care note dated 3/7/25, indicated a right lateral heel unstageable pressure ulcer measuring 4.4 cm long by 2.8 cm wide by 0.2 cm deep with 30% necrotic tissue, 20% granulation, and 20% slough. During interview on 3/10/25 between 5:16 p.m., and 5:18 p.m., R40 stated she was going to the hospital on 3/11/25 to have an X-RAY of her leg to determine blood flow and further stated her heel was painful and pointed to her right heel and stated that was why it was elevated. R40's wheelchair foot rest on the right was pulled down and R40 had a sock on with her right heel resting directly on the foot rest. R40 stated she had a sore on her heel and stated staff usually changed the dressing in the morning, but stated it was changed mid morning on 3/10/25. During interview on 3/12/25 at 7:52 a.m., R40 stated she had a procedure the day prior to increase the blood flow and help heal her foot. During interview on 3/12/25 at 8:26 a.m., registered nurse (RN)-C stated R40 had a diabetic sore on her heel that was a stage II and had some slough but no eschar. During interview on 3/12/25 at 11:19 a.m., RN-B stated she conducted wound rounds with the nurses weekly and stated the wound assessment was documented under the Skin and Wound in the Forms tab. RN-B stated R40 had an unstageable pressure ulcer on the right Achilles heel. RN-B viewed the 2/13/25, note and verified the wound was documented as a stage two with slough and eschar and stated it could be documented as a stage two because of improvement in the heel. RN-B stated she was not sure if a stage two pressure ulcer presented with eschar and slough and was not sure about the recent staging because sometimes there was improvement in the wound and then the wound comes back. During interview on 3/12/25 at 12:14 p.m., registered nurse (RN)-A stated he was the MDS coordinator and scheduled the MDS assessments, completed assessments, and made sure everyone completed their sections. RN-A stated he completed sections A, E, G, H, GG, I, J, K, L, M, N, O, P, and S. RN-A stated they were supposed to schedule skin assessments each week and when looking for skin assessments, looked at the Forms in the electronic medical record (EMR). RN-A stated R40 had an Annual MDS on 1/3/25, and when completing the MDS, looked for a skin assessment for 1/3/25, or around that date. RN-A stated they used to have a wound care manager who documented notes directly into progress notes but did not locate notes related to staging during the window for the MDS after reviewing the progress notes. RN-A stated he could not recall where he went to find the stage of the wound and knew it had been a stage two pressure ulcer and stated he used the RAI manual for guidance. RN-A stated according to the RAI manual, a stage two pressure ulcer was the first layer of skin removed and could also be a blister. RN-A further stated a stage two pressure ulcer did not contain slough, eschar, or granulation tissue. RN-A stated he viewed the Wound Evaluation form 1/1/25, for the MDS and stated the form indicated R40 had a stage two pressure ulcer but was staged incorrectly because a stage two pressure ulcer did not have granulation tissue, or slough and stated the MDS would need to be modified. RN-A stated he had been stating that staging of wounds was not being completed correctly and has completed education on staging of wounds. RN-A further stated he looked at wound pictures, but had to be more critical in what he saw and had not been doing that and further added it was important to have correct staging in order to know whether there has been a decline in the pressure ulcer which could indicate the wound was not being managed correctly. During interview on 3/12/25 at 12:14 p.m., RN-A stated he spoke with the director of nursing and was told they had documentation the wound was almost healed so it would have been a stage two at that point, and added he did not want to retract anything he said. During observation and interview on 3/12/25 at 1:43 p.m., RN-C changed R40's dressing and completed measurements. RN-C stated R40's wound measured 1 cm long by 2.2 cm wide by 0.1 cm deep. RN-C stated he had training on how to stage wounds previously but not at the facility and stated R40's wound was at a stage three. During interview on 3/12/25 at 2:14 p.m., the director of nursing (DON) stated staff rounded with a wound nurse practitioner who changed orders or made recommendations and staged the wounds and nurses at the facility completed wound assessments and completed the Skin and Wound Evaluation and added if you don't click and change information, the information stays in place in the note. The DON stated R40 admitted with a wound vac (a treatment for the wound) and the wound healed and reopened and added R40 was non compliant and added R40 had an angiogram 3/11/25. The DON stated she expected the provider stage the wound and nursing documentation should align with the provider and should be accurate and verified wound documentation notes were not accurate for the wound staging according to the staging definitions. A care plan with the revision history was requested, but was not provided. A policy, Skin Assessment and Wound Management dated 2/2025, indicated a weekly skin inspection was completed by licensed staff. When a new pressure ulcer is identified the following actions will be taken, notify the provider/treatment ordered, notify the resident representative, complete education with the resident and resident representative including risks and benefits, initiate the skin and wound evaluation, notify the nurse manager/wound nurse.

Based on observation, interview and document review the facility failed to demonstrate safe patient handling to reduce the risk for accidents for 1 of 1 residents (R13) reviewed for safety with mechanical lift assisted transfers. Findings include: R13's annual Minimum Data Set (MDS) dated [DATE], indicated he had intact cognition and was dependent on staff for chair/bed-to-chair transfers. The MDS reported diagnoses of hemiplegia (one-sided weakness) following a cardiovascular accident (CVA, stroke), and hemiplegia (one-sided paralysis). R13's Care Area Assessment for functional abilities dated 12/19/24, indicated he was dependent on staff for transfers. R13's care plan revised 1/3/24, identified his activities of daily living (ADL) self-care deficit and directed staff to provide 2-person assistance using the EZstand. A therapy to nursing communication form dated 5/10/24, indicated R13's transfer status under Transfers: EZ Stand. During interview on 3/10/25 at 4:52 p.m., R13 reported using the EZ Stand for transfers and stated it caused him pain to his ribs and lungs. He stated during some transfers, he would hang there and when he would attempt to tell staff to lower him down because I can't breathe and its pushing on my lungs, staff would tell him to stop hollering at him. During observation and interview on 3/12/25 at 12:54 p.m., nursing assistant (NA)-A and NA-B were in R13's room to transfer him from his wheelchair to his bed. NA-B stood behind the mechanical standing lift with the remote control in hand. NA-A put the lift sling behind R13's back and ensured all the sling loops were fastened to the standing lift. NA-A stated because R13 had weakness to his left side, they would need to make sure he was holding onto the standing lift with his hand properly. After the NAs ensured his feet were secured on the standing lift's platform, NA-B used the remote control to lift R13 from the wheelchair into a semi-upright position. R13 was unable to stand straight up; his knees were bent at approximately 80 degrees while his arms were bent at approximately 90 degrees. He was hanging by both shoulders from the standing lift with the sling behind his back and shoulders. NA-A told NA-B to stop going up and began to move the standing lift over towards R13's bed. The surveyor asked R13 if he was able to stand up any straighter. He attempted and was able to straighten his legs, but his arms remained bent, and his upper extremity posture remained unchanged. NA-A pushed the standing lift over his bed and began to lower R13 onto the bed. R13 stated the transfer felt okay but said if he had to transfer like that repeatedly, he would be in a lot of pain. NA-A stated sometimes R13 would say he did not want to get up or that he was not feeling well, and they would leave him be and notify the nurse. When asked if the observed transfer was safe and positioning was appropriate, NA-A said it was okay because he was able to get into bed, but if he was not okay, they would report that to the nurse. During interview on 3/12/25 at 1:11 p.m., physical therapist assistant (PTA) stated if a resident using a mechanical standing lift was observed using bad posturing, like bowing of the arms out or sort of hanging there, it would be an indication the resident should be evaluated by therapy. PTA expected NAs to report such observations to nurses or nurse managers so it could be passed along to the interdisciplinary team (IDT) to discuss. PTA stated residents struggling to use mechanical standing lifts should be reviewed during IDT so they can get on the therapy caseload for evaluation. PTA stated the residents exhibiting bad posturing techniques during transfers could present risks such cutting off blood flow or circulation to their shoulder joints or risk slipping out of the mechanical standing lift during a transfer. PTA denied being notified of any concerns regarding R13's transfers. During interview on 3/12/25 at 2:30 p.m., the director of nursing (DON) stated a safe mechanical standing lift transfer would be one in which a resident could stand for eight seconds, they could fully hold onto or grasp the lift bars and could come to a complete stand without hanging in the mechanical standing lift. The DON expected if staff observed an unsafe transfer to complete a lift and mobility assessment, change the transfer status and update the care plan accordingly. Finally, the DON expected this to be communicated during morning standup so therapy could get involved. A facility policy pertaining to safe transfers was requested but not received.

Based on interview and document review, the facility failed to ensure 1 of the 5 residents (R1) reviewed for immunizations was offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 9/12/24, recommended based on R1's age and vaccine history to give a dose of PCV15, PCV20 or PCV21 at least 1 year after the last dose of PPSVR23. Regardless of which vaccine is used (PCV15, PCV20, or PCV21), their pneumococcal vaccinations are complete. R1's Clinical Profile printed on 3/12/25, indicated R1 was [AGE] years old. The immunization record, printed 3/12/25, indicated R1 received a PPSV23 on 1/17/13. R1's electronic medical record (EMR) lacked evidence of shared clinical decision making occurring with the physician for giving one dose of PCV15, PCV20, or PCV21 as it was more than [AGE] years after the previous pneumococcal dose. R26's EMR and paper chart lacked evidence of R1 being offered or receiving any pneumococcal doses or education. During interview on 3/11/25 at 3:33 p.m., R1 stated didn't remember staff talking or offering a pneumococcal vaccine. R1 stated would have accepted a pneumovax vaccine if offered. During interview on 3/12/25 at 11:28 a.m., the infection preventionist/director of nursing (DON) stated besides the duties as the infection preventionist and DON position, had also been fulfilling the nurse manager's duties. DON stated missed auditing R1. DON stated a resident who received the recommended pneumovax vaccination would prevent someone from getting pneumonia, or if they would get pneumonia, the symptoms won't be as severe. Facility's policy titled Pneumococcal Policy dated 2/2024 indicated: It is the practice of the Health Care Facility to offer all residents the pneumococcal vaccines to aid in the prevention of pneumococcal/pneumonia infections. Facility policy indicated the purpose was to follow recommendations of the Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control (CDC) and/or the state Department of Health for prevention of Pneumococcal disease by identifying those residents at risk for Pneumococcal disease and offering Pneumococcal vaccination.

Based on interview and document review, the facility failed to ensure residents received the medications ordered by the provider for 1 out of 3 residents (R1) reviewed for significant medication errors, which resulted in hospitalization in the intensive care unit (ICU). This resulted in an immediate jeopardy (IJ) for R1 when the facility omitted her apixaban (medication that decreases clotting ability of blood) for six days, for a total of 12 doses, R1 had a stroke and was sent to the hospital. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 2/18/25 at 4:00 p.m., when R1 missed her first dose of apixaban (Eliquis). The director of nursing (DON), administrator, social worker, and corporate clinical nurse were notified of the IJ on 3/5/25 at 11:50 a.m. The IJ was removed on 2/24/25 prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1 was admitted to the facility on [DATE]. R1's care plan dated 2/18/25, indicated R1 was on anticoagulant medication. R1's admission Minimum Data Set, dated dated dated [DATE], indicated she had diagnoses of encephalopathy, atrial fibrillation (A-fib), and heart failure. R1's admission orders, dated 2/17/25, from the hospital, directed to administer apixaban 2.5 milligrams (mg) two times daily. R1's admission orders, dated 2/17/25, directed during your hospital stay, we transitioned you from warfarin (anticoagulant medication) to apixaban for your blood thinner. You should continue to take this as prescribed. R1's Medication Administration Record (MAR) order, entered on 2/17/25, directed give apixaban 2.5 mg two times a day for anticoagulant for one day. The MAR indicated R1 received the medication on 2/17/25 at 4:00 p.m., and 2/18/25 at 8:00 a.m. R1's MAR order entered on 2/24/25 directed give apixaban 2.5 mg two times a day for AFib. The MAR indicated R1 received the medication on 2/24/25 at 8:00 p.m., and on 2/25/25 at 8:00 a.m. A progress note, on 2/24/25 at 4:31 p.m., indicated R1 had a medication error due to missed apixaban doses. A physician note, on 2/25/25 at 2:12 p.m., indicated R1 was sent to the hospital for new onset slurred speech, left sided facial droop and left sided weakness. Patient missed recent doses of apixaban. A physician note, on 2/25/25 at 2:27 p.m., indicated R1's order for twice daily apixaban was entered as a one-time order. R1 was bridged from warfarin to apixaban. R1 received a dose the evening of 2/17/25 and in the morning on 2/18/25. R1 received her next dose in the evening on 2/24/25 and in the morning on 2/25/25, prior to the cerebrovascular accident (CVA) that occurred this afternoon. On 3/4/25, at 12:52 p.m., family member (FM)-A stated R1 had suffered a stroke and remained hospitalized . FM-A stated R1 was receiving hospice care in the hospital and could no longer take food or drink by mouth. On 3/4/25, at 2:27 p.m., registered nurse (RN)-A stated she was working on 2/17/25 when R1 was admitted to the facility. RN-A stated she did not complete verifying accuracy of R1's medications, but she signed them off in the computer system, when she had to abruptly leave her shift. RN-A stated two nurses are expected to verify the accuracy of all orders. On 3/4/25 at 3:05 p.m., the health unit coordinator (HUC) stated she made an error by entering an end date for R1's apixaban. On 3/4/25 at 3:45 p.m., the director of nursing (DON) stated the HUC mistakenly entered an end date for apixaban. The DON stated the process was to have two nurses verify the orders. The first nurse would indicate the verification was complete by documenting in the computer system and on the admission checklist. The first nurse (RN-A) did not complete the verification when she abruptly had to leave her shift, although she documented this was complete in the computer system. RN-A did not document this was complete on the admission checklist. The DON stated the second nurse missed noting an end date was entered for the apixaban. The second nurse signed admission checklist, indicating she verified the accuracy of the orders. The DON stated the policy for medication orders was not followed. On 3/4/25 at 4:24 p.m., FM-B stated she requested to review R1's medication list at a care conference on 2/24/25. FM-B discovered apixaban was omitted. FM-B stated at time of this interview, R1 was unresponsive and could no longer eat, drink, or swallow. FM-B stated R1 was actively dying. On 3/5/25 at 8:38 a.m., medical doctor (MD)-A stated, I think it was the direct cause of her having a stoke. The apixaban was supposed to prevent that. Much less likely that she would be in her current state on hospice. On 3/5/25 at 12:54 p.m., pharmacist-A stated apixaban stays in the system for 3 days. He stated it is for blood clot prevention only and would not work on existing blood clots. On 3/5/25 at 2:40 p.m., MD-A stated apixaban takes 48 to 60 hours to reach the desired therapeutic level. MD-A stated the half-life (time required for the quantity of the medication to reduce to half its initial value) of apixaban was 12 hours. MD-A stated during R1's previous hospitalization on [DATE] a CT of her head indicated she did not have a stroke at that time. MD-A stated apixaban would stay in the body's system for a couple of days. R1 had known atrial fibrillation, giving time for the left atrial appendage (area of the upper left corner of the left chamber of the heart) thrombus (blood clot) to form. MD-A stated R1 had an angiogram (medical imaging of the heart) while hospitalized , with a thrombectomy (medical procedure to remove a blood clot) attempt that was not successful. MD-A stated this resulted in the blood clot in R1's brain, causing a stroke. A facility policy, Medication and Treatment Orders, dated 2/24, directed orders for medications and treatments will be consistent with principles of safe and effective order writing. The past noncompliance IJ began on 2/18/25. The IJ was removed and the deficient practice was corrected by 2/24/25, after the facility implemented a systemic plan that included the following actions: review of procedure for transcribing orders, audit of all residents on apixaban, DON audit of all new resident orders, immediate education for all staff involved (HUCs, trained medication aides, licensed practical nurses, and RNs) with order transcription and further education on the medication apixaban.

Based on observation, interview and document review, the facility failed to ensure required nurse staff information was posted on a daily basis. This had the potential to affect all 58 residents residing in the facility and visitors who may wish to view the information. Findings include: On 3/4/25 at 9:43 a.m., the daily nurse staffing form posted at the nursing station was dated 1/23/25. This was located in a wall mounted frame under directions to view survey results. On 3/4/25 at 9:48 a.m., the director of nursing (DON) stated the daily staffing form should be updated daily. She stated it was very outdated. The DON stated the purpose of posting the document was to provide a rough idea of nurse to patient ratio. On 3/4/25 at 3:24 p.m., the administrator stated staff posting was intended to let people know we are meeting the regulations. The administrator stated she was not aware the posting had not been updated since 1/23/25. The administrator stated she had been responsible for the facility staffing over the previous two months. A policy regarding the nurse staff posting was requested but not received.

Based on interviews and record failed to provide pharmacy services for one of one resident (R1) reviewed for medication administration. R1 did not receive his anti-anxiety medication when it was available in the emergency medication dispensing kit. Findings include: R1's admission record printed on 4/26/24 indicated R1 was admitted to the facility on [DATE] with an admitting diagnosis of acute and chronic respiratory failure with hypoxia. R1's additional diagnoses included congestive heart failure, morbid obesity, opioid dependence, chronic pain syndrome, and low back pain. R1's brief interview for mental status (BIMS) assessment completed on 1/5/24 indicated R1 had a score of 15, which indicated R1 was cognitively intact. R1's medication administration record (MAR) indicated R1 missed a dose of lorazepam on 4/5/24 at 8:00 p.m. The nurse who signed that missed dose indicated a code 9, which stated Other/See Nurse Note. There was no progress note or nurses note for this missed medication. During an interview with R1 on 4/26/24 at 9:21 a.m., R1 stated the facility ran out of his lorazepam (anti-anxiety medication) about two weeks ago but had received it the day of the interview. R1 stated he had talked with his hospice nurse who stated if R1 ran out of Lorazepam, he should let the nurse know to get the medication through the emergency medication kit. R1 stated when he missed the lorazepam his anxiety increased, and he was restless. During an interview with registered nurse (RN)-A on 4/26/24 at 9:58 a.m., RN-A stated if the facility runs out of a resident's medication, the nurse should look in emergency medication kit. RN-A stated the facility pharmacy provides and refills medications in the emergency medication kit. RN-A stated the emergency medication kit includes lorazepam. During an interview with pharmacy manger (PM) on 4/26/24 at 11:13 a.m., the PM stated the facility has an emergency medication kit which included lorazepam. During an interview with the director of nursing (DON) on 4/26/24 at 11:50 a.m., the DON stated if a staff member who passes medications runs out of a resident's medications, her expectation would be to go to the emergency medication kit and get the medication from there. The DON stated the staff members who pass medications are trained on the emergency medication kit when the first start employment at the facility. During an email correspondence with the administrator on 4/26/24 at 4:02 p.m., the administrator stated the nurse should check with the emergency medication kit if a resident is out of a medication. The administrator stated the facility does not have a specific policy for what nurses should do if a resident runs out of medications as it is a standard nursing practice. A policy and procedure provided by the facility name Policies and Procedures: Pharmacy Services for Nursing Facilities by Polaris Pharmacy, effective May 2022, indicated if a current and active medication order cannot be located in the medication cart, the medication should be removed from the medication emergency kit. This statement is located on page 166 of the policy and procedure.

Based on observation, interview, and record review, the facility failed to comprehensively assess residents for the use of bedrails prior to the installation of bed rails for 2 of 4 residents (R2 and R3) and/or review the risk/benefits and obtain written informed consent prior the use of bed rails. Findings include: During an observation on 3/20/24 at 12:44 p.m., R3 did not have bed rails on her bed. During an observation on 3/21/24 at 12:34 p.m., the maintenance director (MD) was walking towards R3's room with grab bars in his hand. During an observation on 3/21/24 at 1:07 p.m., R2 and R3 had bed rails on their beds. R2's admission record printed on 3/20/24 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of endometrium. R2's additional diagnoses included neoplasm related pain and muscle weakness. R2's bed mobility device evaluation assessment dated [DATE] indicated R2 had bed rails. The assessment indicated R2 has not became entangled in the bed mobility device, R2 used the bed rails for repositioning while in bed, R2 used the bed rails to assist with transfers, and the device does not restrict her freedom of movement or normal access to their body. The assessment indicated R2 was able to demonstrate appropriate use of the device. The assessment indicated no alternatives had been attempted prior to the placement of the bed rails. The assessment did not indicate a review of medical diagnoses/conditions/symptoms/behavioral symptoms, size and weight, sleep habits, medications, acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication, mobility in and out of bed, or risks of falling. R2's brief interview for mental status (BIMS) assessment dated [DATE] indicated R2 had a score of 15 which indicated R2 was cognitively intact. R3's admission record printed on 3/20/24 indicated R3 was admitted to the facility on [DATE] with a primary diagnosis of undifferentiated schizophrenia. R3's additional diagnoses included osteoarthritis, vascular dementia with agitation, obesity, history of falling, muscle weakness, pain in left knee, and bilateral acute angle-closure glaucoma. R3's BIMS assessment dated [DATE] indicated R3 had a score of 15 which indicated R3 was cognitively intact. R3's bed mobility device evaluation assessment dated [DATE] indicated R3 had requested bed rails and was still waiting for them to be installed. During an interview with R3 on 3/21/24 at 1:36 p.m., R3 stated the facility nursing staff did not go over the risks versus benefits of the bed rails with her prior to installing the bed rails. During the interview with R3, R3 asked the surveyor what the risks were to having bed rails on her bed. During an interview with the therapy director (TD) on 3/21/24 at 2:06 p.m., the TD stated if a resident asked for bed rails on their bed, the interdisciplinary team (IDT) would meet and make a decision if the resident was appropriate for bed rails or not. The TD stated the nursing staff would go over the risks versus benefits with the resident if they are not on therapy services, but if the resident is on therapy services, the TD or other members of the therapy department would go over the risks versus benefits with the resident. The TD stated he was unaware R3 had bed rails installed earlier in the day. During an interview with the director of nursing (DON) on 3/21/24 at 2:19 p.m., the DON stated the bed rails assessments were completed when the resident was admitted into the facility. The DON stated if the resident needed bed rails during their admission, then the assessment was completed quarterly. The DON stated the assessment was called bed mobility device assessments. The DON stated whoever completed the bed mobility device assessments would go over the risks versus benefits of having the bed rails with the resident. The DON stated she was unaware R3 had bed rails installed earlier in the day. During an interview with the interim nurse manager (INM) on 3/21/24 at 2:39 p.m., the INM stated it was her responsibility to do the bed mobility device evaluation assessment on resident prior to the resident's receiving bed rails. The INM stated she completed an assessment on R3 prior to the installation of bed rails. The INM stated she reviewed entrapment concerns, asked R3 if she wanted the bed rails, went over the risks versus benefits, and explained the purpose of the bed rails. The INM stated she did not have R3 sign an informed consent prior to the installation of bed rails. The INM stated she did not look through R3's medical diagnoses, height, or weight prior to the installation of bed rails. The INM stated the staff member installing the bed rails would look at the height and weight of the resident prior to installing the bed rails. The INM stated she checked on R3 after the installation of the bed rails and stated R3 stated she was fine. During an interview with the INM on 3/22/24 at 9:30 a.m., the INM stated she would obtain informed consent by asking a resident if they wanted the bed rails and then she would do the bed mobility evaluation assessment. During an interview with the MD on 3/22/24 at 9:38 a.m., the MD stated the facility uses three different types of bed rails and each bed has specific rails that attach to each bed. The MD stated the bed rails are not interchangeable with the beds. The MD stated he does not look at the resident's height and weight prior to installing bed rails. The MD stated he did not look at R3's height and weight prior to installing her bed rails. During an interview with the INM on 3/22/24 at 10:54 a.m., the INM stated she did not know there are different types of bed rails. The INM stated the MD is responsible for doing the assessments to indicated what type of bed rails are appropriate for each resident. Bed rails policy and procedure was requested and none was given.

Based on observation, interview and document review the facility failed to ensure the completed Minimum Data Set (MDS) assessment was accurately coded to reflect cognition and mood for 2 of 3 residents (R1 and R2) reviewed for MDS accuracy. Findings Include: R1's optional state MDS dated [DATE], indicated R1 was admitted on [DATE] with diagnoses of cancer, anemia and adult failure to thrive. The assessments for sections for 'C'-Cognitive patterns and 'D'-Mood were blank and not completed in accordance with Resident Assessment Instrument (RAI). During an observation and interview on 12/27/23, at 8:57 a.m. R1 was seated in a wheelchair at a dining room table. R1 stated, I am here because I can't take care of myself anymore at home and I need assistance with basic things now due to my cancer. During an interview on 12/27/23, at 12:05 p.m. with therapy program manager (TPM)-A indicated R1 has not had any cognitive testing completed; R1 was seemingly with it, but did cry a lot. TPM-A stated R1 was stagnating in therapy and a hospice consult has been recommended. [R1's] cancer has metastasized to the right leg, gets weak easily, and needed time to complete activities of daily living (ADL)'s. R1's progress note dated 12/27/23, at 12:20 p.m. indicated R1 had brief interview for mental status (BIMS) and patient health questionnaire (PHQ)-9 assessments completed. R1's PHQ-9 scored a ten indicating moderate severe depression. R1 was offered associate clinic of psychology (ACP) services and agreed. R1's BIMS assessment dated [DATE] scored a 15, indicating R1's cognition was intact. R2's optional state MDS dated [DATE], indicated R2 was admitted on [DATE] with diagnoses of congestive heart failure, anemia, anxiety disorder, and schizophrenia. The assessments for sections for 'C'-Cognitive patterns and 'D'-Mood were blank and not completed in accordance with Resident Assessment Instrument (RAI). During an interview on 12/28/23 at 10:03 a.m., registered nurse (RN)-A indicated he was responsible to do portions of the MDS and submit them. RN-A indicated social worker designee (SWD)-A was responsible to complete section C for cognitive patterns and section D for mood patterns. RN-A stated, both R1 and R2's section C and D were missed for both assessments that were completed on 12/19/23 and 12/8/23 respectively and should have been assessed. During an interview on 12/28/23 at 2:18 p.m. SSD-A indicated she would have been responsible to do R1 and R2 section C and D for their MDS assessments. SSD-A indicated there was not always good communication on which residents she was responsible for doing the assessments on. During an interview on 12/28/23, at 10:42 a.m. nurse manager (NM)-A indicated R1 and R2's most recent MDS assessments lacked an assessment for section C and section D and indicated it should have been completed. During an interview on 12/28/23, at 12:56 p.m. interim DON indicated R1 and R2's most recent MDS assessments lacked an assessment for section C and section D and indicated it should have been completed. R2's BIM's assessment dated [DATE] at 7:06 p.m. identified R2 scored a 15, indicating intact cognition. MDS policy was requested and was not received.

Based on interview and document review, the facility failed to ensure resident specific advanced directive orders were accurately reflected throughout the medical record for 1 of 3 residents (R13) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R13 who would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R13's Provider Orders for Life-Sustaining Treatment (POLST) identified R13 had an active order to administer CPR, however, the physician orders indicated R13 was do-not-resuscitate (DNR). The administrator was notified of the IJ on [DATE], at 3:15 p.m. The IJ was removed on [DATE], at 11:00 a.m., but non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of chronic kidney disease (stage 5) and type II diabetes mellitus. It further indicated R13 required assistance from staff with most activities of daily living (ADL). R13's face sheet/banner in point click care (PCC) (computer program) indicated R13's code status was DNR. R13's physician orders dated [DATE], indicated R13's code status was DNR. R13's POLST signed by provider on [DATE], indicated R13's code status was full code (attempt resuscitation/CPR) and to provide full treatment. R13's care plan dated [DATE], indicated current code status was full code with an intervention of advance directive in place and will be honored during the review period. Review resident's advance directive as needed per resident and/or family request. During interview on [DATE], at 10:28 a.m., R13 stated (via interpreter) he wanted to be full code/attempt CPR. During interview on [DATE], at 10:34 a.m., licensed practical nurse (LPN)-A stated the first place LPN-A would look for code status (if a resident was found unresponsive) would be on the banner of the resident's face sheet in PCC. During interview on [DATE] at 10:37 a.m., registered nurse (RN)-A stated the first place RN-A would look for code status (if a resident was found unresponsive) would be on the banner of the residents' face sheet in PCC. During interview on [DATE] at 11:17 a.m., RN-B stated the first place RN-B would go to look for code status (if a resident was found unresponsive) would be on the banner of the residents' face sheet in PCC. During an interview on [DATE] at 11:20 a.m., the nurse manager RN-C stated the first-place nurses should look to identify a resident's code status was on the banner of the face sheet in PCC. RN-C further stated when a resident returns from the hospital the nurse who readmits the resident was responsible for filling out a new POLST. If there was a discrepancy in the residents' code status between the readmission orders and R13's previous advance directive orders the nurses were to speak with the resident or power of attorney (POA) to find out what they would like their code status to be and then proceed from there depending on the resident's response. RN-C verified R13's physician's orders and the banner on his face sheet in PCC both indicated DNR and stated it was incorrect because he's a full code. During an interview on [DATE] at 1:25 p.m., the director of nursing (DON) stated when R13 came back from the hospital ([DATE]) he had a physician's order indicating he was a DNR. The health unit coordinator (HUC) entered the information into PCC and noticed R13's code status had been full code before he was admitted to the hospital and reported the discrepancy to the nurse (unknown). The nurse was supposed to ask R13 what his wishes were regarding code status but never followed through. The DON also stated nurses were responsible for verifying code status with the resident or POA when they return from the hospital and fill out a new POLST (if needed). If the nurses don't follow this process/procedure resident wishes would not be respected. The facility's policy on POLST documentation revised on [DATE], indicated the purpose of the policy was to identify a code status consistent with resident wishes and to facilitate providing emergency care and services in accordance with the resident ' s plan of care. The IJ was removed on [DATE], at 11:00 a.m. when the facility developed and implemented a systemic removal plan which was verified by interview and document review, which included an audit of all resident's code status to ensure residents have matching code status order, POLST and Advanced Directive. The facility also reviewed and updated their POLST Policy and Procedure, which outlined the implementation of code status and where the staff would locate the code status. All licensed nurses and HUC's were trained immediately or prior to their next scheduled shift regarding the updated POLST procedure and to speak with the resident or resident's POA regarding resident code status if any noted discrepancies. All new admissions and readmissions to the facility will have the order, POLST, and PCC banner match to align with the residents wishes.

Based on observation, interview and document review, the facility failed to provide laundry services in a manner that promoted dignity for 1 of 2 residents (R28) reviewed for dignity concerns. Findings include: R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and did not reject cares. R28 had diagnoses of muscle weakness and depression. R28's MDS indicated he required substantial to maximal assistance with dressing and undressing. Additionally, MDS indicated he found it somewhat important to choose what to wear and very important that his personal belongings were taken care of. R28's care plan dated 11/15/23, identified he had a focus area of self-care deficit and indicated he required assistance with personal hygiene and dressing. During observation and interview on 12/11/23 at 1:37 p.m., R28 sat in a wheelchair and wore a long-sleeved shirt and shorts. R28 stated he ran out of clean clothes and tried for three days to have them cleaned. R28 stated he preferred to wear pants, however, was unable to get staff to wash his soiled personal items and did not have more clean socks or pants to wear, which was his preference. During observation and interview on 12/12/23 at 8:24 a.m., R28 sat in his wheelchair with a white sheet covering the lower half of his body. He reported that during morning cares, he told a NA he had no clean pants and the NA searched the laundry room for pants but could not find any. R28 stated the NA did not take his dirty pants to the laundry. R28 stated he would not leave his room wearing only a sheet and that, it's not my normal lifestyle, but I don't have a choice but to wear dirty jeans. During observation and interview on 12/12/23 at 3:46 p.m., R28 sat in a wheelchair in the hallway wearing jeans that had many stains on both legs and he stated they were dirty. During observation on 12/13/23 at 8:11 a.m., R28 sat in his room with only underwear on. He reported no one had collected his dirty clothes to be laundered. During interview on 12/13/23 at 8:07 a.m., housekeeping manager (HSKP) stated the NAs placed soiled linens and personal items in a tied plastic bag, then down laundry chutes. HSKP stated this happened multiple times per day. HSKP stated that all personal items were labeled, and they tried to return items to residents within the same day or next day. HSKP stated they provide laundry services daily. During interview on 12/13/23 at 8:36 a.m., NA-A stated soiled linens and personal items were placed in a tied plastic bag, brought to the soiled utility room as needed throughout the shift. NA-A stated the housekeeper usually brought personal items back to resident rooms once finished. During interview on 12/13/23 at 9:19 a.m., RN-C stated staff brought soiled personal items out for laundry services a couple times a day. RN-C was not aware of any residents refusing laundry services. RN-C stated that if a resident did not have any clean clothes, the expectation for staff was to search a miscellaneous clothing bin for something to wear while the clothes were cleaned. RN-C stated if there was nothing available, staff could offer a sheet for decency. During interview on 12/13/23 at 1:33 p.m., the director of nursing (DON) stated if a resident did not have any clean clothes to wear, the expectation would be to find a gown to wear. The DON stated she expected staff would make sure residents have clean clothes before they go out or offer a gown or something to cover them otherwise, yes, it would be a dignity issue. Facility policy Admission Policy dated 11/2023, indicated the facility would treat a resident with dignity in a manner and environment that recognized a resident's individuality and psychosocial needs.

Based on interview and document review, the facility failed to a conduct comprehensive assessment to determine causative factors of falls, and failed to develop and implement interventions to reduce falls for 1 of 3 residents (R2) reviewed for falls. In addition, the facility failed to conduct ongoing comprehensive assessment of neurological status following falls for 1 of 1 resident (R2) who sustained harm, a head injury and later died . Findings include A [DATE], State Agency (SA) report indicated R2 had fallen on ,[DATE] and [DATE] hitting his head during both falls. Following the fall [DATE], R2 had begun to vomit and was subsequently transferred to the hospital where R2 was diagnosed with [REDACTED]. During interview at 12:09 p.m. on [DATE], R2's case coordinator (CC)-A stated she had worked with R2 for the past 2 years. R2 had a history of [REDACTED]. R2 experienced extreme mood changes with extreme highs and lows, and required caregivers to provide continuous encouragement to maintain his motivation. CC-A also stated R2 had a history of [REDACTED]. CC-A said R2 was not realistic regarding his physical limitations, but required a walker for mobility. CC-A was not aware of R2's fall prevention care plan. The last time she'd spoken to R2 was on [DATE], when R2 had reported to her he was having a bad day, was dizzy, had sudden weakness and was unable to walk. CC-A stated prior to [DATE], R2 was able to walk, and she was unaware of any recent falls, or significant changes. On [DATE], CC-A had met with facility management and physical therapy to discuss discharge plans for R2. At that time, the facility had identified R2 as unsafe to discharge home because his gait was unsteady, he had exhibited multiple falls, and required stand-by assistance of 1 staff to transfer and walk. CC-A stated throughout (MONTH) 2019, family member (FM)-A had expressed concerns about R2's medication use indicating R2 had a history of [REDACTED]. CC-A also said R2 had experienced a reaction to [MEDICATION NAME] (an antianxiety medication), and had been 'loopy' with changes in cognition whenever he used the pain medication and [MEDICATION NAME]. In early (MONTH) 2020, FM-A had reported to CC-A R2 had passed away from a severe brain bleed on [DATE]. FM-A had informed her R2 had fallen on ,[DATE] and [DATE], hitting his head hard during both falls. R2 was not sent to the emergency room (ER) until he began vomiting after the fall [DATE]. During an interview with FM-A on [DATE], at 11:08 a.m. FM-A stated R2 was admitted to the facility for rehabilitation after a fall and [MEDICAL CONDITION] in his home. FM-A stated R2 had begun falling more frequently during (MONTH) 2019, and had fallen about 8 times. FM-A stated she didn't feel the facility had implemented measures to keep R2 safe. FM-A stated she'd had numerous conversations with the director of nursing (DON) regarding R2's safety and medications, and had repeatedly expressed concerns about R2's safety. The DON told FM-A he would take care of her concerns, but FM-A stated the facility never acted on the concerns to keep R2 safe, and never updated her regarding the plan to do so. FM-A also stated R2 used opioid (narcotic) pain medications and [MEDICATION NAME], and had a history of [REDACTED]. FM-A received a call to inform her R2 had fallen and hit his head 'really hard' on [DATE]. Between ,[DATE] and [DATE], FM-A had not visited the facility, but had spoken with R2 about five times each day. R2 had complained of a bad headache, indicating the nurses were aware, and provided him pain medication. FM-A stated she had asked the nurse to watch him closely, because she was worried about his condition. On [DATE], R2 had fallen and hit his head again. After the fall he'd begun to vomit and was sent to the hospital for evaluation. FM-A said R2 had been diagnosed with [REDACTED]. R2's [DATE], admission Minimum Data Set (MDS) assessment, indicated R2 had intact cognition with [DIAGNOSES REDACTED]. The MDS also indicated R2 exhibited verbal behaviors, required extensive assistance of 1 staff for all activities of daily living (ADLs), had constant severe pain, and exhibited shortness of breath at rest. R2 had a history of [REDACTED]. R2's [DATE], discharge MDS identified R2 had an unplanned discharge due to an acute hospitalization . The MDS indicated R2 required staff supervision for bed mobility and walking in the room, and had experienced 2 or more falls with no injury since prior assessment. R2's undated care plan identified: R2 had limited physical mobility and used a walker. Staff were to provide appropriate supportive care and assistance with mobility as needed. R2 had self-care deficits and required assistive device to maximize independence with turning and repositioning in bed. R2 had impaired balance, and preferred to wear improper footwear, and identified R2 had an actual fall on [DATE] with a minor injury. Interventions indicated staff were to encourage appropriate foot wear, and use a walker sign on the closet door. In addition, R2 had anti-skid strips placed on the floor near the bed and staff were to monitor R2's lying, sitting, and standing blood pressures (orthostatic blood pressures) on the 5th of every month. R2's care plan had not been revised to reflect any new interventions following the falls ,[DATE] and [DATE]. R2's ,[DATE], medication orders included: celecoxib 100 milligrams (mg) every 12 hours for pain; [MEDICATION NAME] extended release (ER) 240 mg every day for high blood pressure; [MEDICATION NAME] 250 mg three times daily for low-level therapeutically; [MEDICATION NAME] 80 mg daily for depression; [MEDICATION NAME] 600 mg three times daily for chronic pain; [MEDICATION NAME] 2 mg tablets, 1 mg every 4 hours as needed for pain; [MEDICATION NAME] 5 mg for [MEDICAL CONDITION]; memantine 1 mg two times daily for dementia; [MEDICATION NAME] ER 10 mg 1 time daily for overactive bladder; and [MEDICATION NAME] 50 mg at bedtime for substance abuse and mood disorder. Review of R2's blood pressures from (MONTH) thru (MONTH) 2019, indicated R2's blood pressures ranged between ,[DATE] to ,[DATE]. A Fall Report dated [DATE], identified at 7:00 p.m. R2's call light was on and an unidentified nursing assistant (NA) found R2 on the floor next to his bed. The report indicated R2 had reported his leg gave out when he tried to get up to go the bathroom. R2 had denied hitting his head, and no injuries were identified. R2's blood pressure was ,[DATE], and his pulse was 79. A Fall Report dated [DATE], identified at 7:30 p.m. R2 was found lying on his back in the bathroom. The report indicated R2 had stated he'd lost his balance getting up from the toilet. Further, the report indicated R2 had skin tears on his right hand, and staff had encouraged R2 to call for help when he wanted to get up, and had reminded him to use his walker. R2 had stated he was strong enough, and needed no staff assistance to go to the bathroom. The report made no mention of whether staff had monitored R2's orthostatic blood pressures. According to the Blood Pressure Summary records, R2's orthostatic blood pressure on [DATE], at 1:41 a.m. was ,[DATE]; at 2:46 p.m. R2's blood pressure was ,[DATE]; and at 5:43 p.m. R2's blood pressure was ,[DATE]. On [DATE], the DON had documented R2 was reluctant to ask for assistance, but continued to have PT and OT, and was deemed independent. The DON's notes indicated PT had changed R2's status to stand by assistance for transfers and ambulation with a walker, and R2's care plan was updated. There was no mention of staff monitoring R2's orthostatic blood pressures. Review of R2's medical record made no mention a fall evaluation had been completed on [DATE], and made no mention R2's fall interventions were evaluated. The [DATE], Fall Report indicated R2's care plan would be updated. Upon review of R2's care plan, no new interventions had been added to R2's care plan as a result of the [DATE] fall. R2's Fall Report from [DATE], at 1:15 p.m. indicated R2 was found in front of the bathroom wearing flip-flops. R2 had stated he was leaving the bathroom when he'd fallen. R2 had no injuries and no immediate interventions or fall reviews were documented in the fall report. A Fall Report from [DATE], at 5:30 p.m. indicated R2 had again been found on the floor. R2 had stated he'd tried to transfer himself to the bed, fell backwards, and had landed on his buttocks. R2 wore improper footwear, and had an unsteady gait. No immediate interventions were added to R2's care plan, nor did R2's Health Progress notes make mention of immediate interventions to prevent falls. R2's [DATE], Health Status Progress Note (PN) included a late Entry at 11:00 p.m.: (R2) fell yesterday at 4:10 p.m. vitals were stable. (R2) wore flip flops and was shaky when he was found on the floor. He stated he fell on his bottom first. (R2) was educated to call for help to transfer to the toilet. There was no indication staff had monitored R2's orthostatic blood pressures. The Blood Pressure Summary Report did not include any documentation for [DATE]. The DON R2's falls on [DATE]. The DON's documentation indicated R2 continued to self-transfer and did not follow cues or ask for assistance. A plan to remove flip-flops and provide gripper socks for safer footwear was identified, and maintenance was asked to place anti-skid strips to the floor near R2's bed to reduce risk of slipping. A sign was placed in the room to remind R2 to call for assistance and use his walker, and a grab bar had been added to the bed on [DATE] to assist with transfers. The DON's note made no mention R2's orthostatic blood pressures were monitored. R2's Fall Report from [DATE], at 7:00 p.m. indicated R2 was found lying on the floor by his bed. R2 had reported he'd tried to go to the bathroom, became dizzy, fell and hit his head. Further, the report indicated no injuries were observed, and R2's blood pressure was ,[DATE]. There was no mention staff had checked R2's orthostatic blood pressure or implementation of neurological assessment. A PN [DATE] at 11:21 p.m., indicated R2 had been found on the floor that day. R2 had stated he became dizzy, fell down, and hit his head. R2 had no injuries identified at that time. R2 was assisted off the floor with 3 staff, and vital signs were stable with a blood pressure reading of ,[DATE]. Staff were to continue to assess R2's neurological status. There was no mention of any other fall interventions having been identified following the fall, and no documentation to verify staff had monitored orthostatic blood pressure, or neurological assessment. Review of R2's record identified no fall risk evaluation was completed following R2's fall [DATE]. R2's [DATE], Blood Pressure Summary report made no mention R2's orthostatic blood pressures were specifically monitored post fall. R2's blood pressures were recorded as ,[DATE] on [DATE]. On [DATE], a progress note identified the IDT had determined R2 would benefit from a pharmacy review of his medications. The note indicated the pharmacist would be notified to conduct a pharmacy review, and staff would await results. There was no mention current interventions had been reviewed, or new fall interventions identified. There was no assessment data gathered by nursing for post fall review. In addition, there was no documentation to identify R2 was consistently monitored for potential head trauma after the initial assessment for early identification of head trauma. A PN from [DATE], at 5:30 p.m. included: (R2) was found lying next to his bed. (R2) stated he tried to hang up his [NAME]et, lost his balance, fell backwards and hit his head. Neuro checks were initiated, and were within normal limits. (R2) had no visible injuries and 1 to 2 hours later, (R2) began to have emesis and confusion, and was sent to the emergency department (ED) for evaluation. There was no documentation to identify R2 was consistently monitored for potential head trauma immediately following the fall in order for early identification of head trauma. On [DATE], the IDT review of R2's [DATE] fall noted R2 had a history of [REDACTED]. The review notes identified interventions implemented as: placing a sign in the room to remind him to call for assistance, anti-skid tape on the floor, PT, and OT, and placing the bed in low position. Further the notes indicated R2's call light was not on and the time of the fall, and he had no visible injury. According to the note, R2's neurological status was intact and R2 was transferred to the ED a few hours later with symptoms of nausea and confusion. During interview with licensed practical nurse (LPN)-A on [DATE] at 2:02 p.m., LPN-A stated when a fall occurred, staff were to assess for injury, monitor vital signs and range of motion (ROM), and assess for head injury. LPN-A stated there was a check list nursing used to ensure the physician, family, administrator, and DON were notified. An incident report was to be completed after all care and contacts were made. Nurses notes were documented in the PN. Staff also complete pain assessments and fall assessments. When a resident has an unwitnessed fall, neurological (neuro) checks are to be done every 15 min (minutes) x 1, then every half-hour, then every 1 hour, then every 4 hours, until stable. LPN-A stated, The facility used to have a neuro checklist, but I'm not sure what happened to it. During interview with registered nurse (RN)-A on [DATE] at 2:25 p.m., RN-A stated, All staff respond when a 'code tumble' is called. Nurse managers complete fall assessments and interview witnesses, assess for vital signs, injuries, and pain. Nursing staff also complete post fall vital signs every shift for 3 days, complete an incident report, and document all vitals in the resident's record. They also record an incident report and nurse's notes for monitoring. Neuro status is monitored every time falls are unwitnessed, or when a resident hits their head, and these are to be done every shift. If a resident has a serious 'hit', they would be monitored every 4 hour hours for 24 hours. Monitoring also depends on what the physician orders. Orthostatic blood pressures are not generally part of the fall assessments. RN-A said there were paper documents at the nurse's desk to record neurological checks and vital signs, and those worksheets would become part of the resident's record. During interview with the DON on [DATE] at 3:20 p.m., the DON described the expectation that nursing staff would complete a fall assessments after every fall. The IDT monitored fall documentation, and follow up with staff to ensure complete fall assessments were completed after every fall. The facility had identified fall assessments were not completed with every fall, and had identified there was no education or follow up with staff to ensure documentation was completed. The facility had no set policy for fall monitoring and neuro checks. Staff were to complete neuro checks when a resident fell . If neurological status was normal immediately after the fall, staff didn't need to do any further monitoring, unless the resident had a change in mentation or condition. Staff were expected to follow the facility's policies and procedures for fall management, implement immediate interventions, and monitor the resident according to the individual resident's symptoms at the time of the fall. The IDT reviewed falls weekly and as needed to ensure interventions implemented were effective, and to ensure additional interventions were identified and implemented when needed. Fall interventions were communicated during daily stand up meetings, and through change of shift verbal reports. The DON also verified there was no documentation available for R2's fall intervention communication and no documentation a fall evaluation including ongoing neurological checks continued after the [DATE] fall. No immediate interventions were documented when R2 was noncompliant. The DON verified if no changes occurred, documentation may not be included in the resident's records. Further, R2 had normal blood pressure monitoring monthly, so no additional monitoring was needed when R2's initial vital signs or neuro checks were within normal limits. During the 72 hour monitoring, if no changes occurred, documentation may not be included in the resident's records. After (R2's) fall on [DATE], the IDT determined (R2) was to have a medication review to address medications and fall involvement, but (R2) had an additional fall, was transported to the hospital, and did not return. The facility's [DATE], Fall Evaluation Safety Guidelines, indicated the purpose was to ensure the facility provided an environment free from hazards over which the facility had control and provided appropriate supervision to each resident as identified through the process of: (1) identifying hazards and risks; (2) evaluation; (3) implementation; (4) monitoring; and (5) analysis. The guidelines indicated falls evaluations were used to identify residents' risks for falling, and were completed on admission, quarterly, annually, and with significant changes in condition. A systems approach identified by the IDT (interdisciplinary team) was responsible for individualizing assessments for safety, identifying hazards, development and implementation of interventions to reduce accidents, and monitoring and evaluation for effectiveness and modification of approaches. Staff were to be educated and properly trained. Fall Management included: To review [MEDICATION NAME] and extrinsic factors, medication review, physical devices for accident prevention and potential hazards. The guidelines indicated residents were to be evaluated for orthostatic [MEDICAL CONDITION] indicating staff were to review and document the presence of orthostatic [MEDICAL CONDITION], and were to identify underlying medical conditions affecting balance, causation of dizziness or [MEDICAL CONDITION], and presence of medication side effects. In addition, the guidelines indicated staff were to document relevant post-fall clinical findings such as vital signs, neuro checks, pain, and changes in a resident's level of consciousness, in the resident's medical record and were to monitor and observe the resident for a minimum of 72 hours. Post fall investigations were to be reviewed on a daily basis in the facility's Risk Watch, to determine if further investigation of the incident was needed. These interventions were to be reviewed for appropriateness along with a weekly IDT review. Although requested, the facility provided no specific neurological check, unwitnessed fall, or head injury policies or procedures. In addition, R2's hospitalization record and neurological check data were not provided.

Based on interview and document review, the facility failed to ensure that ordered treatments and repositioning were provided to 1 of 3 residents, R1, to prevent and treat pressure ulcers. The facility also failed to accurately document the severity of R1's wounds and provide additional treatments. A Medication Administration Record [REDACTED]. There is no documentation that staff applied the paste in August, September, or October. A MAR indicated [REDACTED]. There is no documentation that staff applied the ointment in August, September, or October. A MAR indicated [REDACTED]. There is no documentation that staff applied the lotion in August, September, or October. A Treatment Administration Record (TAR) order for R1, dated (MONTH) 17, (YEAR), indicated to apply barrier cream to coccyx, surrounding buttocks, and bilateral ischium BID and PRN for incontinence. The facility did not provide documentation for August. For September, one staff documented completing this treatment on (MONTH) 7, (YEAR). Staff did not document any applications in October. A MAR indicated [REDACTED]. There is no documentation that staff completed a weekly skin assessment in August. A TAR order for R1, dated (MONTH) 17, (YEAR), indicated to complete a weekly skin assessment on bath day, noting a (+) for a new area of skin impairment and a (-) for no new area of skin impairment. Days that had been highlighted in (MONTH) were (MONTH) 3, 10, 17, and 24. Staff did not document completing a weekly skin assessment in September. (MONTH) 1 was highlighted for a weekly skin assessment; however, no staff documented an assessment on that day. R1's care plan, dated (MONTH) 17, (YEAR), indicated R1 had the potential for a pressure ulcer due to immobility. An occupational therapy (OT) evaluation, dated (MONTH) 18, (YEAR), indicated that R1 had an open area on her sacrum, and that staff applied a dressing. An OT Treatment Encounter Note, dated (MONTH) 22, (YEAR), indicated that R1 was dependent for bed mobility. A document dated (MONTH) 24, (YEAR), indicated that a physical therapy assistant discharged R1 from therapy with the following recommendations: that staff provides passive range of motion for R1's upper and lower extremities at least once per day, and repositions her every two hours. Review of R1's care plan indicated there was no intervention to reposition R1 every two hours. A physician assessment, dated (MONTH) 25, (YEAR), indicated there were no skin concerns. An admission skin assessment, dated (MONTH) 28, (YEAR), indicated that on the backside of her body R1 only had purple bruising on her right hand. A nurse practitioner assessment, dated (MONTH) 5, (YEAR), indicated that R1 had scattered bruising of her bilateral upper extremities. An occurrence report, dated (MONTH) 6, (YEAR) at 9:15 a.m., indicated a nursing assistant (NA) informed staff about areas of concern on R1's buttocks. The report indicated R1 had incontinence-associated [MEDICAL CONDITION] (IAD) on her bilateral buttocks and a pressure blister on her posterior thigh. The pressure blister measured 1 centimeter (cm) by 15 cm, and the right buttock wound measured 3 cm by 2 cm, with no depth. Staff cleansed the areas, applied a barrier cream, and called the doctor. The report indicated a family member stated, This is a recurring thing. The report also indicated the wounds were house acquired, but also that they occurred at [MEDICAL TREATMENT]. A progress note dated (MONTH) 6, (YEAR) at 9:36 a.m., indicated that a NA informed a nurse about areas on R1's buttocks, which were determined to be IAD. Staff also noted a right posterior thigh pressure blister that measured 1 cm by 15 cm. Staff cleansed the wounds and applied barrier cream. A progress note dated (MONTH) 6, (YEAR) at 3:18 p.m., indicated that R1 had severe IAD on her buttocks with three open areas. On (MONTH) 6, (YEAR), a nurse faxed a concern to the provider, which indicated that R1 had IAD on her right bilateral buttocks and a pressure blister on her right posterior thigh. The nurse requested an order for [REDACTED]. A TAR order for R1, dated (MONTH) 6, (YEAR), indicated to monitor bilateral buttocks for IAD in the A.M. and P.M. Of the 52 times that staff could have documented completing the monitoring in (MONTH) and October, staff documented it 20 times. A TAR order for R1, dated (MONTH) 6, (YEAR), indicated to monitor her right posterior thigh in the A.M. and P.M. Of the 52 times that staff could have documented completing the monitoring in (MONTH) and October, staff documented it 20 times. A TAR order for R1, dated (MONTH) 6, (YEAR), indicated to apply 40% zinc oxide BID with brief change and PRN. Of the 52 times that staff could have documented applying the zinc oxide BID in (MONTH) and October, staff documented it 20 times. Staff did not document any PRN applications in (MONTH) or October. A TAR order for R1, dated (MONTH) 6, (YEAR), indicated to apply [MEDICATION NAME] paste to affected areas topically BID and PRN with brief changes. Staff did not document any BID or PRN applications in (MONTH) or October. R1's care plan dated (MONTH) 6, (YEAR), instructed staff to apply barrier cream after each episode of incontinence, to send briefs and wipes to [MEDICAL TREATMENT], to check R1 every two hours and assist with toileting PRN, and to provide the appropriate incontinent product. R1's care plan, dated (MONTH) 6, (YEAR), indicated that R1 had actual moisture associated skin damage on her buttocks due to bowel and urinary incontinence. The care plan instructed staff to use disposable briefs and to check and change R1 every two hours and PRN for incontinence. A TAR order for R1, dated (MONTH) 7, (YEAR), indicated to send incontinence brief and wipes with R1 to [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays. Of the 12 days that are highlighted on the TAR for September, staff documented sending the brief and wipes to [MEDICAL TREATMENT] eight times. Skin grid documentation of R1's sacral wound on (MONTH) 6, 15, 22, and 29, (YEAR) indicated that R1 did not have any pressure ulcers. On (MONTH) 6, (YEAR), when staff initially identified the wound, a nurse documented that the wound was not present on admission and was IAD. On (MONTH) 29, (YEAR), a nurse documented that R1's sacral wound measured 2.5 centimeters (cm) long by 2.4 cm wide by 0.1 cm deep, with scant serosanguinous drainage and no odor. No eschar, tunneling, or undermining was noted. Skin grid documentation of R1's left buttock wound on (MONTH) 6, 15, 22, and 29, (YEAR) indicated that R1 did not have any pressure ulcers. On (MONTH) 6, (YEAR), when staff initially identified the wound, a nurse documented that the wound was not present on admission and was IAD. On (MONTH) 29, (YEAR), a nurse documented that R1's left buttock wound measured 3.5 cm long by 1.6 cm wide by 0.1 cm deep, with scant serosanguinous drainage and no odor. No eschar, tunneling, or undermining was noted. Skin grid documentation of R1's right buttock wound on (MONTH) 6, 15, 22, and 29, (YEAR) indicated that R1 did not have any pressure ulcers. On (MONTH) 6, (YEAR), when staff initially identified the wound, a nurse documented that the wound was not present on admission and was IAD. On (MONTH) 29, (YEAR), a nurse documented that R1's right buttock wound measured 3 cm long by 1.5 cm wide by 0.1 cm deep, with scant serosanguinous drainage and no odor. No eschar, tunneling, or undermining was noted. Staff documented a concern for R1 on (MONTH) 15, (YEAR). The concern indicated R1's roommate told a family member that R1 was left in feces for an extended period. Under Work Around the document indicated, said were short-handed. A progress note dated (MONTH) 19, (YEAR) at 10:20 a.m., indicated that R1's buttocks were still reddened and unchanged. A progress note dated (MONTH) 21, (YEAR) at 2:56 p.m., indicated that R1's wounds were showing improvement as evidenced by being smaller. A progress note dated (MONTH) 26, (YEAR) at 1:12 p.m., indicated that R1's wounds were showing improvement as evidenced by being smaller. A physician assessment, dated (MONTH) 28, (YEAR), indicated that R1 had scattered bruising of her bilateral upper extremities, no other skin concerns were noted. A progress note, dated (MONTH) 2, (YEAR) at 10:22 p.m., indicated that R1 was sleepy in the morning, being very lethargic and disoriented. R1 had a low blood pressure and staff contacted the on call provider at 4:30 p.m. The provider ordered staff to send R1 to the emergency room , which staff did at 4:58 p.m. On (MONTH) 3, (YEAR), under the heading Skin Problem Pressure Injury/Ulcer Coccyx (Active), hospital staff documented a pressure ulcer on R1's coccyx that was present prior to admission. A hospital palliative care conference note, dated (MONTH) 3, (YEAR) at 9:23 a.m., indicated R1 has skin problems on her backside, and these cause her pain. A hospital progress noted, dated (MONTH) 3, (YEAR) at 9:03 p.m., indicated a skin assessment was completed and R1 had a large pressure ulcer on her coccyx, with a large amount of serosanguinous drainage. R1 rated the pain on her coccyx 10/10. A hospital progress note, dated (MONTH) 4, (YEAR) at 11:07 a.m., indicated R1 had a pressure ulcer on her coccyx, with a large amount of drainage on the pad beneath her. A hospital progress note dated (MONTH) 4, (YEAR) at 1:00 p.m., indicated that a wound care nurse completed a wound assessment. The progress note indicated R1 had multiple wounds that were malodorous with necrotic tissue, and bruising on the backs of her thighs. R1 had an unstageable pressure ulcer on her coccyx measuring 3 cm long by 1.5 cm wide, with non-viable tissue. R1 had a stage 3 pressure ulcer on her sacrum measuring 5 cm long by 3.5 cm wide by 2 cm deep, with non-viable tissue. R1 had a stage 2 pressure ulcer on her left buttock measuring 4 cm long by 2.5 cm wide. R1 had an unstageable pressure ulcer on her right buttock measuring 9 cm long by 2 cm wide by 0.2 cm deep, with non-viable tissue. A resident grievance report dated (MONTH) 5, (YEAR), completed by facility management, indicated R1's family member reported that the facility caused R1's sore because staff were not providing any care to her. The report indicated R1's skin was within normal limits upon admission. The report indicated R1 returned from [MEDICAL TREATMENT] on (MONTH) 6, (YEAR) soiled. The wound care specialist's skin assessment found severe IAD on R1's sacrum and right and left buttock. The Director of Nursing (DON) called the [MEDICAL TREATMENT] center, who agreed to change R1's brief in the future, if the facility sent briefs and wipes. Per the report, a family member confirmed the [MEDICAL TREATMENT] center can let R1 sit in a soiled brief. The report indicated that staff checked and changed R1's brief every two hours, and that staff were turning and repositioning R1. During an interview on (MONTH) 15, (YEAR) at 3:08 p.m., Licensed Practical Nurse (LPN)-A stated R1 had reddened skin on her coccyx and buttocks due to IAD when she came to the facility, but that it was not a big area. LPN-A stated R1 could not turn herself in bed and had multiple risk factors for skin breakdown. LPN-A stated she did not remember R1 having any wounds, but she worked with R1 at the beginning of her stay, before R1 changed rooms. LPN-A stated she thought staff were turning R1 more than every two hours, plus applying lotion, and that the repositioning should be on R1's care plan and documented on her TAR. LPN-A stated R1 did not refuse cares and was not combative, that she was a nice woman. When interviewed on (MONTH) 15, (YEAR) at 4:43 p.m., LPN-B stated she thought she had cared for R1 for one shift. LPN-B stated she did not see, or remember anyone reporting to her, that R1 had any skin issues or wounds. LPN-B stated R1 was in bed all the time, and she did not think R1 could reposition herself. LPN-B stated upon admission a nurse does a skin assessment, and then every time a shower is given the NA will call the nurse to assess the resident's skin. LPN-B stated she never did a skin assessment on R1. LPN-B stated she did not remember how often staff repositioned R1, but she thought not everyone charted repositioning in progress notes. During an interview on (MONTH) 15, (YEAR) at 5:17 p.m., RN-C stated R1's skin was assessed upon admission, and he did not recall any skin issues. RN-C stated he did not become involved until R1 developed IAD. RN-C stated R1 was going to [MEDICAL TREATMENT] and having stool incontinence, and [MEDICAL TREATMENT] staff would not do anything during the four-hour [MEDICAL TREATMENT] period when R1 was recumbent on a gurney. RN-C stated stool is alkaline with a pH of nine, and that after 15 minutes of contact skin will have a mild burn, after one hour a moderate burn, and after four hours a severe burn. RN-C stated risk factors for R1 to have skin breakdown included: resistance to turning due to pain from a [MEDICAL CONDITION], obesity, prolonged periods of being out of the facility for [MEDICAL TREATMENT] three times per week with incontinence of stool, the inability to reposition herself in bed, and a history of having a sore. RN-C stated most IAD does not get beyond a second-degree burn, and that R1's family told him R1 had a problem with IAD several times from going to [MEDICAL TREATMENT]. RN-C stated as soon as staff informed him of R1's skin issues, R1 had a partial thickness wound on her sacrum and both buttocks. RN-C stated he obtained an order for [REDACTED]. RN-C stated [MEDICAL TREATMENT] staff did not always change the resident, but the situation improved and R1's wounds starting getting better. RN-C stated R1's wounds reached a stagnant point as her health deteriorated. RN-C stated the causative factor for R1's wounds and their deepening was stool, R1's deteriorating health, and poor protein intake. RN-C stated he thought R1 developed eschar before discharge, but without undermining or tunneling. RN-C stated R1's wounds never advanced to full thickness, except if eschar was present and staff could not assess the depth. RN-C stated stable, dry eschar protects from further burning of the skin with IAD, and that debridement was not done. RN-C stated he was certain R1's wounds caused her pain, but most of her pain revolved around her [MEDICAL CONDITION], and he thought R1 refused turning due to pain from her [MEDICAL CONDITION]. RN-C acknowledged that R1's wounds, with black eschar, could have been due to a combination of pressure and exposure to stool. When interviewed on (MONTH) 15, (YEAR) at 7:00 p.m., the Executive Director (ED) stated she did not know if R1 had any skin issues upon admission, but she knew the facility was tracking some sort of area during R1's stay. The ED stated there was a concern because R1 was sitting at [MEDICAL TREATMENT] with stool, the former Director of Nursing contacted the [MEDICAL TREATMENT] center, and [MEDICAL TREATMENT] staff agreed to provide incontinence care if the facility provided the supplies. The ED stated R1's family wanted her lying flat and did not want R1 to get up or come out of her room for meals. During an interview on (MONTH) 16, (YEAR) at 8:47 a.m., family member (FM)-E stated R1 had been in a wheelchair for [AGE] years and her skin was very vulnerable to breakdown. FM-E stated R1 had a pink mark from a healed sore on her coccyx when she admitted to the facility. FM-E stated neither she nor her sister saw repositioning at the facility, except when FM-E asked staff do to it, which was twice. FM-E stated staff never came into the room and said they had to reposition R1. FM-E stated any movement caused R1 pain, including repositioning, but once she was in a position she would be more comfortable. FM-E stated she never requested that R1 not be repositioned; the only thing she requested is that R1 not be in a chair. FM-E stated her family knew R1's history and she had to be moved or her skin would breakdown, that repositioning was imperative. FM-E stated family was told R1 needed to be repositioned every two hours, but she did not remember by whom. FM-E stated family knew nothing about R1's skin issues or any skin treatments, except for one call she received when R1 got her thumb caught in a siderail and had a bandage. FM-E stated between her sister and herself visiting, they were with R1 for four to five hours each weekday, and a few hours on each weekend. FM-E stated that when R1 discharged to the hospital, her skin was rotting and emitted a smell. FM-E stated R1 was incontinent, and when FM-E notified staff, it could take 10-30 minutes before staff would change R1. FM-E wondered how long it might take staff to change R1 during the night. FM-E stated part of the problem was communication; she wondered why the facility did not tell the family about R1's skin problems. In email correspondence on (MONTH) 16, (YEAR) at 5:12 p.m., the Administrator indicated that staff charting of repositioning for R1 would only be located in R1's progress notes. Review of R1's progress notes indicated that staff charted repositioning R1 17 times, from the date of R1's admission on (MONTH) 17, (YEAR) until her discharge on (MONTH) 2, (YEAR). When interviewed on (MONTH) 22, (YEAR) at 3:25 p.m., FM-F stated she visited R1 at the facility on non-[MEDICAL TREATMENT] days, arriving before lunch and leaving sometime after R1 ate. FM-F stated R1 always said her buttocks hurt, but she did not know R1 had sores again. FM-F stated she told nursing staff that R1's buttocks were hurting and they would give R1 a pain pill. FM-F stated R1 had some aches and pains in her shoulder, and she did say her hip hurt too, especially when moved, but many times R1 complained about pain on her buttocks. FM-F stated family wanted R1 to be comfortable, and FM-F would have to ask staff to reposition R1, staff did not explain the need for repositioning or offer to do so. FM-F stated on a couple of occasions R1 needed to use the bathroom, FM-F asked staff to help, but R1 was incontinent soon thereafter, and 20-30 minutes passed before staff provided cares. FM-F stated R1's roommate told her R1 would ask staff to clean her up, but it took quite some time for staff to do so. During a second interview on (MONTH) 25, (YEAR) at 10:06 a.m., RN-C stated R1 did not have any staged pressure ulcers. RN-C stated wound treatments should only be documented on R1's MAR, TAR, and in progress notes. RN-C stated when staff obtained an order for [REDACTED]. under control since for four hours at a time R1 was potentially lying in stool. When interviewed on (MONTH) 22, (YEAR) at 10:08 a.m., the provider stated when R1 was admitted to the facility, nothing was immediately brought to her attention about R1 having any skin issues. The provider stated at some point staff called about IAD and wanted orders for a barrier cream. The provider stated R1 had IAD on her buttocks and coccyx area that became quite severe as time progressed. The provider stated staff told her R1's wounds had progressed to full thickness skin loss by the end of her stay. The provider stated the full thickness wound(s) should have been staged as a pressure ulcer, that she thought one wound was a stage III. When reviewing the wound documentation, the provider stated she did not understand why the staging said not applicable, that the wound nurse was not calling R1's wound(s) a pressure ulcer or putting a stage. In the wound documentation, the provider noted she could see that wounds were measured and became larger, but the documentation indicated wound depth did not change. The provider stated she recalled being verbally told R1's wounds were getting deeper, and the wounds staff were most concerned about were on R1's right and left buttocks. The provider stated as R1's wounds progressed, there should have been other treatments besides zinc oxide barrier cream; if R1's wounds were progressing, other treatments should have been tried. The provider stated causative factors for R1's wounds were pressure, incontinence, the inability to reposition herself, and her overall debility with pain. The provider stated at the time of R1's stay in the facility, she was not aware R1 had any pressure ulcers, eschar, or full thickness skin loss. The provider stated that besides trying to relieve pressure on R1's wounds, other treatments could have included dressings to pack the wounds to try to facilitate healing, or dressings to reduce pressure and protect the area such as foam dressings. The provider did not recall R1 or her family saying that R1 could not be repositioned, although repositioning could have caused pain or bleeding with her [MEDICAL CONDITION]. A facility policy dated (MONTH) (YEAR) and titled Mitigating Factors for the Development of Pressure Ulcers, indicated clinical conditions that can increase the likelihood of a pressure ulcer being unavoidable include: resident immobility, continuous urinary incontinence, chronic bowel incontinence, end stage [MEDICAL CONDITION], [MEDICAL TREATMENT], malnutrition due to poor appetite, non-compliance with care interventions such as turning, repositioning, and treatments, among others. The policy indicated under Procedure, 1. Ensure all routine preventive care is provided for pressure ulcers. A facility policy dated (MONTH) (YEAR) and titled Weekly Skin Assessment, indicated The center requires staff to complete a Weekly Skin Assessment. This assessment includes a head to toe visualization of the resident's skin. The policy indicated that documentation of the weekly skin assessment was to be on the TAR. A facility policy dated (MONTH) (YEAR) and titled Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, indicated Neglect is failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.