Every finding on record at The Villas at the Park

Based on observation, interview and document review the facility failed to ensure a resident received appropriate interventions to prevent contractures for a resident who was admitted to the care facility without contractures (permanent shortening of tissue, such as muscle, tendon or skin leading to the inability to straighten joints fully and to permanent deformity and disability) for one of two residents (R20) reviewed for range of motion. This resulted in actual harm when R20 developed severe contractures of bilateral upper and lower extremities. Findings include:R20s significant change Minimum Data Set (MDS), dated [DATE], indicated R20 was admitted to the care facility on 3/20/19. The MDS indicated R20 was not on any range of motion or restorative nursing programs. R20's previous MDS dated [DATE] further indicated R20 had range of motion impairment on only one side of his body and also lacked any mention of a range of motion or nursing restorative program. The MDS dated [DATE] further indicated R20 was independent with bed mobility rolling side to side. R20's diagnoses list indicated R20 had several medical diagnoses including aphasia (impaired ability to understand or produce speech as a result of brain disease or damage) and hemiplegia (a form of paralysis that affects one side of the body, usually due to a brain or spinal cord injury) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (stroke) affecting right dominant side, dated 4/19/20.R20's care plan, dated 7/9/2019, indicated R20 had an activity of daily living self-care performance deficit r/t [related to] acute ischemic CVA [cerebral vascular accident] and dementia, refusal of cares and varying level of cares needed indicating resident has preference to lie on sides in 'fetal position' as this is most comfortable for him. The care plan indicated R20 required a Hoyer lift for transfers, dated 4/20/20, however fall interventions were in place on 8/27/23, indicating R20 was utilizing a walker and to keep walker in reach and also had a wandering guard, dated 2/2/23 for exit seeking behavior. The care plan further indicated R20 was independent with transfers upon admission and lacked any interventions regarding, or to prevent, R20's contractures (i.e. range of motion). R20's Balance/ROM (range of motion) Assessment, dated 5/14/24, indicated R20 had no impairment of his upper and lower extremities including shoulder, elbow, wrist, hand and hip, knee, ankle, foot joints.R20's Census report indicated R20 was admitted to hospice services on 7/24/24, and his guardian revoked hospice services on 10/10/25.R20's electronic medical record (EMR) indicated R20 was hospitalized on [DATE] after hospice services were revoked due to refusing oral intake. It was noted R20 had visible signs of pain with right lower and upper extremity movement but was able to tolerate passive range of motion and was dependent on staff for bed mobility. The note further indicates R20's lack of range of motion affect R20's ability to safely and independently engage in all activities of daily living. R20's physical therapy note from his hospitalization, dated 10/16/25, indicated R20 had contractures of all extremities; right lower extremity: contracted in 45-degree knee flexion, left lower extremity: contracted in about 15-20-degree flexion, left upper extremity: contracted at 50-60-degree flexion.R20's facility occupational therapy evaluation, dated 11/11/25, indicated R20 was unable to sit up unassisted and due to contractures of all extremities, it was not attempted to have R20 bear weight or attempt ambulation.During observation on 11/17/25 at 2:41 p.m., R20 was lying in bed on his right side in a fetal position in bed.During observation on 11/18/25 at 12:33 p.m., R20 was lying in bed on his right side in a fetal position in bed.During observation and interview on 11/19/25 at 8:20 a.m., nursing assistant (NA)-B stated R20 use to be able to sit up in bed and get up in his broda chair (specialized wheelchair designed for comfort, posture support, and safety) but was no longer getting out of bed due to contractures in his knees, stating when R20 came off hospice he declined and now doesn't move. NA-B and NA-C provided morning cares and a brief change for R20. R20's legs were extremely contracted, with the knees bent and unable to straighten as NA-B and NA-C rolled him side to side to provide peri care and a clean brief. R20 was noted to grimace and call out in distress when rolling side to side. NA-B confirmed R20 was unable to straighten his legs and was not receiving any passive stretching from the NAs, nurses or therapy staff.During an interview on 11/18/25 at 1:32 p.m., physical therapist (PT)-A stated R20 had been able to move all extremities spontaneously and was getting up onto his broda chair while on hospice. PT-A stated R20 had declined and she would be surprised if he could tolerate getting up in a chair anymore. PT-A stated R20 was last on physical therapy caseload in July of 2024 but had received an occupational therapy consult on 11/11/25.During an interview on 11/18/25 at 2:19 p.m., occupational therapist (OT)-A stated she completed an evaluation with R20 on 11/11/25 due to his brother requesting a consult for fall prevention and to help R20 walk again. OT-A stated R20 used to get up walking but had been bed-bound for quite a bit. OT-A stated during her evaluation, R20 was unable to maintain a sitting position, was contracted in all of his joints, and due to the severe contractures in his knees preventing him from straightening his legs she could not even attempt to get him to bear weight.During an interview on 11/19/25 at 11:44 a.m., nurse manager and licensed practical nurse (LPN)-A stated R20's contractures progressed while he was on hospice and therapy and/or range of motion was not initiated due to R20 being on hospice.During an interview on 11/19/25 at 1:35 p.m., R20's provider and physician assistant (PA)-A stated R20's care would have been managed by hospice until about mid-October when he was revoked from hospice services. PA-A stated it was never brought to her attention while R20 was on hospice that he was becoming more contracted and over the summer hospice chose not to do anything about his contractures. PA-A stated R20 should be evaluated by occupational therapy for his contractures and that range of motion or stretching had not been initiated sooner because R20 was on hospice, stating she assumed hospice would have been addressing those needs.During an interview on 11/19/25 at 1:16 p.m., R20's hospice registered nurse case manager (RNCM)-A stated she became R20's RNCM in June or July of this year. RNCM-A stated at that time R20 was able to stand and pivot transfer and did not have any contractures. RNCM-A stated R20 would always lay in bed with his legs crossed and straight. RNCM-A stated after she took over as case manager, R20's legs started becoming more and more contracted until they could not be straightened anymore. RNCM-A stated since R20 was on hospice services, therapy and/or range of motion services were not provided.During an interview on 11/20/25 at 7:50 a.m., the director of nursing (DON) stated she believed R20 was not as severely contracted until the end of R20's hospice service in October, worsening after his revocation from hospice in mid-October. The DON stated neither hospice nor the hospital post hospice revocation recommended any therapy or range of motion programs so range of motion exercises were never initiated for R20. The DON stated when OT evaluated R20 on 11/11/25, she would have expected them to initiate a range of motion program if needed despite the goal of the evaluation being to determine if R20 would benefit from services to gain strength in hopes to walk again. The DON confirmed R20 was no longer getting up in his Broda chair, confirming it may be too uncomfortable for him.During an interview on 11/20/25 at 8:25 a.m., OT-A stated range of motion exercises are used to slow down or prevent the development of contractures and are a comfort thing as even dressing can become painful when someone is as contracted as R20 has become. OT-A stated she checked her evaluation with R20 from 11-11-25 and had recommended staff to do range of motion exercises with dressing. During an interview on 11/20/25 at 9:54 a.m., R20's provider physician-A stated there were multiple ways to prevent contractures and/or prevent them from getting worse, including in R20's situation. Physician A stated hospice residents' care would be decided by the hospice care team as some residents may want or benefit from therapies to focus on comfort even when they are on hospice services, confirming hospice resident can and should receive therapy services focused on comfort while they are on hospice. Physician-A stated he was not aware of how severe R20s contractures had become and would have expected R20's contractures to be assessed for treatment to prevent them from getting so severe, stating he would have also expected to be notified if hospice was not adequately addressing R20's contractures so he could be involved with treatment. Physician-A stated therapy and range of motion is helpful, but nursing care is also important (i.e. elevating legs in bed to help straighten them) and at times medication such as muscle relaxers are used.A facility policy on range of motion service and/or services to prevent contractures was requested and not received.

During observation and interview, the facility failed to implement interventions to ensure resident's personal care information was kept secured and out of public view when stored on 1 of 3 mobile medication carts. This had the potential to affect 14 residents (R3, R4, R9, R14, R27, R28, R30, R32, R35, R40, R43, R47, R48, and a discharged resident) on the long-term care unit whose personal information was left unattended on a medication cart in the hallway corridor. Findings include:During observation and interview on 11/19/25 at 9:05 a.m., an unattended medication cart had a form titled East nursing care sheet with 13 resident names, room numbers, and notations including other personal information such as nutritional needs such as tube feeding, blood sugars, blood pressures, heart rates, recent falls with confusion and wearing adaptive equipment. Electronic medical record (EMR) access username, password, and wifi information was also included. In addition, the cart had an opened narcotic logbook with two residents' information including name, room number, and narcotic dosage information. Two residents and one staff member walked past the unattended medication cart. At 9:07 a.m., registered nurse (RN-A) walked out of a resident room down the hall and towards the unattended medication cart. RN-A stated she was responsible for the unattended medication cart with the exposed resident care sheet and the opened narcotic logbook. RN-A stated, it should not be left open like that because of HIPAA. RN-A stated the narcotic logbook should be closed so the information is not visible to anyone walking past it.During interview with director of nursing (DON) on 11/1925 at 9:08 a.m., DON stated expectation of patient information to be covered and secured.Electronic mail received from DON 11/19/25 at 9:37 a.m., identified the two residents who names and information exposed from the narcotic logbook were R3, and R30.During an interview on 11/19/25 at 12:59 p.m., nursing assistant (NA)-A stated care sheets should not be kept in an open area to ensure patient privacy. NA-A stated it was important that this information was kept out of the open to ensure staff members or visitors who were not permitted didn't see resident's private medical information.During an interview on 11/19/25 at 1:10 p.m., registered nurse (RN)-A stated all documents with resident personal information should be kept private such as in the nursing station with the door locked or turned over if it is a document that is actively being used. RN-A stated this was important ensure patient privacy.Undated facility policy titled HIPAA and Confidentiality of Client Matters identify, The Resident [NAME] of Rights and the HIPAA Privacy and Security Standards require protection of and restrict the disclosure and use of clients' individual health information.

Based in interview and document review, the facility failed to ensure a resident had an appropriate diagnosis and indication for use for a prescribed antipsychotic medication for one of five residents (R12) reviewed for unnecessary medications. Findings include:R12's admission minimal data set (MDS), dated [DATE], indicated R12 was admitted to the care facility on 10/29/25, had moderate cognitive impairment and had received antipsychotic medication during the 7-day lookback period.R12's diagnoses list, dated 10/29/25, indicated R12 was at the care facility with a primary diagnosis of sequelae of cerebral infarction (long term conditions post stroke).R12's physician orders, dated 10/29/25, indicated R12 had an order for Seroquel (an antipsychotic medication) 12.5 milligrams (mg) at bedtime.R12's November medication administration record (MAR) indicated R12 had received a dose of Seroquel every evening that month for a total of 19 doses.R12's electronic medical record (EMR) lacked evidence R12 had an appropriate diagnosis and indication for use for Seroquel.During an interview on 11/19/25 at 11:44 a.m., nurse manager and licensed practical nurse (LPN)-A confirmed R12 did not have an appropriate diagnosis of indication for use in the EMR for Seroquel use and stated it would be expected that medications, including indication for use, would be reviewed during admission to the care facility.A facility policy titled Psychotropic Medication Use, dated 5/2025, indicated the indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. The medical record must show documentation of adequate indication and diagnosed condition.

Based on observation, interview, and document review, the facility failed to ensure that residents requiring assistance with eating were provided services by qualified staff for 1 of 1 residents (R47) reviewed requiring a mechanically altered diet.Findings include: R47's quarterly Minimum Data Set (MDS), dated [DATE], indicated R47 had severe cognitive impairment and was dependent on staff for assistance with eating. The MDS indicated R47 was on a mechanically altered diet and utilized a feeding tube.R47's care plan dated 7/2/25, indicated R47 required assistance from staff with eating. R47's speech therapy discharge note dated 10/7/25, indicated R47 had a diagnosis of dysphagia, respiratory failure, and a traumatic brain injury. The note from the speech therapist recommended R47 be on a minced & moist (food consists of small, soft lumps) diet with thin liquids. The note indicated R47 required staff supervision/assistance at mealtime to swallow safely. The note indicated R47 should be sitting at 90 degrees while intaking food/liquids. R47's order summary dated 11/12/25, indicated R47 required a minced and moist textured diet with thin liquids. The summary indicated R47 received nutrition through a feeding tube twice a day. During the entrance conference on 11/17/25 at 12:29 p.m. with the administrator and director of nursing (DON), the administrator confirmed that the facility did not employ any paid feeding assistants. During an observation and interview on 11/18/25 at 8:20 a.m., R47 was observed lying in bed in his room with the head of the bed (HOB) at a 30-to-45-degree angle, with solely the social services director (SSD) accompanying him. The SSD was observed sitting next to R47 and assisting the resident with eating, repeatedly bringing utensils full of food to R47's mouth. R47 was observed with no signs of choking or coughing, and his HOB remained at a 30-to-45-degree angle. At 8:30 a.m., the SSD confirmed he had assisted R47 with eating his morning meal. The SSD stated he helped with feeding residents whenever it was needed and had assisted residents with eating in the past at the facility. The SSD confirmed he was not a certified nursing assistant (CNA), and although he had attended a seminar in college on assisting residents with eating, he was not formally certified to do so. The SSD stated he thought he had completed some training on assisting residents with eating while at the facility but wasn't exactly sure when. The SSD's training records regarding feeding residents from before the survey start were requested from the facility and not received. During an interview on 11/18/25 at 9:28 a.m., the administrator stated that after hearing about the incident with the SSD assisting a resident with eating earlier in the day, she had completed immediate education with the SSD on feeding residents. The administrator stated the SSD did not have any previous training at the facility regarding feeding and was not certified to do so. The administrator stated she would expect nursing staff to assist R47 with eating, and this was not something the SSD should assist with. During an interview on 11/19/25 at 9:43 a.m., the DON stated the nurses and nursing assistants were the only ones at the facility who had met the requirements to feed residents. The DON stated that the SSD had not met the requirements as he did not have a certification to feed residents. The SSD stated that if he wanted to help with feeding residents, he would need to take a class to become certified in this. The SSD stated that after she had found out that the SSD had assisted R47 with eating, she had completed an assessment on R47 and determined that no harm had occurred. A policy regarding assisting residents with eating was requested but not received.

Based on observation, interview and document review the facility failed to ensure a resident (R20) was assessed and care planned for a dignified toileting experience for a continent resident who was told to wet himself for toileting.Findings include:R12's admission minimal data set (MDS), dated [DATE], indicated R12 was admitted to the care facility on 10/29/25, had moderate cognitive impairment and required extensive assistance with most activities of daily living (ADLs).R12's diagnoses list, dated 10/29/25 indicated R12 as admitted to the care facility with a primary diagnosis of sequelae of cerebral infarction (long term conditions post stroke).R12's bladder evaluation, dated 11/4/25, indicated R12 had functional incontinence which could be related to the following impaired mobility, manual dexterity impairment, lack of toilet or toilet substitute, use of restraints, medications. R12's care plan, dated 11/6/25, indicated R12 transferred with the assistance of an easy stand (a machine that lifts an individual directly from a seated surface, like a wheelchair or bed, into a standing position.)During an interview on 11/17/25 at 1:51 p.m., R12 stated he was able to sense when he needed to urinate, and facility staff would tell him to wet himself when he asked to use the toilet. R12 stated it felt awful to have to urinate in his brief and would prefer to use a urinal or the toilet.During an interview on 11/18/25 at 2:19 p.m., occupational therapist (OT)-A stated she worked with R12 last week to get him to use the urinal, stating he was more fatigued last week than he has been this week so they will work on getting him to the commode today. OT-A stated R12 was able to sit on the side of the bed and shimmy his pants down and just needed assistance to place the handheld urinal. OT-A stated she could understand why R12 was frustrated because staff were telling him to go [urinate] in his pants when he could control his bladder. OT-A stated the floor staff could be assisting him with the handheld urinal placement. During an interview on 11/19/25 at 8:20 a.m., nursing assistant (NA)-B and registered nurse (RN)-B both stated R12 was able to let them know when he needed to urinate but he needed to use his brief because his hands shake, and he could not place the handheld urinal on his own.During an interview on 11/19/25 at 11:44 a.m., nurse manager and licensed practical nurse (LPN)-A stated it was expected of staff to use a bed pan or a urinal with resident who was asking to use one, or asking to use the toilet, indicating the resident could sense the need to urinate. LPN-A confirmed the floor staff should assist R12 with placement of the handheld urinal if he was asking or aware he needed to urinate. LPN-A stated it was never okay for staff to tell a resident to wet yourself.A facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities Policy, dated 3/31/23, indicated It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.

Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 2 of 5 residents (R7, R12) reviewed for use of psychotropic medications. Findings include:R7 R7's admissions Minimum Data Set (MDS) dated [DATE] identified R7 with severely impaired cognition, dependent for all cares, and diagnoses of anoxic brain damage (loss of oxygen to the brain for a period of time resulting in damage), seizures, schizophrenia, and dysphagia (impaired swallowing). In addition, R7 had a feeding tube for nutrition. R7 physician orders dated 8/18/25 identified: Haloperidol [psychotropic] Oral Tablet 5MG, Give 5mg via G-Tube two times a day for . related to SCHIZOPHRENIA,UNSPECIFIED (F20.0);CATATONIC SCHIZOPHRENIA (F20.2). R7's medication administration records (MARs) identified R7 was administered Haloperidol August 2025: 51 doses, September 2025: 60 doses, October 2025: 61 doses, missing dose on October 29 8:00 a.m. timeslot, November 2025: 31 doses as of 11/18/2025. However, R7's EMR was reviewed and lacked evidence a signed consent for use of the medication was obtained prior to it being provided. Further, R7's EMR lacked evidence the risks of expected benefits of the medication regimen had been reviewed or discussed with R7's resident representative (FM-B) prior to administering it. During interview with nurse manager (NM) on 11/19/25 at 8:59 a.m., NM stated facility expectation to receive or obtain written informed consents for psychotropic medications upon admission from resident or residents' family. NM stated, it was done with [R7's] daughter (FM-B). NM looked in R7's electronic medical record (EMR) and verified consent was missing. During interview with FM-B on 11/19/2025, at 11:09 a.m., FM-B stated she did not recall signing a form or being told by the facility specifically about any of R7's Haloperidol. FM-B stated she did not receive explanation of the risk or benefits, other treatment alternatives or other options to prescribing Haloperidol to R7. Findings include: R12's admission minimal data set (MDS), dated [DATE], indicated R12 was admitted to the care facility on 10/29/25, had moderate cognitive impairment and had received antipsychotic medication during the 7-day lookback period. R12's physician orders, dated 10/29/25, indicated R12 had an order for Seroquel (an antipsychotic medication) 12.5 milligrams (mg) at bedtime. R12's November medication administration record (MAR) indicated R12 had received a dose of Seroquel every evening that month for a total of 19 doses. R12's electronic medical record (EMR) lacked evidence R12 and/or their representative was informed in advance of the risks and benefits of the medication and any treatment alternatives or other options available. During an interview on 11/17/25 at 1:58 p.m., R12 stated he could not recall signing a consent for any medication upon admittance to the care facility. During an interview on 11/19/25 at 11:44 a.m., nurse manager and licensed practical nurse (LPN)-A confirmed she was not able to find a consent for R12's Seroquel and that it would be expected that a consent would be received during admission to the care facility. Electronic messaging (email) from director of nursing (DON) on 11/19/2025 at 1:01 p.m., DON stated, We did not complete informed consents for [R7] and [R12] on admission as medications were started in the hospital. There was a misunderstanding if informed consents only needed to be done if facility started a psychotropic or increased the dosage. Facility policy titled Psychotropic Medication Use Policy, revised 5/2025 identified, 6. Consent: Provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment. a. Obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice.

Based on observation, interview and document review the facility failed to ensure a bed bound resident was care planned for, and received, adequate activities for social and mental stimulation for one of two residents (R20) reviewed for activities. Findings include:R20s significant change minimal data set (MDS), dated [DATE], indicated R20 was admitted to the care facility on 3/20/19 and was dependent on staff for all activities of daily living. The MDS further indicated R20 was not assessed for activity preferences nor did staff complete an activity assessment. R20's diagnoses list indicated R20 had several medical diagnoses including aphasia and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dated 4/19/20.R20's Census report indicated R20 was admitted to hospice services on 7/24/24 and revoked hospice on 10/10/25.R20's Activity Participation Review, dated 9/18/25, indicated R20 preferred to listen to his favorite music in his room and watch[es] TV. He likes to have visitors from hospice staff and with his brother.R20's care plan, dated 9/18/25, indicated R20 lived at this facility for some time. The resident is formerly from [another country] and was a lawyer for many years. [R20] occasionally will attend activities but not participate as he likes to watch and be in the company of others. In his free time, the resident enjoys people-watching, snacking, resting, reading, and relaxing. He enjoyed painting in the past. English is his second language. Most current interventions were also dated 9/18/25 and lacked updated interventions when R20 discharged from hospice services. During observation on 11/17/25 at 2:41 p.m., R20 was lying in bed, his eyes were open, and he was unable to verbally communicate. No music was on his room, and his roommates TV was on, but he did not have a TV that could be seen from his bed. During observation on 11/18/25 at 12:33 p.m., R20 was again lying in bed, in the fetal position with music, TV or any other type of activity or stimulation. R20 appeared to be awake. During observation and interview on 11/19/25 at 8:20 a.m., R20 was again lying in in bed, in the fetal position with music, TV or any other type of activity or stimulation. R20 appeared to be awake. Nursing assistant (NA)-B and NA-C entered R30's room to provide morning cares. NA-B stated R20 used to get out of bed with hospice but since he revoked hospice services R20 doesn't move and does not get out of bed or attend activities. During an interview on 11/19/25 at approximately 11:58 a.m., the therapeutic recreation director (TRD) stated it was expected that residents were reassessed for activity preference quarterly and with a significant change in condition, such as admitting or discharging from hospice services. The TRD stated the care plan would then be updated after the correlating assessment, stating she would have to look at whether R20's care planned activities had been updated after discharging from hospice services. The TRD stated R20 was in a private room while on hospice services and staff would play special music for R20 on his TV. The TRD confirmed R20 had been in bed for quite some time now. The TRD did not follow up with any additional information regarding R20 being reassessed for activity preference or care plan updates since 9/18/25.During an interview on 11/19/25 at 11:44 a.m., nurse manager and licensed practical nurse (LPN)-A stated R20 was isolated per his choice, saying he will either ignore you or bat you away if he didn't want to engage, or give thumbs-up if he was happy. During an interview on 11/20/25 at 7:55 a.m., the director of nursing (DON) stated she believed R20 had a radio with CDs from hospice, indicating she would care plan for R20 to have music playing in his room and ensure a CD and/or CDs were in his room for use. A facility policy on activities was requested but not received.

Based on interview and document review, the facility failed to ensure binding arbitration agreements of 1 of 3 residents (R23) were clearly communicated in a form and manner that they understood prior to signing the forms. Findings include:R23's quarterly Minimum Data Set, dated [DATE] identified R23 with intact cognition and no impairment in memory or mood.Record review of R23's MN admission Packet in her electronic medical record (EMR) identified admission to facility on 1/20/23, however it was electronically signed 11/17/25, by both R23 and the social services director (SS-D).During interview with R23 on 11/18/25 at 10:56 a.m., R23 verified she had been a resident of the facility since January of 2023 and had no memory issues. R23 stated she was aware of what arbitration is and defined it as, arbitration is when you have a dispute of some kind and both sides agree to have somebody to listen to both sides. Let them decide instead of going to a jury. R23 stated no one from the facility spoke to her on 11/17/25 about signing and agreeing to arbitration in cases of disputes. R23 stated she did not sign paperwork or computer on 11/17/25. In addition, R23 stated, I am not sure I would agree to it anyways.During interview with R23's emergency contact family member (FM-A) on 11/18/25 at 12:08 p.m., FM-A stated she was familiar with the forms that were signed when R23 was admitted to facility in 2023. RM-A stated, [R23] can let you know whether she agreed to it [arbitration] or not. She would remember.During interview with SS-D on 11/18/25 at 11:08 a.m., SS-D stated process for reviewing the arbitration process with new admissions was to present a video and explain to the resident or their representative how arbitration works. SS-D reviewed R23's MN admission Packet in her EMR dated 11/17/25. SS-D stated the signature throughout the packet was his and it was all dated 11/17/25 and not the date of R23's admission to facility in 2023. SS-D stated, I don't recall talking to [R23] yesterday. I did not sign that form yesterday.During interview with administrator on 11/18/25 at 11:18 a.m., the administrator reviewed R23's MN admission Packet in her EMR and stated, we audited [the resident charts] yesterday [when SA entered the facility]. I don't know if [R23] admission packet was scanned in or not in 2023, so SS-D went in and reviewed it with R23. The admission packet was signed yesterday and downloaded yesterday into the EMR. Administrator stated, this is definitely confusing that [SS-D] signed the scanned forms here and he doesn't remember discussing this form with [R23]. R23 would definitely remember if she signed the paperwork yesterday or not. If she said she did not sign anything then she did not.Facility policy on arbitration was requested and not received.

Based on observation, interview, and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 2 of 2 residents (R30, R33) identified at risk for pressure ulcers. This resulted in actual harm when R30 developed two deep tissue injuries which worsened to unstageable pressure injuries on the heels after admission, and R33 developed a stage two pressure ulcer after admission that worsened to an unstageable pressure ulcer. Additionally, the facility failed to reposition 1 of 2 residents (R30) in accordance with the current care plan, and failed to accurately stage a pressure ulcer and failed to accurately assess nutritional needs and implement provider ordered nutritional interventions to aide in healing for 1 of 2 residents (R33) reviewed for facility acquired pressure ulcers. Findings include: The National Pressure Injury Advisory Panel (NPIAP) guidance dated 2016, identified a deep tissue pressure injury (DTPI or DTI) as persistent non-blanchable deep red, maroon, or purple discoloration with intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. 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. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or stage 4). An unstageable pressure injury was defined as obscured full-thickness skin and tissue loss, full-thickness skin, and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough or eschar (dead tissue). If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Additionally, the NPIAP Evolution of Deep Tissue Pressure Injury process dated 1/8/21, identified DTI was one of the most serious forms of pressure injury. The process leading to DTI included: 1. 48 hours after a pressure event a DTI presents as intact, discolored skin from pressure 2. 24 to 48 hours after intact skin color change, the discolored skin blisters 3. Seven to 10 days after intact skin color change the DTI is classified as an unstageable pressure injury related to necrosis (death of body tissue). R30's admission Minimum Data Set (MDS) dated [DATE], identified she had intact cognition, no behaviors, and no rejection of care. Substantial/maximal assistance was required for lower body dressing and putting on/taking off footwear. Walking was not attempted due to medical condition or safety concerns. Diagnoses included adult failure to thrive, cauda equina syndrome (spinal disc compression with symptoms that may include less or changed sensation between the legs, the back of the legs, the feet, or the heels), lumbosacral radiculopathy (compressed nerve roots in lower back which include symptoms of numbness, tingling or reduced sensation in the legs), and presence of left artificial knee joint. R30 was at risk for pressure ulcers but had none. Pressure reducing device for chair and bed were selected as current treatments. Turning and repositioning program was not selected. R30's admission pressure ulcer Care Area Assessment (CAA) dated 7/2/24, was triggered due to risk of potential alteration in skin integrity related to frequent incontinence of bowel. Staff assistance was required for bed mobility and transfers, and the Braden skin risk assessment identified her to be at risk for pressure ulcers. Risk was further complicated by presence of indwelling urinary catheter, several significant comorbidities, recent complicated hospitalization s, and history of noncompliance and refusal of cares. R30 had no pressure injuries and worked with physical and occupational therapy. R30's hospital progress note (prior to facility admission) dated 6/19/24, identified she was unable to move her legs and had diminished sensation. R30's admission 48-hour care plan dated 6/27/24, identified she required assist with bathing, dressing, hygiene, transfers, and movement in bed. A pressure redistribution mattress was present on the bed and chair, and skin integrity would be monitored daily during cares and weekly by nurses. Turn and reposition or reminders were not selected as an intervention. R30's comprehensive care plan dated 6/27/24, identified she had an alteration in skin integrity due to adult failure to thrive and surgical incision. The care plan lacked risk factors affecting sensation in the lower legs such as cauda equina syndrome and lumbosacral radiculopathy. Interventions lacked floating heels, heel protection, or to turn and reposition every two to three hours and as needed. R30's comprehensive care plan updated 8/8/24, identified she had an alteration in skin integrity related to adult failure to thrive, history of coccyx ulcer pressure injury, surgical incision, and DTI on bilateral heels. New interventions also dated 8/8/24, included heel lift boots at all times when in bed; and on 8/24/24, an intervention was added to turn and reposition or give reminders to offload every two to three hours and as needed. R30's quarterly MDS dated [DATE], identified additional diagnoses of anxiety, neurogenic bladder, osteoarthritis of the knee, muscle weakness, and difficulty walking. R30 was at risk for pressure ulcers and now had two unstageable pressure ulcers with suspected DTI in evolution. Nutrition interventions were in place to manage skin problems, and pressure ulcer care treatment was provided. R30's admission Braden Scale for Predicting Pressure Sore Risk dated 6/26/24, had not identified any sensory perception problems in the lower legs, which would have increased the risk scoring. R30's nurse practitioner (NP) admission note from the in-house provider group dated 6/28/24 at 12:00 a.m., identified she was severely deconditioned from long hospitalization as well as recent total knee arthroplasty (replacement) on 5/2024. R30's admission Skin Evaluation and Skin Risk Factors assessment dated [DATE], identified an overall Braden score of 15-18, which was mild risk. A surgical incision was present on the lower back. A pressure reducing ultra foam mattress was in place, however turning and repositioning schedule or floating the heels were not identified as an intervention. R30's Occupational Therapy (OT) Evaluation and Plan of Treatment dated 6/27/24 through 7/25/24, identified therapy attempted to transfer R30 to wheelchair with EZ stand (standing lift). R30 complained of too much pain even before hips were lifted off the bed. Further transfers were declined. Additionally, R30 required maximum assist of staff to sit on edge with both hands supporting her body on the sides of her hips. Once her hands were lifted, she was unable to maintain sitting balance for more than a few seconds. R30's OT Discharge Summary dated 6/27/24 through 8/15/24, identified she had achieved the highest practical level. She required maximum assistance with Hoyer for transfer (full body mechanical lift) and maximum assistance for lower body dressing. R30's mobility function score was zero (score range zero to 12; with 12 being the highest function). R30's Physical Therapy (PT) Evaluation and Plan of Treatment dated 6/28/24 through 7/27/24, identified a medical history of osteoarthritis (OA) and surgical procedure (s/p) bilateral total knee arthroplasty (TKA), right knee being done on 5/1/24, and recent prolonged hospitalization for osteomyelitis and discitis. R30 could not care for herself at home and required placement in the transitional care unit (TCU). Right and left lower extremity strength was impaired. R30's PT Discharge Summary dated 6/28/24 through 8/15/24, identified she had exhausted benefits and declined treatment. A Hoyer lift was still recommended due to lower extremity weakness and low tone. R30 was unable to stand due to poor leg strength and poor tone. R30's mobility function score was three (score range zero to 12; with 12 being the highest function). R30's Weekly Skin Assessments dated 6/26/24 through 8/8/24 had not noted the heels were offloaded. R30's progress note dated 8/8/24 at 2:10 p.m., identified discoloration (DTI) noted on bilateral heels during wound rounds. The progress note identified R30 consistently offloaded heels with pillows in bed, however, this was not listed as an intervention in the care plan or nursing assistant tasks or documented prior to the DTI. R30's weekly NP-A Wound Consult forms identified the following: -8/1/24, seen for post-surgical spinal wound routine wound evaluation. R30 had multiple comorbidities affecting wound healing and wound progression, as well as risk for wounds including risk for malnutrition, limited mobility, muscle weakness which predisposed patient to wounds due to weakness, and inability to move about or reposition. Reposition per facility protocol/policy, encourage good nutrition and movement habits, continue to follow-up per routine schedule or sooner if needed. Heel ulcers were not noted on this consultation. - 8/8/2024, seen for surgical incision, impaired skin integrity, limited mobility, and muscle weakness. R30 was resting in bed on her back and accepting to wound cares. DTIs were noted on bilateral heels, and it was again noted R30 had limited mobility especially in her lower extremities. Skin prep (topical barrier) was applied, and heels were offloaded with pillows to free float heels. Nursing was instructed to provide Prevalon boot (heel protection boot) for offloading when available. Wound care orders included: Skin prep/open to air-daily, float heels, Prevalon boot on daily when available, follow wound care team weekly. The wounds were identified as new, in-house acquired with the right heel DTI measuring 4.62 centimeters (cm) long and 4.92 cm wide. The left heel DTI measured 3.21 cm long by 3.13 cm wide. -8/15/24, resting in bed on her back and accepting to wound cares. The DTI to bilateral heels increased in size and she had limited mobility especially lower extremities. Skin prep applied and offloaded with bunny boots (foam cushioned boot). Prevalon boots were on order. Continue to encourage aggressive offloading. Wound care orders otherwise remained the same. The right heel DTI measured 4.21 cm long and 3.61 cm wide. The left heel DTI increased in size and measured 3.21 cm long by 3.73 cm wide. - 8/23/24, resting in bed on her back and accepting to wound cares. Bilateral heel DTIs were stable and drying. No new open areas noted. Bunny boots were on for offloading. Aggressive offloading and repositioning were encouraged. Wound care orders otherwise remained the same. The right heel DTI measured 3.31 cm long and 3.08 cm wide. The left heel DTI measured 3.1 cm long by 3.75 cm wide. -8/29/24, Wound care orders otherwise remained the same. The right heel DTI increased in size and measured 3.84 cm long and 4.64 cm wide. The left heel DTI measured 2.97 cm long by 3.69 cm wide. -9/5/24, resting in bed on her back and accepting to wound cares. Bilateral heels are stable and eschar now. R30 continues to wear offloading boots. No new open areas noted. Encouraged aggressive offloading and repositioning. Wound care orders otherwise remained the same. The right heel DTI measured 3.89 cm long and 4.07 cm wide. The left heel DTI measured 3.4 cm long by 3.21 cm wide. -9/12/24, resting in bed on her back and accepting to wound cares. Bilateral heels were improving and getting smaller. Heels are now eschar and dry. Wound care orders otherwise identified: skin prep/open to air-daily, float heels, Prevalon boot on daily when available, heel protectors on both feet always when in bed. Must float heels with folded pillows in addition to heel boots every shift. The right heel DTI measured 3.64 cm long and 4.04 cm wide. The left heel DTI increased in size measured 2.53 cm long by 4.01 cm wide. - 9/19/24, bilateral heels were stable, however the wounds were peeling and draining at the edges. R30 was compliant with wearing her Prevalon boots. Wound care orders otherwise remained the same. The DTI were now classified as in-house acquired unstageable pressure ulcers due to slough and/or eschar covering the wound bed. The right heel unstagable pressure ulcer measured 2.84 cm long and 3.03 cm wide. The left heel unstagable pressure ulcer increased in size measured 3.69 cm long by 2.35 cm wide. - 9/26/24, identified bilateral heels were stable, however the wounds were peeling but appeared to be smaller. R30 was compliant with wearing her Prevalon boots. Wound care orders included: stable, clean with wound cleanser, apply Medihoney, cover with foam dressing one time a day AND as needed, float heels, Prevalon boots on daily when available, heel protectors on both feet always when in bed. Must float heels with folded pillows in addition to heel boots every shift. The right heel unstageable pressure ulcer measured 3.33 cm long and 1.94 cm wide. The left heel unstageable pressure ulcer measured 2.7 cm long and 2.79 cm wide. -10/2/24, bilateral heel unstageable pressure sores are improving. All wounds mechanically debrided (removal of dead tissue) and redressed. Wound care orders otherwise remained the same. The right heel unstageable pressure ulcer measured 2.15 cm long and 3.14 cm wide. The left heel unstageable pressure ulcer measured 1.96 cm long and 2.97 cm wide. -10/10/24, R30 was in bed resting on her back with pillow offloading her feet and accepting to wound cares. Noncompliant with Prevalon boots although strongly encouraged to wear to promote wound healing. The wound dressing removed from the heels was not as ordered. Nurse manager was present when dressings were removed. The bilateral heel wounds were deteriorating. The wound beds were very sloughy (soft and watery) with drainage. All wounds mechanically debrided and redressed. Unable to sharps debride due to intolerance. Always discussed importance of aggressive offloading and repositioning and compliance with Prevalon boots. The right heel unstageable pressure ulcer increased in size measured 2.98 cm long and 3.45 cm wide. The left heel unstageable pressure ulcer measured 2.1 cm long and 1.43 cm wide. -10/17/24, R30's right heel wound deteriorated. Left heel was stable. The open wound beds were very sloughy with necrotic tissue and drainage. All wounds mechanically debrided and redressed. Unable to sharps debride due to intolerance. Wound culture was collected. Wound care orders remained the same. The right heel unstageable pressure ulcer increased in size measured 4.52 cm long and 4.79 cm wide. The left heel unstageable pressure ulcer measured 1.81 cm long and 2.23 cm wide. R30's corresponding progress note dated 10/17/24 at 1:41 p.m., identified wound care orders changed to Santyl ointment instead of Medihoney. During the start of a continuous observation on 10/23/24 at 7:05 a.m., R30 was in bed on her back, eyes closed. The head of the bed was elevated about 10 degrees. R20 had blue cushioned boots on both feet with wedge cushion underneath her calves, visible because blankets were pulled up over her feet. -At 8:12 a.m., licensed practical nurse (LPN)-A entered R30's room with a breakfast tray. R30 remained in the same position without moving in bed and was not offered to offload and reposition. -At 8:15 a.m., nursing assistant (NA)-D entered R30's room and said good morning, ok you want to sleep. R30 remained in the same position without moving in bed and was not offered to offload and reposition. -At 10:00 a.m., LPN-A entered and removed her breakfast tray. R30 remained in the same position without moving in bed and was not offered to offload and reposition. -At 10:02 a.m., LPN-A entered R30's room. R30 asked LPN-A to pull the blanket over her feet. R30 remained in the same position without moving in bed and was not offered to offload and reposition. -At 10:10 a.m., trained medical assistant (TMA)-A knocked and entered R20's room for a safety check and exited. R30 remained in the same position without moving in bed and was not offered to offload and reposition. It was three hours and five minutes since R30 has been repositioned. -At 10:26 a.m., TMA-A brought R30 her medications. R30 brought the medication cup to her mouth and then drank from a cup of water, without elevating her head of bed or offloading her body. R30 remained in the same position without moving in bed and was not offered to offload and reposition. When asked, TMA-A stated R30 was not able to fully offload her lower body and staff were expected to do that for her. During a follow up interview with R30, she stated staff were supposed to come in and move her upper and lower body and they had not. R30 was agreeable to get staff to help her reposition. -During a follow up interview at 10:31 a.m., NA-D stated a resident was typically repositioned every two to three hours. When night shift left and day shift came on, last repositioning times were discussed. NA-D stated he did not recall if R30's repositioning was discussed. -During an interview at 10:32 a.m., RN-A stated staff should review the care plan to determine how often to reposition. RN-A was not aware it had been almost three and a half hours since R30 was last repositioned, and he would get the NAs to help her because R30 could not move her lower body to fully offload. RN-A was not sure if orders to float her heels were present before the development of pressure ulcers. RN-A stated if a resident had reduced feeling in the legs, they would consider adding in the intervention to float heels to prevent pressure ulcers. RN-A stated he would get staff to reposition R30. -At 10:35 a.m., NA-A and NA-D entered R30's room. NA-A stated R30's legs and knees do not bend. NA-A and NA-D stated R30 was currently compliant with floating her heels and wearing the boots in bed. NA-A stated R30 should have been repositioned by now, but they were busy and R30 had not called for assistance. -At 10:55 a.m., the end of the continuous observation, NA-A and NA-D assisted R30 to turn to her side with maximal assist and provided personal cares. Wrinkles from the mattress and pillows were noted on her back and legs. There were indentations on lower legs from the wedges floating her heels. It was three hours and 50 minutes since R30 was last repositioned. During an interview on 10/23/24 at 12:10 p.m., the wound care consultant nurse practitioner (NP)-A stated R30 was at high risk for pressure ulcers upon admission, due to surgery, not able to move on her own, and malnutrition, and had to be pushed to adequately reposition. R30's level of assist required for offloading had not improved since her admission. NP-A stated the root cause of DTI was most likely laying in bed with the heels always on her bed. NP-A stated R30's heels were at high risk for breakdown when she was admitted , and floating the heels would be a standard intervention for someone with limited mobility. NP-A stated heel protection measures such as cushioned boots or floating the heels could have prevented the pressure ulcers. NP-A stated prior to the pressure ulcer development, she did not observe R30's heels floated during weekly wound rounds. NP-A stated repositioning every two to three hours, per care plan, should be appropriate if she's compliant, going almost 4 hours could contribute to further pressure ulcers due to R30 not being able to offload. NP-A stated the pressure wounds at this point were unstageable and were classified as facility acquired. During an interview on 10/24/24 at 11:11 a.m., the director of nursing (DON), stated risk factors for pressure ulcers included being in bed most of the time, malnutrition, and improper footwear. The DON stated the main intervention to prevent pressure ulcers on the heels were weekly nursing assessments, and interventions included turn and reposition, float the heels, and offload pressure. The DON stated R30 was at risk upon admission and after the development of the pressure ulcers she was at moderate risk. The DON stated R30 was given a risk and benefits form for not complying with wound care, but this was after the pressure ulcers had developed. The DON stated heel protection was not included in R30's care plan upon admission due to determined risk. Additionally, R30 had pigmented skin color which made it more difficult to see pressure ulcer formation. When asked if pigmented skin color would have increased R30's risk for the admission skin assessment the DON stated she was unsure. When asked about a root cause analysis, the DON stated the pressure ulcers developed after admission and she could find a root cause analysis form to share, however, she did not have the form at this time. The DON stated development of a DTI was likely from being in bed most of the shift. The DON stated after R30's pressure ulcers, education was completed with the staff on assessing pigmented skin color and on pressure ulcer prevention measures. The DON stated refusals of repositioning would be listed in R30's Tasks section of the electronic medical record, however, this documentation was not provided. The undated Pressure Injury Root Cause Analysis (RCA), identified due to pigment of resident skin, staff did not perceive the discoloration on heels to be pressure related. The RCA lacked a cause such as medical devices mattress pressure, friction or shearing, wheelchair foot rest pressure, or type of footwear utilized. During an interview on 10/24/24 at 12:42 p.m., the PT who had worked with R30 stated the amount of movement R30 had in her lower legs upon admission was the level of someone that was a paraplegic (paralyzed from the waist down). The PT stated R30's status remained the same because she still needed a full Hoyer lift to transfer. The PT stated R30 could not fully offload, especially in the lower body. 46885 The State Operations Manual (SOM) defined the various presure ulcers as follows: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. It may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) are not present. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar may be visible but does not obscure the depth of the tissue loss. A stage four pressure ulcer is full thickness loss of the 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. Undermining and or tunneling often occur. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. An unstageable pressure ulcer is obscured 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 slough or eschar is removed, a stage three or stage four pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then reclassified stage should be assigned. A deep tissue pressure injury (DTPI) is intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent 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. If necrotic tissue, subcutaneous tissue (deepest layer of skin), granulation tissue (new connective tissue), fascia (connective tissue), muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. R33's Medical Diagnoses form indicated a right knee effusion, mild cognitive impairment, muscle weakness, difficulty in walking, deficiency of other specified B group vitamins, type 2 diabetes mellitus with diabetic polyneuropathy (a type of nerve damage that affects multiple nerves in the body), disease of the spinal cord, other tear of the lateral meniscus, current injury of the right knee, and chronic pain. R33's quarterly MDS dated [DATE], identified intact cognition, did not reject care, had impairment in range of motion (ROM) to one side of upper and lower extremities, was independent in rolling from lying on the back to the left and right side, was 60 inches tall and weighed 229 pounds, and had no or unknown weight loss. R33's quarterly MDS dated [DATE], identified a cognitive assessment was not completed, did not reject care, was 72 inches tall and weighed 230 pounds, did not have 5% or more weight loss in the last month. Further, R33 was at risk for pressure ulcer development and had one or more stage one pressure ulcer. R33's Optional State Assessment (OSA) MDS dated [DATE], identified R33 required extensive assistance with bed mobility, transfers, and toileting. R33's CAA dated 5/30/24, identified R33 was at risk for pressure ulcers due to the need for extensive assistance with bed mobility and incontinence, and did not have a pressure ulcer but would be addressed in the care plan to avoid complications and minimize risks. R33's nutritional status care plan dated 5/27/24, identified R33 was on a regular diet with no concerns reported. R33 had the following interventions: diet per physician order, obtain weight monthly, registered dietician or culinary director to consult as needed, the resident is on a regular diet with no concerns. Further an intervention dated 7/10/24, was written, Dietary Preferences (Specify). No dietary preferences were documented. R33's alteration in mobility care plan dated 5/27/24, identified R33 required an assist of two with transfers and partial to moderate assistance with rolling left to right in bed. R33's risk for alteration in skin integrity care plan dated 5/28/24, indicated R33 had a stage one pressure ulcer to the left heel and had the following interventions: 5/28/24, pressure redistribution cushion to wheelchair, and chair. 6/14/24, monitor skin integrity daily during cares. Weekly skin inspection by the nurse. 6/14/24, turn and reposition or reminders to offload every two to three hours and as needed as resident allows. 9/19/24, heel boots at all times while in bed. 10/21/24, low air loss air bed, pressure redistribution. The care plan lacked an intervention for a wedge cushion in the bed. R33's skin integrity care plan dated 9/24/24, indicated staff were to follow current risk/benefit form, and interventions included a risk benefit form was completed an on file for skin integrity noncompliance with skin interventions 9/24/24. R33's alteration in blood sugar care plan dated 10/2/24, indicated R33 had a potential for alteration in blood sugar due to diabetes, and interventions included providing a diet as ordered and encourage R33 to follow the prescribed diet. R33's group sheet indicated R33 had wounds and required assist of one for bed mobility. R33's physician orders indicated the following orders: 5/27/24, regular diet, regular texture, regular thin consistency. 8/8/24, weekly skin inspection by licensed nurse. 9/19/24, 1. left heel wound, skin prep to heel and allow to dry. 2. boots and float heels freely. 10/21/24, air mattress monitor working order and replace as needed. The physician orders were reviewed and lacked any orders for any nutritional supplement. R33's Braden Scale for Predicting Pressure Sore Risk forms were reviewed and identified the following: 7/9/24, R33 scored a 16 indicating R33 was at risk for developing a pressure sore. 9/19/24, R33 scored a 16 on the Braden scale. 9/26/24, R33 scored a 14 indicating R33 was at moderate risk for developing pressure ulcers. R33's weights were reviewed and indicated the following: 5/25/24, 232.8 pounds 5/26/24, 230 pounds 6/2/24, 231.5 pounds 6/16/24, 230.7 pounds 6/30/24, 230 pounds 7/7/24, 229 pounds 8/4/24, 230 pounds 9/24/24, 219 pounds 10/11/24, 217 pounds R33's Clinical Nutrition Evaluation form dated 5/30/24, indicated R33's height was documented as 60 inches and weighed 230 pounds and BMI (body mass index) was not documented. R33's Clinical Nutrition Evaluation form dated 7/10/24, Under the heading, Dietary Preferences Likes/Dislikes indicated large portions, likes cereal, bacon, eggs, and toast, juice, milk. Further, under the heading, Skin Condition indicated R33 had no skin issues noted. Under the heading, Additional Information indicated R33's current weight was 230 pounds and his height was 72 inches tall with a BMI of 31.1 with preferences for large portions. R33's Clinical Nutrition Evaluation dated 9/22/24, indicated a height of 75 inches and the most recent weight of 230 pounds was from 8/4/24. Under the heading, Supplements indicated, NA. Further, under the heading, Skin Condition indicated No skin issues noted and R33 preferred large portions. R33's nurse practitioner noted dated 9/16/24, indicated R33 had bilateral foot pain specifically in the heels without breakdown in hands or heels. R33's PT notes dated 10/21/24, indicated R33 was given a heel float wedge to improve his ability to float heels if he did exercises or bed mobility on his own. Pillows required much re-adjusting to truly float heels. R33's progress notes were reviewed and indicated the following: 5/28/24 at 12:18 p.m., R33 did not have skin breakdown upon admission and presented with a poor appetite. 6/12/24, physician note indicated R33 had a poor appetite. 9/19/24, at 8:52 a.m., R33 had an unstated pressure sore on the left heel and verbalized pain. 9/19/24 at 1:25 p.m., indicated nursing staff found an area of discoloration on the left heel and pressure injury interventions were initiated including heel boots and offloading while in bed and would be followed on wound rounds. 9/20/24 at 12:10 p.m., R33 was compliant with heel boots and floating heels. 9/26/24 at 1:42 p.m., R33 preferred floating heels with pillows versus boots and a risk versus benefits was on file. 10/4/24 at 3:11 p.m., monthly nutrition risk note from the dietary department indicated R33 had a stage one pressure ulcer on his heel with an effusion to the right knee, mild cognition impairment, muscle weakness, diabetes with a current weight of 219 pounds which was down from 230 pounds on 8/4/24. The note indicated R33 ate 100% and preferred large portions. Large portion and double meat would be added, would offer a sandwich at bedtime, and would monitor and document meal intakes and obtain weights per policy. The note lacked documentation R33 was provided Glucerna or equivalent per facility protocol, Juven or Prosource 30 milliliters by mouth twice da [TRUNCATED]

Based on observation, interview, and document review, the facility failed to implement fall interventions for 1 of 2 residents (R40) reviewed with a history of falls. Findings include: R40's admission Minimum Data Set (MDS) dated [DATE], indicated R40 had intact cognition, did not reject cares, had a walker, required partial to moderate assist with toileting, showering and lower body dressing, required supervision for transfers from chair to bed, required partial to moderate assist with toilet transfers, and did not have a history of falls. R40's Medical Diagnosis form undated, indicated the following diagnoses: heart failure, muscle weakness, difficulty in walking, neoplasm of unspecified behavior of brain, malignant neoplasm of unspecified part of the right bronchus or lung, and metabolic encephalopathy (a change in how the brain works). R40's physician orders indicated the following order: 10/11/24, apixaban (an anticoagulant) oral tablet 5 milligram (MG) give 1 tablet by mouth two times a day related to atrial fibrillation (irregular, fast heart beat). R40's care plan dated 9/3/24, indicated R40 was at risk for falls due to osteoarthritis and had the following interventions in place: physical therapy (PT) per physician orders, follow PT and occupational therapy (OT) instructions for mobility function, low bed, keep room clean and free of clutter, keep call-light in reach, and monitor and document on safety. Review information on past falls and attempt to determine the cause of falls, record possible root causes, alter or remove any potential causes if possible, educate the resident, family, caregivers, and interdisciplinary team (IDT) as to causes. The care plan lacked interventions for applying non-slip tape to R40's room. Further, R40's care plan indicated R40 required assist of one for ambulation. R40's care guide indicated R40 was assist of one with activities of daily living (ADLs) and required stand by assist with ambulation. The care guide lacked information for fall prevention interventions. R40's nursing progress note dated 10/3/24 at 7:42 a.m., indicated R40 was found on the floor around 5:45 a.m., on her left side and R40 stated she was trying to go to the bathroom and slipped. R40's interdisciplinary team (IDT) note dated 10/3/24 at 4:10 p.m., indicated R40's fall was reviewed by the IDT and indicated upon return from the hospital, R40 would have gripper socks at nighttime, and non-slip tape on the bedroom floor. R40's Fall Review Evaluation Updated form dated 10/3/24 at 4:18 p.m., indicated R40 had a recent fall, and under a heading, Summary/Interventions indicated R40 was sent to the hospital for further evaluation and upon return would be encouraged to wear gripper socks at night and would have non-slip tape placed on the floor in R40's room. R40's IDT note dated 10/23/24 at 12:20 p.m., indicated IDT reviewed R40's fall interventions and universal fall precautions remained in place, R40 was stable with gripper sock intervention following recent fall and planned to resolve non-skid tape on R40's floor. R40's history and physical dated 10/3/24 at 5:43 p.m., indicated R40 had a history of Alzheimer's disease, small cell lung cancer (SCLC) that progressed to a stage four with brain metastasis in February 2023, ischemic cardiomyopathy, and coronary artery disease and was unable to identify when she fell , or provide a history. The history and physical further indicated R40 fell on [DATE] at 5:00 a.m., and hit the left side of her head and her left hip. During observation on 10/21/24 at 2:09 p.m., R40 had a faded bruise located on R40's left cheekbone. R40 had a walker at the bedside with two hand rails on the bed. During observation on 10/22/24 at 9:47 a.m., R40's floor lacked non-slip tape. During observation on 10/23/24 at 10:40 a.m., R40's floor lacked non-slip tape. During interview on 10/23/24 at 11:01 a.m., nursing assistant (NA)-A stated R40 went to the bathroom independently and added R40 didn't bother them and thought R40's family member put R40's clothes out. During interview on 10/23/24 at 11:16 a.m., registered nurse (RN)-A stated they looked at the care plan and a Kardex to know what kind of cares a resident required and stated R40 would walk in the room independently. R40 repeated the same questions, asking how she wore her compression stockings. RN-A stated an intervention for non-slip tape was documented in the progress notes and RN-A verified R40's room lacked non-slip tape and stated it was important to have the intervention in place to reduce the risk of R40 falling. During interview on 10/23/24 at 11:39 a.m., the director of nursing (DON) stated NA's documented in the electronic medical records (EMR) and used care guides to know what cares a resident required. The DON further stated every resident had universal fall precautions in place including occupational therapy (OT), physical therapy (PT), keep the call light in reach, low bed, keep the room free of clutter, and were in place prior to R40's fall and they monitored for bruising because R40 was on an anticoagulant. The DON viewed R40's note dated 10/3/24, that indicated R40 would have non-slip tape on the bedroom floor and stated it was a double intervention, R40 was forgetful and not always compliant and stated tape would be a further intervention. A policy, Fall Prevention and Management, dated February 2024, indicated the facility identified residents at risk for falls, implemented fall prevention interventions, provided guidelines for assessing a resident after a fall and assisted staff in identifying causes of the fall. Staff may also identify and implement relevant interventions to try to minimize serious consequences of falling. Staff will clarify the details of a fall and the IDT will review falls at a.m. meetings and document interventions, first aid, or treatment, and care plans will be updated to reflect fall interventions.

Based on observation, interview, and document review, the facility failed to ensure a self administration assessment (SAM) and a physician's order was completed to allow a resident to safely administer their own medication for 1 of 1 resident (R18) observed with medication at the bedside. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had intact cognition, and cardiorespiratory conditions, pneumonia, respiratory failure, asthma, chronic obstructive pulmonary disease, or chronic lung disease. R18's Medical Diagnosis form undated, indicated R18 had chronic respiratory failure with hypoxia (low oxygen levels in the body), pneumonia due to other gram-negative bacteria, obstructive sleep apnea, dyspnea (shortness of breath), other specified chronic obstructive pulmonary disease, emphysema, and bronchiectasis (a condition where the airways widen and causes coughing with mucus and frequent infections) uncomplicated. R18's Physician Orders form indicated the following orders: 4/16/24, Advair diskus inhalation aerosol powder breath activated 500-50 microgram (MCG)/ACT (actuation) give 1 puff orally twice a day for asthma, administered by clinician. 4/18/24, Ipratropium-Albuterol inhalation solution 0.5-2.5 milligrams (MG) per 3 milliliters (ML) (nebulizer) inhale orally four times a day related to chronic respiratory failure with hypoxia. 8/28/24, ok for resident to self administer nebulizer after nursing set up medication. R18's Self Administration of Medication Evaluation form dated 8/28/24, indicated R18 was capable of self administration of inhalation medication to include nebulizer administration of medication. A box below indicated R18 was able to self administer nebulizer after set up by the nurse. Instruction for self administration of medications with the resident was completed by the nurse. R18 was able to demonstrate to the satisfaction of the nurse manager or designee the following: knowledge of what the medication was for, ability to recognize the medication and verbalize understanding of the purpose of the medication, the manual dexterity sufficient to self administer the medication accurately. Five check boxes were left unmarked which included: knowledge of the correct times to take medication, the ability to produce all currently used medication containers and that these reflect the current physician prescribed medications, that all medications are stored properly (if stored in resident's room), the ability to read the label/instructions on the medication container/package, and the ability to accurately report the medication use to nursing staff. The form lacked information R18 was capable of self-administering Advair powder which was not a nebulizer. R18's care plan dated 8/28/24, indicated R18 chose to self-administer nebulizer treatments after the nurse set the medication up. Interventions indicated to monitor usage of nebulizer treatments after resident completed nebulizer and nursing to administer all other medications and monitor response and side effects as needed. During interview and observation on 10/21/24 at 5:54 p.m., R18 had an Advair diskus on the bedside table. R18 stated they changed it so it could be left in the room so he could keep an eye on it. During observation on 10/22/24 at 3:01 p.m., R18 had the Advair diskus on the bedside table. During observation on 10/23/24 at 7:28 a.m., R18 was in bed and the Advair diskus was located at the bedside. During observation on 10/24/24 at 7:20 a.m., trained medication aide (TMA)-A entered R18's room to check his vital signs and moved the bedside table the Advair was located on. At 7:22 a.m., TMA-A stated they looked at the care plan to know what kind of cares a resident required. If a resident refused cares, it was reported to the supervisor and documented in the progress notes. TMA-A further stated in order for a resident to self administer a medication, they had to have a physician's order and stated R18 could not self administer medications. TMA-A stated they set up the nebulizer and timed it and went back. TMA-A stated he would have to look up whether R18 could self administer the Advair. At 7:26 a.m., TMA-A went into R18's room and verified Advair was located on the bedside table and asked R18 if someone left the medication there the night before and R18 stated, it's always there. At 7:27 a.m., TMA-A looked at the electronic medical record and viewed the medication administration record (MAR) and stated he did not see an order for R18 to self administer the Advair and called licensed practical nurse (LPN)-B over at 7:29 a.m. LPN-B viewed the orders form, opened the Advair order, and stated they did not have an order for R18 to self administer the Advair. LPN-B further stated they evaluated the patient and if the patient could administer a medication by themselves, they obtained an order from the provider. LPN-B opened the Self Administration of Medication Evaluation form dated 8/28/24, and verified the evaluation form did not mention the Advair inhaler and stated the items a resident could self-administer were checked in the check boxes, and if a resident was not able to do something the item was not checked. LPN-B further stated, according to the evaluation, R18 could not self administer the Advair. During interview on 10/24/24 at 7:39 a.m., LPN-A stated they completed a SAM assessment and obtained an order from the provider and the order would only include whichever medications were approved to self administer. LPN-A stated if there were unchecked items in the Self Administration of Medication Evaluation form, it indicated the resident could not do that portion of the assessment. During interview on 10/24/24 at 7:47 a.m., the director of nursing (DON) stated unless there was a physician's order and a completed SAM, a resident could not self administer a medication. The DON further stated the physician wrote the order for the nebulizer treatment and verified the SAM evaluation form did not indicate Advair and only the nebulizer. A policy on self administration of medications was requested. A policy, Self-Administration of Medications, dated 2/2024, indicated residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether SAM is safe and appropriate for the resident: the medication is appropriate for self-administration, the resident is able to read and understand medication labels, the resident can follow directions and tell time to know when to take the medication, the resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff, the resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow the medications and the resident is able to safely and securely store the medication. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on observation, interview, and document review, the facility failed to ensure freedom of movement was not restricted when multiple pillows were placed by nursing staff adjacent to the resident's body, blocking the egress section of a perimeter mattress, underneath the fitted sheet which could not be removed easily by the resident for 1 of 1 resident (R104) reviewed for potential restraints. Findings include: R104's admission Minimum Data Set (MDS) dated [DATE], identified he had severely impaired cognition, and hallucinations and delusions had occurred. There was no behavior directed toward others and no rejection of care. Diagnoses included traumatic brain injury and anxiety. Falls occurred prior to entry but none since admission. Trunk restraints were not used. Extensive assist of two staff were required for bed mobility and transfers. R104's Care Area Assessment (CAA) for falls dated 10/22/24, was triggered due to a potential for falling due to poor muscle control and use of psychotropic meds. He was found on the floor several times since admission to TCU (transitional care unit), but it was determined that he crawled out of bed and put himself on the floor. R104's care plan dated 10/11/24, identified he was at risk for falls related to diffuse traumatic brain injury with loss of consciousness status unknown. Resident consistently made attempts and crawled out of low bed. Resident always had two fall mats on either side of bed and a perimeter mattress. A soft touch call light was in place and staff were also directed to follow any physical and occupational therapy instructions. Interventions lacked placing pillows under the sheet over the perimeter mattress egress section. R104's admission care conference form dated 10/7/24, lacked discussion of pillows under the fitted sheet. R104's progress notes identified the following: 10/7/24 at 11:30 a.m., after discussion with family members, family members say resident often rolled out of bed during hospital stay. Resident family members express concern about this. Perimeter mattress provided to resident along with bilateral fall mats. Resident family member inquired about side rails as well. Will update provider and provide resident with adequate bed mobility devices. 10/8/24 at 1:15 p.m., resident exhibited inconsolable behaviors. Resident was unable to be redirected and exhibited visual hallucinations, agitation, and attempting to crawl out of bed on to floor repeatedly. DON (director of nursing) by bedside as 1:1 while provider and family were contacted. Resident was sent out to the hospital. 10/10/24 at 2:24 p.m., resident was readmitted back to the facility from the hospital and presented with an episode of exhibiting inconsolable behavior with visual hallucination and attempting to crawl out of bed multiple times. 10/11/24 11:03 a.m., IDT (interdisciplinary team) met to review resident behaviors. Behaviors include crawling from bed, calling out, outbursts of screaming, disrobing, visual/ auditory hallucinations. Per family/ POA, behaviors are like what resident exhibited in hospital post traumatic brain injury. Fall mats in place with low bed and perimeter mattress to help reduce resident desire to crawl out of bed and safety with these behaviors. 10/13/24 10:17 a.m., resident was on the floor and ss (social services) assisted cnas (nursing assistants) to get him to bed. Resident was agitated and ss spent time with resident to keep him company and distracted. 10/14/24 at 8:24 p.m., throughout the first half of shift resident continuously tried to propel himself out of bed. Resident had one leg dangling outside the bed while screaming numerous times. Medications were administered and staff were provided for 1:1 supervision. 10/15/24 at 1:02 p.m., resident continues to exhibit baseline impulsive behaviors. 1:1 not needed at this time due to safety precautions in place and baseline behavior for resident post TBI. Therapy continues to work with resident, PT recommending Hoyer lift (full body lift) currently. 10/16/24 at 1:15 p.m., a care conference was held with the resident's power of attorney and IDT team and noted to refer to form for detail. The associated care conference form dated 10/24/24, lacked mention of using pillows over the perimeter mattress egress section. During observations and interviews on 10/21/24 at 5:28 p.m., R104 was in a low bed, the bed had bilateral grab bars and the left side of the bed was placed against the wall. On the right side of the bed facing out to the room, there were two large, cushioned mats on the floor. R104 attempted to crawl out of bed but could not get his legs up over pillows which were placed next to him, under the fitted sheet of the bed and over the perimeter mattress egress section in the middle of the mattress. Nursing assistant (NA)-E and NA-F entered R104's room, R104 was trying to get his knees on the ground, his upper body was still on the bed behind the pillows, and he was grabbing out at the air with his hands. NA-E stated R104 was a fall risk and that's why the mats were on the floor and pillows under the sheet to keep him from crawling out of bed. NA-F stated R104 could not walk, needed to be transferred with a Hoyer lift and could not get out of bed per therapy recommendations. NA-E and NA-F positioned R104 him back into a central position in bed and adjusted three pillows back into place under the fitted sheet; two standard bed pillows and one decorative plush pillow. NA-E said R104 could not remove pillows under sheet next to him. During another observation at 10/21/24 at 5:39 p.m., NA-C entered the room with NA-E and NA-F and changed R104's incontinence brief and wet bed linen. No skin breakdown was observed. Then, NA-C placed the same pillows in the same position. NA-C stated the pillows were placed to keep him from falling out of bed, along with the floor mats and low bed. NA-C stated R104 required 1:1 staff over the weekend due to behaviors. When asked if the pillows as a fall intervention was listed on the care plan, NA-C, NA-E and NA-F stated they did not know. During an interview on 10/21/24 at 5:52 p.m., R104's guardian (FM)-A stated she had removed extra pillows from his bed before helping him to eat. Otherwise, the only other fall interventions she was aware of was floor mat, side rails (grab bars), perimeter mattress and a room change to be closer to the nurse's station. FM-A could not recall if pillows were placed under the fitted sheet. FM-a stated he could crawl out of bed but couldn't likely stand due to his brain injury. During an interview and observation on 10/22/24 at 9:49 a.m., NA-B and NA-A stated they completed his morning cares already. R104 had floor mats next to the bed and pillows were again observed next to R104, under the fitted sheet blocking the mattress egress section. R104 made no attempts to get out of bed. During an interview and observation on 10/22/24 at 1:46 p.m., registered nurse (RN)-A stated fall interventions were listed on the care plan and on the Kardex for nursing assistants. RN-A went into R104's room and opened the closet to find the Kardex form, which was not in the plastic laminated paper holder. When asked about the pillows placed under R104's fitted bed sheet, he stated he believed those were in place to prevent rolling out of bed. R104's care plan was reviewed with RN-A, and the pillow intervention was not found. When asked if the pillows would create additional hazards during R104's attempts to crawl out of bed, he agreed it might increase the risk of injury or behaviors if he could not move around in bed. RN-A stated he did not think R104 had the cognitive capabilities to know how to remove the pillows from under the fitted sheet. During an interview on 10/22/24 at 1:55 p.m., RN-B stated she would not typically use pillows to block a perimeter mattress egress to keep a resident in bed, but pillows could be used on top of the sheet to prevent pressure sores, such as under the heels. RN-B stated the pillows would keep R104 from crawling out of bed, because he liked to turn onto his stomach in bed and put his knees on the ground. During an interview and observation on 10/22/24 at 2:16 p.m., the director of nursing (DON) stated R104 required assistance to turn and reposition safety but could make movements on his own to roll the lower half of his body off the bed. The DON stated due to frequently crawling out of bed, R104's fall interventions included low bed, perimeter mattress, mats on the floor, soft call light, grab bars, and psychology review or medications. The DON stated pillows under the mattress were not included as a fall intervention and doubted it would qualify as a restraint, but agreed restricted movement could potentially contribute to skin integrity issues or mood or behavior issues. The DON and administrator accompanied surveyor to R104's room but were unable to view the pillows as they had been removed. The DON and administrator accompanied surveyor to talk to RN-B to see who removed the pillows. RN-B stated he removed the pillows in case they were considered a restraint. The administrator and DON asked RN-B if family requested staff to place pillows under the sheet and RN-B said no. The administrator stated if restraints were used there needed to be a thorough assessment first of the system used, with IDT and physician involvement, and in this case, there was not, and staff education should be completed. During an interview on 10/22/24 at 2:31 p.m., the physical therapist (PT) stated she had evaluated R104 upon admission and he would have a hard time removing pillows under a fitted sheet. The PT stated she would not want pillows blocking the egress on the perimeter mattress as it was not a realistic intervention. Mobility should be allowed with the least number of obstacles in the way. During follow up observation on 10/23/24 at 7:16 a.m., NA-B was seated in R104's room. NA-B stated R104 started on 1:1 supervision today so her job was to sit here and redirect him. During an interview on 10/23/24 at 8:07 a.m., licensed practical nurse (LPN)-A stated she was unsure how R104's night went but they got him a ceiling projector for entertainment and to keep his focus. A policy on restraints was requested and not provided. The facility's policy titled Fall Prevention and Management dated 2/2024, identified facility staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the nature of or type of fall, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. Staff may also identify and implement relevant interventions to try to minimize serious consequences of falling. Staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. The policy lacked guidance on how to ensure different interventions were not restraints.

Based on observation, interview, and document review, the facility failed to ensure orders for compression were implemented for 2 of 2 residents (R40, R45) reviewed for edema. Findings include: R40's Optional State Assessment (OSA) dated 9/8/24, indicated R40 had intact cognition, did not reject cares, and required limited assistance with bed mobility, transfers, and toilet use. R40's admission Minimum Data Set (MDS) dated [DATE], indicated they had no impairment to range of motion, used a walker, and required partial to moderate assistance for showering/bathing, dressing lower body, and donning and doffing footwear. R40's Medical Diagnosis form undated indicated the following diagnoses: heart failure, difficulty in walking, cognitive communication deficit, neoplasm (tumor) of unspecified behavior of brain, malignant neoplasm of unspecified part of right bronchus or lung, secondary malignant neoplasm of brain, and metabolic encephalopathy. R40's Physician Orders form indicated the following orders; 10/11/24, torsemide 40 milligrams (MG) give 40 mg by mouth twice daily for heart failure and lower extremity edema. 10/18/24, Knee high compression stockings on every day and evening shiftt. R40's care plan dated 9/3/24, indicated R40 had an alteration in cognition due to a neoplasm of the brain and metabolic encephalopathy (brain dysfunction). R40's care plan dated 9/3/24, indicated R40 had a self care deficit due to a neoplasm of the brain and metabolic encephalopathy and required partial moderate assistance with lower body dressing. The care plan lacked information R40 required compression stockings, or had edema. R40's nursing assistant care guide indicated R40 was independent with dressing, required assistance of one staff with activities of daily living (ADLs), and lacked information R40 had compression stockings, or had edema. R40's progress notes were reviewed and lacked documentation R40 refused compression stockings. During interview and observation on 10/21/24 at 1:58 p.m., R40 was in bed, legs were swollen, and feet were up in the bed. R40 stated she had compression stockings she wore at bedtime. R40 was not wearing any compression stockings. During observation on 10/21/24 at 2:17 p.m., R40's compression stockings were not visible in R40's room. During observation on 10/22/24 at 9:56 a.m., R40 had white compression socks on the left hand rail on the side of the bed towards the window. During observation on 10/22/24 at 10:11 a.m., R40 was in bed and her compression stockings were located on the hand rail. During interview on 10/23/24 at 10:40 a.m., R40 did not have compression stockings on, stated she just started using them, and then stated she could not tell if she was using them at this time. R40 had compression stockings located on the bed rail closest to the window. R40 stated the compression stockings did not hurt her legs. During interview on 10/23/24 at 11:01 a.m., nursing assistant (NA)-A stated R40 got up to use the bathroom independently and further stated R40 could get dressed by herself. NA-A thought R40's family member put clothing out for R40 and thought either the nurse or therapy put on R40's compression stockings. During interview on 10/23/24 at 11:16 a.m., registered nurse (RN)-A stated in general nursing assistants are educated on how to put on compression stockings and stated the NAs knew what kind of cares a resident required based on the care plan and a Kardex. RN-A further stated R40 had swollen legs two weeks earlier, was monitored closely, torsemide was increased due to retention of fluid, and compression stockings were ordered to reduce swelling. RN-A stated R40 was not able to put on or take off the compression stockings by herself and added R40 was confused. Further, RN-A stated they provided education to the aides and stated the NAs should be applying R40's compression stockings and stated the Kardex was usually in the closet, but stated it was not located in R40's closet. R40 was in bed and dressed and stated the compression stockings could be applied. R40 asked repeatedly whether she wore the stockings in the morning and at night. At 11:25 a.m., RN-A donned both compression stockings and stated it was the NA's responsibility to donn the compression stockings and would have been beneficial to have the Kardex in the room. During interview on 10/23/24 at 11:39 a.m., the director of nursing (DON) stated aides documented in point of care where the tasks are and used care guides to know what cares a resident required. The DON stated they did not use Kardex and revamped the careguides and the nurses had access to the care plans. The DON verified R40 had an order for compression stockings. 51577 R45's quarterly Minimum Data Set (MDS) dated [DATE], indicated R45 was cognitively intact and had diagnoses of chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes) and leg pain. Had no rejection of care and required maximum assistance with lower extremity cares. R45's provider orders dated 9/18/24, indicated R45 required compression socks on in the morning and off in the evening. R45's Medical Administration Record (MAR) and Treatment Administration Record (TAR) dated 10/2024, lacked documentation R45 used or refused compression socks. R45's progress note dated 10/22/24 at 3:16 p.m., stated R45 had edema and utilized compression socks. The note also indicated R45 wore compression socks before admission. R45's care plan reviewed 10/22/24, lacked identification of R45's edema and intervention of compressions socks. During observation on 10/22/24 at 8:23 a.m., registered nurse (RN)-B was in R45's room helping them get dressed and could only find one compression stocking, so they were not applied. RN-B stated that they would see if they could find another. RN-B assisted R45 to stand, pulled up their pants, and helped them walk to a chair with bare feet. During observation on 10/23/24 at 7:27 a.m., R45 was wheeling in their wheelchair into the elevator and was not wearing compression socks. During observation and interview on 10/22/24 at 8:23 a.m., R45 stated staff did not put his compression socks on him because they could not find them, and the socks needed to be ordered. R45 stated they were required to reduce the swelling in his lower legs. R45's lower legs had hard, pitting edema on the ankles and skin folds. When interviewed on 10/23/24 7:59 a.m., R45 stated the facility did not have their socks, as the workers misplaced one of them. R45 stated their legs felt better when wearing them, and they had been missing for about a week. R45 stated one sock was on the commode rail, however, was not visible. R45 was unsure if the compression socks were ordered. When interviewed on 10/23/24 at 9:11 a.m., nursing assistant (NA)-J stated they helped R45 with their cares such as pulling up pants. NA-J stated they did not usually work on this side of facility, and did not have a current care plan sheet. NA-J stated they did what resident requested, and did not see or know if compression socks were ordered for R45. When interviewed 10/23/24 at 10:41 a.m., RN-B stated the cares that are expected to be done for edema would be to follow doctor's orders, including compression socks, diuretics and weight checks, and to update the provider if there are changes. RN-B did not know if R45 had orders for compression socks, and confirmed they were not listed on the care plan or electronic medical record. When interviewed 10/23/24 1:43 p.m., licensed practical nurse (LPN)-A stated if a resident had edema, staff would gather information and call the doctor to get orders for medication and compression socks, and these would be listed in the electronic record and the care guide sheets. They expected staff to document cares and medications given on the MAR/TAR. They confirmed R45 should wear compression socks due to a diagnosis of chronic venous insufficiency. When interviewed on 10/23/24 at 2:00 p.m., the director of nursing (DON) stated the expectation of staff was to follow orders for wearing compression socks and document them in a progress note. They stated it was important to follow doctor's orders to treat the diagnosis and be compliant. A policy regarding edema management and following orders was requested but not provided. A policy, Activities of Daily Living dated 3/31/23, indicated the facility will provide the necessary care and services to ensure that a resident's abilities in ADLs do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the ADLs.

Based on observation, interview, and document review, the facility failed to ensure an occupational therapy (OT) ordered hand splint program was implemented for 1 of 2 residents (R14) reviewed for positioning and mobility. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified he could understand with clear comprehension and could be understood. The cognitive assessment was not completed. Diagnoses included hemiplegia (paralysis and weakness) affecting right dominant side and muscle weakness. Extensive assistance of two staff was required for bed mobility. R14's quarterly MDS's dated 10/3/24, 8/13/24, and 5/16/24, identified no rejection of care and no days of restorative splint or brace assistance occurred. R14's activities of daily living (ADL) Care Area Assessment (CAA) dated 2/27/24, was triggered due to extensive assist of one to two staff for bed mobility, toileting, dressing, and personal hygiene, and total assist with two staff for Hoyer transfers was required. R30 was non-ambulatory and was at risk for further decline in ADL's, falls, contractures, further isolation, and complications of immobility: pressure ulcers, muscle atrophy, incontinence, and contractures. Proceed to care plan to prevent/minimize risks; work with resident to maintain current level of functioning. R14's care plan dated 10/10/24, identified he required the use of a splint for his right hand for positioning and contracture management. Goals include to wear the splint on the right hand for 15 minutes/24 hours or to tolerance to prevent contractures/increase PROM (passive range of motion), decrease pain, reduce muscle tightness, and allow participation in ADL's. Interventions included: 1. Check for skin breakdown under right hand brace 2. PROM exercises 3. Resident refuses to wear splint as it is uncomfortable. Therapy to follow up to indicate if bracing is still indicated. 4. Resident splint: unless medically contraindicated don splint or brace by putting thumb in first and spinning to don. Don/doff per schedule and as tolerated. Observe skin for complication related to use every shift and with each removal and application. Observe and report pain, offer medication as needed. R14's OT note dated 10/16/23, identified R14 declined use of previous right wrist splint, and said it rubbed on his hand and fingers and hurts to wear it for any length of time. OT modified palm guard by inserting red foam roll to provide some prolonged pressure and slow stretch into his right hand. The resident did report that this felt better than the splint as it did not rub nearly as much. OT placed in hand and checked after 2-3 hours for use with no increased pain noted by the resident. R14's OT discharge summary dated 10/26/23, identified the goal was met for hand roll splint toleration wearing schedule of six to eight hours daily to prevent further contracture of his right fingers, hand, and wrist. Staff demonstrated ability to don and doff right palm guard with hand roll. Discharge recommendations the identified splint/brace (palm guard with roll) prognosis was good if staff consistently followed through. R14's progress notes dated 10/23/23 through 10/24/24, lacked documentation he refused the OT recommended hand splint program. R14's Treatment Administration Record (TAR) dated 6/1/24 through 8/31/24, identified an order with start date of 11/23/23, to place brace (splint) after moving hand and all fingers within resident's tolerance of movement. The order was check marked as having been completed daily by nursing before being discontinued on 8/26/24. R14's order discontinuation summary dated 8/26/24, identified the above brace order from the TAR was discontinued and the section for reason for discontinuation was left blank. There was no rationale for stopping the splint. R14's care conferences dated 8/9/24 and 10/8/24, lacked a discussion about the hand splint or contracture. During an observation and interview on 10/21/24 at 6:54 p.m., R14 was in bed. A hand roll splint was on top of his bedside table. When asked about the splint, R14 stated his right hand could not be opened anymore. R14 used his left hand to uncover his right hand from the sheet, his right hand was observed to be contracted in a fist position. There was also an unpleasant odor to his right hand. R14 said the hand roll splint was for his right hand but it was too painful to wear. During an observation on 10/22/24 at 8:11 a.m., R14 was in bed without the splint on. During an interview on 10/22/24 at 1:38 p.m., nursing assistant (NA)-A stated therapy would tell the staff if a resident had a splint program. NA-A stated she had worked at the facility for a year and was not aware of R14's splint program. NA-A agreed R14's hand was contracted into a fist position. During an interview on 10/22/24 at 1:40 p.m., trained medication assistant (TMA)-A stated R14 used to have a splint, but he had not seen it. TMA-A reviewed the orders and said there were no current orders for it. If the order was active it would show up for nursing to check off upon the order's completion. During an interview on 10/22/24 at 1:43 p.m., the certified occupational therapist assistant (COTA) reviewed R14's therapy medical record and stated he was seen for right hand contracture last year from 7/2023 until 10/26/23. Therapy worked with him on ROM (range of motion) and slow stretch to make donning of palm guard easier. R14 was discharged from therapy with orders for scheduled hand roll splint 4-6 hours daily to prevent further contracture, teach nurses and update care plan and upon discharge teaching, staff were able to demonstrate the don and doff process. The COTA stated therapy was not updated the hand roll splint was no longer implemented as intended and would expect nursing to follow up so they could reassess as that process was usually part of the training provided to nurses when a splint program was implemented. The COTA stated there were not measurements of the contracture on file, so she was unable to determine if the contracture had worsened without the splint program implementation. Additionally, contractures could cause pain and contribute to skin breakdown, especially in the palm due to moisture and pressure. During an interview on 10/22/24 at 1:55 p.m., registered nurse (RN)-B stated if a resident had a splint, there should be an order in place. RN-B stated if splint interventions were in the care plan they should be implemented, if the resident was not using the splint, therapy should be updated so a reassessment could be started. During a follow up interview on 10/23/24 at 1:30 p.m., R14 was sitting up in his wheelchair. There was no odor to his hand. He stated staff have not offered the hand splint and he said he probably could not tolerate it due to the discomfort. During an interview on 10/22/24 at 2:07 p.m., the director of nursing (DON) reviewed R14's splint care plan and agreed the last update coinciding with the MDS was on 10/10/24, so the care plan was up to date. The DON stated the care plan identified he refused the splint, however, was not able to answer when asked if therapy followed up in accordance with the care plan. During a follow up interview on 10/24/24 at 11:34 a.m., with the DON and administrator together, the DON stated contractures posed a risk for skin breakdown and pain and after reviewing the medical record did not see a rationale why R14's splint was discontinued on 8/26/24. The DON stated the checkmarks after the order on the TAR identified the program was carried out as ordered up until it's discontinuation date. The administrator stated R14 was cognitively intact and could speak for himself and had refused the splint. When asked for documentation of refusals, or a conversation with R14 on risks of not wearing a splint and the options of a reassessment with therapy, none was provided. During a follow up observation and interview with R14 on 10/24/24 at 11:59 a.m., he stated nursing staff put a rolled-up washcloth in his hand today as they were worried his fingernails would cut into his palm, he also stated his skin can get iffy since his hand was stuck closed, and he did not want more problems. The DON walked by R14's room and was called in to observe the washcloth and R14 stated it felt good, he had it on for about one hour now without pain. An assistive device and/or splint program policy was requested and not provided. The facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities dated 3/31/23, identified based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility would provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable.

Based on observation, interview, and document review, the facility failed to conduct regular inspections of hospital bed rails as part of a regular maintenance program. Findings include: R204's admission Minimum Data Set (MDS) dated [DATE], indicated R204 had intact cognition, required partial to moderate assistance with bed mobility, was always incontinent of bowel and bladder, required substantial assistance with dressing, did not have an impairment in range of motion to upper extremities, and did not use bed rails. R204's Medical Diagnosis form undated, indicated the following diagnoses: dementia, urinary tract infection, ulcerative pancolitis (a type of inflammatory bowel disease) with unspecified complications, diarrhea, and Alzheimer's disease. R204's physician orders dated 10/22/24, indicated R204 could have bilateral grab bars. R204's care plan dated 9/28/24, indicated R204 was at risk for falls and interventions included monitoring and documenting on safety, and remove any potential causes if possible. Further, R204 had an alteration in mobility due to Alzheimer's dementia and the goal was R204 would move safely within her environment. An intervention dated 10/22/24, indicated R204 required grab bars to the bed to aid in bed mobility. R204's Bed Mobility Device Evaluation dated 10/21/24, indicated R204 required bilateral grab bars to assist with repositioning in bed. R204's nursing progress notes dated 10/21/24 at 11:54 p.m, 10/22/24 at 1:08 a.m., 10/23/24 at 1:43 p.m., indicated R204 was turned and repositioned frequently. During interview and observation on 10/22/24 at 8:06 a.m., R204's hand rail on R204's left side swung out and was not secured to the bed. R204 stated she used the rail. The hand rail on R204's right side was steady. During observation on 10/23/24 at 7:34 a.m., R204's left sided bed rail was still loose. During interview and observation on 10/23/24 between 10:16 a.m., and 10:36 a.m., nursing assistant (NA)-A and NA-D stated R204 was not able to turn herself in bed. At 10:17 a.m., NA-D stated he was going to assist R204 with cares. At 10:19 a.m., NA-D raised the head of the bed. At 10:20 a.m., R204's hand rails were up on both sides of the bed. At 10:21 a.m., the head of the bed was lowered down. At 10:23 a.m., NA-A and NA-D assisted to turn R204 towards her left side and R204 grabbed the bed rail on the left. At 10:26 a.m., R204 was assisted to turn towards R204's left side and grabbed the bed rail and the rail moved outward. At 10:34 a.m., NA-D raised the foot and head of the bed and at 10:35 a.m. NA-D lowered the bed. At 10:36 a.m. the left hand rail appeared to be missing a part to prevent the rail from moving outward. During interview on 10/23/24 at 1:47 p.m., registered nurse (RN)-A stated the nurse manager or director of nursing (DON) was notified if bed rails were needed and would contact maintenance to have them installed. RN-A stated everyone checked the rails, and maintenance double checked rails. RN-A stated the nurses checked the rails as often as they could when they went into the room to make sure everything was ok and when in contact with the resident, since things changed on a daily basis. RN-A stated they touched the bed rails, however, may not check all residents' bed rails, and stated it should be completed frequently on a day to day basis. During interview on 10/23/24 at 1:58 p.m., NA-D stated there were no issues with bed rails. During interview on 10/23/24 at 1:58 p.m., licensed practical nurse (LPN)-A stated maintenance checked bed rails for sturdiness and for repairs and if a resident was deemed appropriate for bed rails, therapy and nursing would obtain orders. LPN-A further stated the NAs or residents using the bed rails made sure they were sturdy. LPN-A stated she had not seen whether maintenance completed any recheck on bed rails for sturdiness. During interview on 10/23/24 between 2:24 p.m., and 2:31 p.m., the maintenance director (M) stated a physician's order was needed prior to installing bed rails and further stated bed rails were not placed on the bed until the order was obtained. M further stated he checked to make sure bed rails were in working order and staff notified him if a rail was loose, and stated staff were in residents' rooms working with them and checked to make sure bed rails were in working order. M stated bed rails were checked everyday adding he walked through the building to check the rooms and looked to see if something looked loose and would shake the rails. M further stated he had not been informed of loose rails. At 2:31 p.m., M verified R204's left bed rail was missing a lock. During interview on 10/24/24 at 10:10 a.m., the administrator stated she expected maintenance to check bed rails on rounds, nursing staff to complete checks, and stated she expected maintenance to get to it on weekly rounds if not daily. A policy was requested as well as a log of when bed rail checks were completed. A maintenance log dated 10/10/24, indicated a bed rail inspection was completed. No other documentation was provided for the bed rail for R204's bed that was ordered on 10/22/24. An email from the administrator dated 10/24/24 at 10:22 a.m., indicated the facility did monthly bed rail inspections, and they were trying to locate a relevant policy, however a policy was not provided.

Based on observation, interview, and document review, the facility failed to ensure staff utilized enhanced barrier precautions (EBP) during wound care and failed to ensure current standards of infection control practice for catheter care was followed for 1 of 2 residents (R30) observed for wound care and catheter care. Findings include: EBP R30's quarterly Minimum Data Set (MDS) dated [DATE], identified she had intact cognition, and no behaviors or rejection of care occurred in the lookback period. Diagnoses included stress incontinence and neurogenic bladder. Currently, two unstageable pressure injuries presenting as deep tissue injury were present and R30 had an indwelling catheter. R30 required extensive assist of two staff for bed mobility, transfers, and toilet use. R30's care plan dated 9/11/24, identified EBP were in place due to foley catheter. Interventions included to follow EBP and don/doff PPE (personal protective equipment) when high contact cares were required. The care plan lacked EBP for wound care. R30's undated banner from the front page of the electronic medical record (EMR) identified Special Instructions: Staff to follow enhanced barrier precautions R/T (related to) indwelling catheter and wounds. During an observation on 10/21/24 at 5:17 p.m., R30's bedroom door had an EBP sign on it and PPE bin directly outside the room entrance, containing gowns, gloves, and masks. The EBP sign directed staff to wear gloves and a gown for the following high contact resident care activities: dressing, bathing, transfer, hygiene, changing incontinence products, and device care including line care, catheter care, tubes, tracheostomy, and wound care. During an observation and interview on 10/22/24 at 10:24 a.m., registered nurse (RN)-B and RN-C walked past the PPE bin, entered R30's room, used hand sanitizer, and put gloves on. RN-B leaned over with scrub top touching R30's bed linens, removed the blanket off R30's right foot, unwrapped and removed dried bloody gauze wrap from the right foot pressure ulcer and right lower leg abrasion and disposed the dressing in the garbage can. The wounds were now open to air. RN-B changed gloves and started to spray wound cleaner on new gauze to clean the wounds. At this point surveyor asked RN-B if PPE was required. RN-B said, yes, she removed gloves, exited, got a gown out of the bin outside the room, donned the correct PPE and RN-C did the same. During a follow up interview on 10/22/24 at 1:55 p.m., RN-B stated she should have had a gown on during wound cares to prevent the spread of any germs before starting direct resident care for wound dressing changes but forgot. Catheter Care The Minnesota State Health Force Center of Excellence; Nursing Assistant Skill Video number 57 dated 9/26/19, identified to empty a urinary catheter drainage bag the following critical steps must be completed correctly: place a barrier on the floor, place a urine collection container on top of the barrier, remove the drainage outlet from the bottom of the bag, open the outlet and drain the catheter bag contents into the container, close the outlet and wipe the end of the tube and tube holder with an alcohol wipe. R30's care plan dated 8/9/24, identified the following interventions for catheter care: position catheter bag and tubing below the level of the bladder and away from entrance, monitor and document intake and output as per facility policy, monitor for s/sx (signs and symptoms) of discomfort on urination and frequency, monitor/document for pain/discomfort due to catheter, and monitor/record/report to MD (medical doctor) for s/sx UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The care plan lacked infection control measures during emptying the catheter. R30's nurse practitioner (NP) progress note dated 10/16/24, identified a history of UTI. During an observation on 10/23/24 at 10:35 a.m., nursing assistant (NA)-A, with gloves and gown on, placed a urinal on the floor, opened the bottom outlet of the catheter bag, emptied 1,000 milliliters (mL) into a urinal, closed the outlet, walked to the room's bathroom, emptied the urinal in the toilet, returned and reopened bottom outlet, drained another 250 mL, closed the outlet, walked to the bathroom, emptied the urine in the toilet. NA-A had not placed a barrier on the floor under the urinal and had not used an alcohol wipe to clean the bottom drainage outlet after draining. During a follow up interview on 10/23/24 at 10:55 a.m., NA-A stated she was not prepared to empty the catheter and should have used a barrier on the ground for urine drips and alcohol wipe to clean. R30's room lacked the needed supplies. During an interview on 10/23/24 at 11:50 a.m., NA-D stated when emptying a catheter, a barrier should be used on the floor and then clean the drainage outlet with alcohol wipe for infection control. During an interview on 10/24/24 at 11:11 a.m., the director of nursing (DON) stated she would expect staff to wear the required EBP PPE prior to active wound care and expected standards of practice to be followed during foley catheter care. The facility policy EBP dated 4/1/24, identified EBP referred to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO (multidrug resistant organisms) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident care activities included: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. The facility policy Indwelling Catheter Care Procedure dated 7/21/23, identified when emptying the catheter bag, don new gloves, uncap bottom outlet of bag, drain urine into measuring container, cleanse outlet with alcohol swab and recap the outlet. Measure urine and dispose of it in toilet. Remove gloves and wash hands. The facility policy lacked instruction to place a barrier on the floor under the measuring container.

Based on observation, interview and document review, the facility failed to ensure a community-use glucometer was properly cleaned and disinfected between patient' uses for 1 of 1 resident (R45) observed to have their blood glucose checked. This had potential to affect 4 of 4 residents (R45, R41, R246, R35) who were diabetic on the same unit. In addition, the facility failed to ensure appropriate hand hygiene was completed with personal cares for 1 of 2 residents (R246) whose cares were observed. Findings include: GLUCOMETER CLEANING: On 11/8/23 at 7:47 a.m., medication administration was observed with registered nurse (RN)-A present. RN-A removed a black-colored, zip-style (closed) bag from the medication cart and placed it on top of the cart before preparing R45's oral pills. When finished, RN-A picked up the zipped bag from the cart along with R45's prepared oral pills and brought them to her room. Inside the room, RN-A opened the zipped bag and removed an Assure Platinum glucometer from it. RN-A retrieved and donned a pair of gloves from the bathroom, and inserted a new strip into the device to test R45's blood glucose. RN-A then used a lancet to [NAME] R45's finger exposing a visible blood flash. RN-A touched the exposed blood droplet to the strip which had been inserted into the glucometer. A reading was obtained with RN-A stating aloud, 301. RN-A removed the strip from the glucometer and disposed of it in the trash. RN-A then placed the glucometer back into the black-colored bag and zipped it closed without any attempt to clean or sanitize the device. RN-A returned to the medication cart with the zipped-closed bag and placed it on top of the cart. RN-A prepared and administered R45's insulin, and then again returned to the cart to start another resident' medication administration. There was no attempt to remove or clean the used glucometer. When interviewed on 11/08/23 at 8:16 a.m., RN-A verified they had not cleaned or sanitized the device after use but added, Technically I should [clean it]. RN-A stated the device was used for all the patients on the unit and should be cleaned with purple wipes [i.e. sani-wipes], however, there weren't any to use. RN-A then looked around and observed a container with an orange-colored lid (i.e., bleach wipes) and expressed they could maybe use those instead but weren't sure. RN-A verified blood product was used (i.e., inserted via the strip) with the device, and stated they work for a nursing agency (i.e., SNSA) but had not been trained or told prior to working on the floor with any directions or facility' process on how to clean or sanitize the device. RN-A added, I showed up and worked. RN-A stated, in hindsight, they should have cleaned the device so we don't spread germs to other patients. An Ark Care Technical Brief, dated 9/2019, identified directions listed for, Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System. This outlined the device could be used for testing on multiple patients, however, cleaning and disinfecting the device should be completed to minimize the risk of transmitting blood-borne pathogens adding, The meter should be cleaned and disinfected after use on each patient. Further, the brief listed several chemicals (i.e., germicidal wipes, sani-wipes) which could be used. A provided electronic mail (i.e., e-mail) correspondence from the nursing home administrator, dated 11/8/23, identified a total of four diabetic residents (R45, R41, R246, R35) resided on the unit where RN-A had been observed to use the community glucometer without cleaning or sanitizing the device. On 11/08/23 at 11:43 a.m., the director of nursing (DON) was interviewed. DON stated the glucometer should be cleaned and disinfected between each patient use using sani-wipes. DON stated they had not personally completed any competencies for the agency nurses' on the cleaning of the glucometer but expressed maybe another department (i.e., HR) did but added, I don't know for sure. Further, DON verified the glucometer should have been cleaned for proper infection control adding, That's how infections spread. A facility' policy on glucometer use and cleaning was requested, however, none was received. 47372 HAND HYGIENE: During continuous observation of personal cares on 11/8/23, at 7:20 a.m., nursing assistant (NA)-C and NA-D walked into R246's room. Without performing hand hygiene, NA-C and NA-D donned gloves. NA-C assisted R246 roll to right side. NA-D placed gloved hand on R246 and proceeded to take off R246's brief which was soiled with urine and feces, rolled it up, and placed it in a plastic trash bag. NA-D doffed gloves and placed them into the trash bag and proceeded to grab new gloves. Without performing hand hygiene, NA-D donned new gloves. NA-C then took out a clean sanitary wipe and handed it to NA-D who assisted R246 clean perinium area and backside and placed the soiled sanitary wipe and doffered his gloves into the plastic garbage bag. Without performing hand hygiene, NA-D then donned a new pair of gloves. NA-C assisted the resident to roll to his right side and NA-D placed a new brief on the resident with the help of NA-C. NA-D then went to R246's closet, while still wearing gloves, and retrieved one pair of black pants and a pair of grey pants for the resident to choose from to wear. During an interview on 11/8/23, at 8:16 a.m., NA-D stated that when helping a resident with a brief change, and going from dirty to clean tasks, they are to wash hands prior to placing new gloves on hands and touching the resident, in-between performing a dirty to clean task and placing clean gloves on hands. NA-D stated that performing hand hygiene properly helps reduce resident infections. Did NA-D indicate if he did hand sanitize when completing this task and if not why? During an interview on 11/9/23, at 2:18 p.m., the DON stated she expects that when staff go from dirty to clean tasks, they would dispose of their glove, sanitize their hands, and place new gloves and do that in-between each dirty to clean task.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for 3 of 6 residents (R25, R38, R45) observed to received medication. A total of four (4) errors out of 31 opportunities were identified resulting in a 12.9% (percent) facility' error rate. Findings include: R25's Order Summary Report, dated 10/11/23, identified R25's current physician-ordered medications and treatments. This included an order for acetaminophen 500 milligrams (mg) by mouth every six hours as needed (PRN) for pain. The order had a listed start date of 9/26/23. On 11/06/23 at 2:19 p.m., registered nurse (RN)-A prepared R25's medications at a mobile cart in the hallway by the nurses' station. R25 was standing next to the cart and, upon being asked, rated their pain an eight [out of 10]. R25 then returned to their room while RN-A continued preparing R25's medications for administration at the cart. RN-A reviewed R25's electronic Medication Administration Record (MAR) which outlined the same order for acetaminophen as listed on R19's Order Summary Report (dated 10/11/23). However, RN-A removed an opened bottle of acetaminophen from the cart and placed two 500 mg tablets (i.e., 1000 mg) into the medication cup with R25's other oral medications. RN-A then picked up the cup of medications, locked the MAR screen on their cart, and turned to walk to R25's room. RN-A was then stopped by the surveyor and verified the medications in the cup were ready for administration. RN-A stated they were pretty sure the MAR directed to give two 500 mg tablets of acetaminophen to R25 and returned to the medication cart to review the order. RN-A verified R25's MAR and verified it directed to only provide one 500 mg tablet and not two as they had prepared. RN-A added, That's exactly how easy it [error] can happen. RN-A then removed one tablet of the acetaminophen from the prepared medications and returned to R25's room to provide them. R38's Order Summary Report, dated 10/11/23, identified R38's current physician-ordered medications and treatments. This included an order for, Sennalax-S Tablet 8.6-50 MG (Sennosides-Docusate Sodium) . 1 tablet by mouth two times a day, with a listed start date of 9/15/23. On 11/06/23 at 7:42 p.m., licensed practical nurse (LPN)-A prepared R38's medications at a mobile cart in the hallway using R25's electronic Medication Administration Record (MAR). This outlined the same order for Sennalax-S as listed on R38's Order Summary Report (dated 10/11/23). LPN-A removed an opened bottle of Senna (labeled sennosides only) from the cart and placed one brown-colored tablet into the cup with R38's other medications. LPN-A then picked up the cup from the cart, locked the MAR screen on their cart, and turned to walk down to R38's room. LPN-A was then stopped by the surveyor and verified the medications in the cup were ready for administration. LPN-A returned to the medication cart and reviewed R38's current orders. LPN-A verified the medication order directed to give sennosides with docusate sodium (i.e., Senna-S) and inspected the medication cart, however, was unable to locate any supply of that medication. At this time, licensed practical nurse unit manager (LPN)-B presented to the medication cart and reviewed LPN-A's medications which remained in the cup. LPN-B verified the brown-colored sennosides tablet was not the same medication ordered because Senna-S was an orange-colored tablet. LPN-B stated the pharmacy, at times, did not always send the right medications for the stock supply, so they would look for some quick. LPN-B returned after several minutes and expressed they did not have any of the medication on-hand, so they were sending an employee to the local drug store quick to get some. LPN-A then removed the brown-colored sennosides tablet from R38's prepared medications and went to his room to administer the remainder of them. R45's Interagency Physician Discharge Orders/Instructions, dated 10/30/23, identified R45 had been hospitalized for several medical conditions, including diabetes mellitus, and was being discharged to the nursing home. The orders directed to monitor R45's blood glucose three times a day prior to meals, along with other numerous medication orders including Lispro insulin (i.e., Humalog) one to five units subcutaneous three times a day per sliding scale and Vitamin D3 50 micrograms (mcg) by mouth once daily. On 11/8/23 at 7:47 a.m., RN-A prepared R45's medications at a mobile cart in the hallway. RN-A then removed several punch-pack style cards with R45's oral medications from the cart and started to prepare them for administration while referencing the MAR which included the same order for Vitamin D3 as outlined on R45's orders (dated 10/30/23). RN-A removed an opened bottle of Vitamin D3 25 mcg capsules from the top of the cart, however, RN-A only placed one capsule (i.e., 25 mcg) in the cup for administration. RN-A then locked their MAR screen, and turned to enter R45's room down the hallway. RN-A was then stopped by the surveyor and verified the prepared medications were ready for administration. RN-A returned to the medication cart and reviewed R45's Vitamin D3 orders in the MAR. RN-A verified the MAR directed to administer 50 mcg of the medication, however, they had only placed 25 mcg of the medication in the cup for administration (i.e., error). RN-A then added another 25 mcg capsule to the cup and returned to R45's room to provide the medications. RN-A checked R45's blood glucose using a community glucometer which resulted 301. RN-A stated they would retrieve R45's insulin and return. RN-A returned to the medication cart and removed an opened Lilly-brand Lispro insulin flexpen from the medication cart and placed it on top while reviewing the MAR. RN-A stated the orders were to administer four units for a blood glucose of 301, and removed a new Assure Duo Pro needle from a box in another medication cart parked adjacent. RN-A then picked up the insulin pen and walked towards R45's room while dialing the insulin pen to four units. RN-A was stopped just prior to entering R45's room by the surveyor and questioned on the need to prime the insulin needle prior to delivery of the ordered dose. RN-A stated the pen was already primed as it only had to be done once when the pen was first opened. RN-A then entered R45's room and delivered the medication using the un-primed needle and flexpen. RN-A then returned to the medication cart and reiterated they were unsure if the new needle should be primed or not adding, Some you do, some you don't. RN-A then reviewed the box of needles for directions, however, there were no package inserts or manufacturer directions inside to review. An Assure ID Duo-Shield (needle) Training Guide, dated 3/2020, listed written and photo instructions for using the needles with an insulin flexpen. The instructions directed, Before injection, be sure to read the user instructions for the pen injector device for proper use and control ., and outlined a section labeled, Priming the pen injection device, which directed, Prime the pen injection device according to the instructions for the pen injection device. A corresponding Lilly-brand Lispro (insulin) Instructions for Use, dated 2/2020, identified step-by-step instructions to administer a dose of insulin using the device. This included a section labeled, Priming your Pen, which directed to turn the dosing dial to two units, hold the device upright, and depress the dial. A visible drip of insulin should be seen and, if not, repeat the previous steps until such is visible. The instructions further outlined, If you do not [bolded] prime before each injection, you may get too much or too little insulin. On 11/8/23 at 11:43 a.m., the director of nursing (DON) was interviewed. The surveyor reviewed each of the observed medication administration errors, and the DON stated they would investigate the situation and follow-up. However, the DON stated insulin pens should be primed with the two units before each administration. This was best practice and also in accordance with the manufacturer guidelines. On 11/9/23 at 10:41 a.m., a subsequent interview with DON was held. DON verified they had a chance to follow-up on the reported administration errors and review each involved resident' medical record. DON stated the potential for an error was there with each administration and they were going to follow-up with education to the involved staff members. DON stated had the residents' actually received the medications (instead of the surveyor stopping them) then they would follow the policy for a med error, however, since the residents' didn't actually receive the wrong medication or doses, they reiterated a need for education. DON stated it was important to ensure the correct medication and doses were given to for resident safety. A provided Medication Administration - General Guidelines policy, dated 5/2022, identified medications would be administered as prescribed in accordance with good nursing principles and practices. The policy outlined, FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered, adding, A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication .

Based on observation, interview and document review the facility failed to provide hygienic nail care to 2 of 3 residents (R35 and R19) reviewed for dependent activities of daily living (ALD's). R19's annual Minimum Data Set (MDS) assessment dated [DATE], included R19 was severely cognitively impaired, had diagnoses of dementia and aphasia (difficulty speaking), and no behavioral concerns. R19's Cognitive Loss/Dementia Care Area assessment dated [DATE], included he required assistance with ADLs. R19's ADL Functional/Rehabilitation Potential was not assessed or triggered. R19's ADL care plan dated 4/20/20, indicated he often used his hands to eat and required set-up and encouragement for personal hygiene, but lacked nail care assistance needs. His behavioral focus dated 4/1/22, included R19 had behaviors of putting fecal matter on his plates/trays at mealtimes. A note from the Associated Clinic of Psychology dated 8/23/23, instructed staff to continue to monitor for signs that he is smearing or digging [feces], and consider keeping fingernails short. Ongoing monitoring for any signs of digging/residue on fingers can help manage and continue to keep client clean and maintain hygiene. R19's Order Review History dated 11/9/23, included weekly skin inspection by licensed nurse, and complete MHM Weekly Skin Inspection in [electronic medical record] every Thursday evening for skin care, document all refusals in a nurse's note, starting 7/20/23. R19's MHM Weekly Skin Inspection V forms identified it was Not Necessary to trim his fingernails on 9/21/23, 10/9/23, 10/12/23, 10/18/23, and 11/2/23. The medical record lacked documentation for the weeks of 9/28 and 10/25. R19's Progress Notes lacked documentation of refusal of cares, including bathing or nail care, from 9/1/23, through 11/7/23. During observation on 11/7/23 at 10:36 a.m., R19 was seated on a chair in the hallway by the nurses' station. His fingernails were noted to be several millimeters long with brown crusted matter filling the underside of all nails. During observation on 11/7/23 at 12:18 p.m., R19 was seated in a chair in his room with a tray table in front of him containing a plate of what appeared to be rice, sweet potatoes, and another unidentified food item. R19 used his fingers on his left hand to pick up food bites and place them in his mouth throughout the meal until it was gone. During interview on 11/7/23 at 1:07 p.m., nursing assistant (NA)-D stated NAs completed and documented nail care on bath days unless a resident was diabetic, and if a resident refused, they charted it. They stated R19 ate on his own after set-up, and had dementia and some behaviors, including resisting cares and defecating and urinating is his room and smearing feces around, but if in a good mood would let staff wash his hands and trim his nails. During observation and interview on 11/7/12 at 1:37 p.m. license practical nurse (LPN)-B stated NAs completed nail care for non-diabetic residents on bath days and charted both completions and refusals. LPN-B observed R19's fingernails and confirmed they were long and soiled and described them as not great. They asked R19 if they could get someone to cut them and R19 expressed willingness. LPN-B stated staff should have attempted to clean and trim them and document it in the record and was unsure why it was identified as unnecessary in the chart. They stated it was important to keep them clean and trimmed for infection control purposes and to prevent scratching and skin integrity concerns. 47372 Findings include: R35's Face Sheet form, printed 11/7/23, indicated R35 had diagnoses that includes metabolic encephalopathy, intellectual disabilities, type 2 diabetes, and delusional disorders R35's admission Minimum Data Set (MDS), dated [DATE], indicated the assessment of daily and activity preference was not conducted by staff. Additionally, R35 is dependent of staff for showering/bathing and toileting. R35's quarterly MDS, dated [DATE], indicated R35 was moderately cognitively impaired and did not refuse care. R35's Care Area Assessment (CAA), dated 6/27/23, indicated that the ADL functional assessment was not completed or triggered. R35's care plan, dated 6/23/23, indicated that R35 required assistance of two staff for bathing and assistance of one staff for personal hygiene. R35's orders, dated 10/27/23, directed licensed nurses to document R35's skin inspection weekly, every day shift Saturday and to document any refusals. R35's bath and nail care assessment, dated 11/4/23, indicated staff performed and assisted the resident with bathing and nail care. R35's treatment administration record (TAR), printed 11/7/23, indicated that on 11/4/2023, staff assisted the resident with bathing. The electronic medical record (EMR) did not indicate the resident refused bathing or nailcare assistance from staff. During an observation on 11/7/12 at 8:47 a.m., all 10 of R35's fingernails were approximately 1/2 in length with a buildup of dark black residue underneath the fingernail bed. R35 indicated that he would like them trimmed and cleaned. During an interview on 11/7/23 at 12:55 p.m., CNA-A stated that if R35 needed his nails trimmed and cleaned, she will call a nurse because the resident is diabetic. CNA-A went to visit R35 in his room, looked at the residents' fingernails and indicated that they were too long and dirty and if not cleaned properly, could cause an infection. During an interview on 11/8/23 at 8:00 a.m., CNA-C stated that during bath days, she will assist R35 with nail care. If a resident was to refuse, she would re-approach the resident and attempt to provide nail care. If CNA-C was unsuccessful, she would inform the Registered Nurse (RN). During an interview on 11/7/23 at 1:37 p.m., the nurse manager (LPN-B) stated that on bath days, residents are to have their nails trimmed and cleaned by a certified nursing assistant (CNA). If the resident is diabetic, a licensed nurse is required to trim the nails. LPN-B stated that R35's nails are pretty long and soiled and should be trimmed. During an interview on 11/8/23 at 12:38 p.m., the Director of Nursing (DON) stated that she would expect staff to follow the care plans for the residents and provide care in a timely manner per the resident's preferences. She expected that nail trimming be performed on shower/ bath days and as needed. If they are visibly dirty, staff should be sure to clean underneath the nailbed. If residents refuse nail care, staff are expected to reapproach the resident three additional times, inform the nurse of any refusals, and document refusals. A policy titled, Activities of Daily Living (ADL's)/ Maintain Abilities, dated 3/31/23, indicates that a resident who is unable to carry out their own ADLs, that staff will assist them as necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R3) were comprehensively assess for safety and ability who were observed to self-administer medications. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 was cognitively intact, required set-up assistance for eating and oral hygiene, had complaints of difficulty or pain with swallowing, and had diagnoses of diabetes, seizure disorder, and traumatic brain injury. R3's care plan indicated she had difficulty swallowing and must sit up when drinking or eating anything, no matter how small the amount per speech therapy recommendations. R3's Upper GI (gastrointestinal) Endoscopy note dated 10/25/23, indicated she had an esophageal dilation procedure to widen two severely narrowed areas in her esophagus, and was to return for a second procedure in one to two weeks. R3's record lacked evidence of a second procedure. R3's Order Review History Report dated 11/9/23, included orders for the following medications to be given at 2:00 p.m.: -Calcium Citrate + Oral Tablet (Multiple Minerals with Vitamins) one tablet one time per day for supplement -Duloxetine HCl Delayed Release, 90 milligrams (mg) one time per day for major depressive disorder -Meloxicam Tablet 7.5 mg, one tablet once per day for chronic pain syndrome -Oxybutynin Chloride ER 10 mg, one tablet one time per day for urinary leakage -Lamotrigine tablet, 200mg two times per day for bipolar -Gabapentin Oral Capsule, 900 mg by mouth three times per day for neuropathy -Levetiracetam Oral Tablet 500 mg, Give 500 mg by mouth three times per day for seizures. The report also included and order for Ondansetron HCl Oral Tablet 4 mg, one tablet every eight hours as needed for nausea and vomiting. During observation and interview on 11/6/23 at 1:09 p.m., R3 was lying in bed with a full plate of spaghetti and a salad on her bedside table. R3 stated she started coughing and couldn't eat it because it was getting stuck on the way down. She stated she recently had surgery to open her esophagus but sometimes thing still got stuck. R3 was observed coughing periodically during interview, and stated she would ask for anti-nausea medication to see if it would help. During observation on 11/6/23 at 1:18 p.m., registered nurse (RN)-C entered R3's room where R3 requested anti-nausea medication. RN-C left the room and went to the medication cart. At 1:21 p.m. RN-C returned to R3's room where she was heard coughing, and then left. During observation and interview on 11/6/23 at 2:56 p.m., R3 was lying in bed semi-upright, her plate of spaghetti fully eaten on the bedside table. A medication cup containing several pills was sitting next to the food tray. R3 stated the nurse gave the pills to her earlier but she was throwing things up and unable to swallow them, so they set them there until she could get the pills down. One container of anti-fungal powder approximately 25 percent full sat on R3's nightstand. R3 stated sometimes staff left the powder there so she could put it on herself. R3 procedded to take the medication without incident. During interview on 11/6/23 at 3:09 p.m., RN-C stated it was not unusual for R3 to have a cough and they gave her some anti-nausea medication for it. They stated sometimes she took her medication with applesauce, and it could take a long time for her to take her medications, however R3 had an order to allow her pills to be left at bedside. They stated a resident needed to be assessed before handing the medications off to make sure the resident could take them but was unsure if there was any specific form for that assessment other than within the initial admission assessment. Upon review of R3's medical record, RN-C was unable to find an order or medication self-administration assessment. During interview on 11/8/23 at 8:46 a.m., licensed practical nurse (LPN)-B stated if a resident wished to self-administer medications staff completed an assessment to make sure it was safe, provided resident education, and got an order from the provider. They stated R3 had an esophageal stricture and difficulty swallowing and identified it would not be appropriate for R3 to self-administer medications because she likely could have trouble swallowing them. During interview on 11/8/23 at 9:04 a.m., director of nursing stated if a resident wished to self-administer medications staff would complete an assessment, and obtain a provider order. She stated R3 had a recent esophageal dilation and should not self-administer due to the potential for choking. In addition, it would be difficult to know what time they were taken, or if they were taken at all. The Medication Administration - General Guideline policy dated 5/2022, included the resident is always observed after administration to ensure that the dose was completely ingested. In addition, residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. The Self-Administration of Medications policy dated 5/2022, indicated if a resident desires to self-administer medications, and assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility in the care planning process.

Based on observation, interview and document review, the facility failed to accurately complete assessments of pressure related areas to reflect changes and/or deterioration of the wounds, implement care plan interventions including to provide wound care as ordered, and reassess and implement changes to the plan of care when pressure ulcers deteriorated for 5 of 6 residents (R1, R3, R4, R5, R6) reviewed for pressure ulcers. R1, R3, R4 and R5 sustained actual harm due to infection and/or worsening of the pressure ulcers. The immediate jeopardy began on 1/10/19, when R1 was hospitalized following a clinic visit related to deterioration of his wound and subsequent infection. The administrator, regional director of clinical services and clinical consultant were informed of the immediate jeopardy on 2/5/19, at 4:24 p.m. While the Immediate Jeopardy was removed, non-compliance remained at the lower scope and severity of a G. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated he required extensive assistance with bed mobility, total assistance with transfers and toileting and used an indwelling Foley catheter to manage urinary incontinence. The MDS indicated R1 was always incontinent of bowel and identified a stage II pressure ulcer (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister), two stage III pressure ulcers (Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible) and a stage IV pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), all present on admission to the facility. R1's care plan dated 1/3/19, and identified impaired cognitive function. A comprehensive assessment of R1's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. The care plan did not identify R1's pressure ulcers and lacked evidence of interventions to prevent worsening of existing ulcers or prevention of new ulcers. A Twin City Physician's Skilled nursing note dated 12/28/18, indicated R1 had wounds on the sacrum, right ischial tuberosity (known informally as the sit bones) and bilateral heels. Review of R1's Treatment Administration Record (TAR) dated (MONTH) 2019, identified the following orders: Sacral Wound: cleanse wound, pack with VASHE soaked Kerlix, cover and secure with tape. The TAR lacked evidence of treatment orders for R1's heel ulcers and the right ischial tuberosity. Review of R1's Wound Assessment Details Reports identified the following wounds: 1/2/19, Pressure ulcer to sacrum, stage IV. Tissue type described as bright beefy red 100%. Size 9 centimeters (cm) x 5 cm x 4 cm. A correlating photo of the wound identified slough (white or yellow covering on the base of the wound) and eschar (dead tissue found in a full-thickness wound) in the wound bed. 1/9/19, Pressure ulcer to sacrum stage IV. Tissue type described as bright beefy red 100%. The assessment did not have a correlating photo. Review of R1's facility Progress Note dated 1/10/19, indicated R1 went to a clinic appointment in the morning. Facility received a call from the clinic around 3:30 p.m. that he was admitted to the hospital for an infection in his coccyx wound. During interview on 2/4/19, at 3:11 p.m. the director of nursing (DON) reviewed R1's physician orders [REDACTED]. The DON stated the nurses would not have known what treatment to administer to the wounds. During interview on 2/4/19, at 6:12 p.m. the registered nurse (RN) consultant for the facility viewed the photo of R1's wound dated 1/2/19. The RN consultant described the wound as some slough, some eschar but stated she would not stage the wound. The RN consultant stated the DON did all the wound rounds and could give more information, During a subsequent interview on 2/4/19, at 6:13 p.m. the DON viewed the photo of R1's wound and stated the wound was a stage IV and contained necrotic tissue (eschar). The DON stated it was a significant change from the previous week but she had not notified the physician. The DON further stated the physician only looked at the wounds if requested by the facility. R3's Admission MDS dated [DATE], indicated he had intact cognition, required extensive assistance for bed mobility and total assistance for transfers and toileting. The MDS indicated R3 had an indwelling catheter, was always incontinent of bowel and identified two stage IV pressure ulcers present on admission. R3's care plan dated 1/10/19, identified a self care deficit related to [MEDICAL CONDITION] and sacral and lower extremity wounds. The care plan directed staff to complete weekly assessments, photos and measurements and assess and monitor wound healing weekly. A comprehensive assessment of R3's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. In addition, a reassessment was not completed when the pressure ulcers had worsened to determine if care plan interventions were appropriate. R3's TAR dated (MONTH) 2019, identified the following wound orders: Left foot third toe sore - cleanse with normal saline daily and apply [MEDICATION NAME] dressing and wrap. Ulceration of sacrum - [MEDICATION NAME] to ulceration of sacrum and bilateral lower extremities, cover and wrap. Ileac Crest, cleanse with wound cleanser and apply saline wet dressing and cover two times daily. An Order Summary Report indicated the treatment was ordered on [DATE], following surveyor inquiry. Review of the TAR indicated none of R3's wound treatments had been completed 2/1/19, 2/2/19 and 2/3/19. On 2/5/19, at 10:19 a.m. a wound observation was completed with RN-A. R3's toes had multiple dark areas with dry skin. On R3's left calf, two open areas were present. The upper wound contained large amounts of drainage and slough was present in the wound bed. The lower area contained approximately 30% slough. R3's second and fifth toes of his right foot had black nails. The second toe knuckle was gray in color and contained slough, eschar and purulent drainage. A wound on R3's right shin contained contained purulent drainage. R3's right ischial tuberosity wound had a deep wound bed containing 100% dark gray slough. At 10:20 a.m. R3 stated it had been a while since his treatments had been done. R3 stated, I spent the whole weekend asking and they never got done. He stated no reason had been given. R3 further stated he had been in the facility for about a month and it had been a while since a physician had looked at his wounds. A review of R3's Wound Assessment Details Report identified the following: 1/23/19, vascular ulcer left lower leg back, 10 cm x 3.5 cm x unknown. Bright red beefy tissue 100%. 1/30/19, vascular ulcer left lower leg back, 100% red beefy tissue. 10 cm x 3.5 cm x unknown depth. No drainage present and wound edges intact. Review of wound pictures showed a slight increase in size. 2/5/19, left lateral lower leg distal, active stage II pressure ulcer 3.3 cm x 1.1 cm x .10 cm. 100% bright red/pink tissue, scant drainage. There was no assessment to indicate how the ulcer went from vascular to pressure related. 2/5/19, left lateral lower leg proximal, active stage II pressure ulcer 6.9 cm x 3.5 cm x .2 cm. Bright pink/red tissue 100% of wound bed. 1/30/19, right iliac crest stage IV, 100% bright beefy red tissue in the wound bed, 3.1 cm x 1.5 cm x 2.5 cm. A correlating photo of the wound depicts gray slough in the wound bed. 2/5/19, right ischial tuberosity, unstageable pressure ulcer with 40% pink/red tissue and 60% slough present in wound bed. light drainage present. 4 cm x 2.3 cm x 2.1 cm. The record lacked evidence of previous assessment of this wound. 2/5/19, right inner ankle pressure ulcer stage II. Pink/red tissue in wound base, 2.3 cm x 2.6 cm x .1 cm. No previous assessment noted in the medical record. 1/30/19, right lower leg front, vascular, 100% bright red wound bed 6.5 cm x 3.01 cm x unknown. 2/5/19, right lower leg front stage II pressure ulcer. Pink/red tissue 100% 7 cm x 2.1 cm x 0 cm. Wound was previously assessed as a vascular wound. R3's medical record lacked evidence of assessment of his toes. R4's Significant Change MDS dated [DATE], indicated she was severely cognitively impaired, required extensive assistance for bed mobility and transfers and identified one stage II pressure ulcer present on admission. R4's care plan revised on 2/5/19, following surveyor inquiry identified an unstageable pressure ulcer to the left heel. The care plan directed staff to float heels off the bed and provide heel boots when in bed and up in wheel chair. A comprehensive assessment of R4's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. In addition, a reassessment was not completed when the pressure ulcers had worsened to determine if care plan interventions were appropriate. R4's TAR dated (MONTH) 2019, identified the following wound orders: Cleanse area to left heel with wound cleanser twice daily, pat dry, apply Santyl ointment, foam heel dressing and wrap. R4's TAR dated (MONTH) 2019, was requested but not received. During observation on 2/5/19, at 11:36 a.m. RN-A completed R4's dressing change. R4's wound had a foul odor that could be smelled while covered and with heel protector in place. RN-A removed a bandage from R4's left heel that was dated 2/1/19. R4's dressing was saturated with wound drainage. R4's heel was open and contained approximately 90% slough in the wound bed. Review of R4's Wound Assessment Details Report identified the following: 1/16/19, left heel pressure ulcer stage II, 100% intact skin. 3 cm x 2.75 cm x unknown. A correlating photo of the wound depicted 100% black eschar. 1/23/19, left heel pressure ulcer, blister stage II. Intact skin 100%, no drainage, measuring 3 cm x 2.75 cm. A correlating photo of the wound depicted eschar and slough in the wound bed. 1/30/19, left heel stage II 100% intact skin. no drainage, edges distinct and intact. 3 cm x 2.74 cm x unknown depth. A correlating photo of the wound depicted 80% yellow slough in the wound bed 2/5/19, left heel ulceration facility acquired, Pink/red tissue 60% slough 40%. 1.2 cm x 4 cm x unknown depth, unstageable. There was no reassessment related to the worsening of the pressure ulcer. On 2/5/19, at 10:13 a.m. the RN consultant viewed a picture of R4's wound dated 1/30/19. The correlating assessment identified the wound as 100% intact skin. The RN consultant described the wound in the photo as slough, stated she could see pink tissue in the base of the wound then stated, I would call it necrotic tissue. The RN consultant stated the facility liked to have the same nurse see the wound each week because they used the same verbiage. The RN consultant further stated while reviewing the assessments of R4's wounds, that changes had occurred in (MONTH) and again in late January. She stated the physician should have been updated to determine if new orders were needed. R5's quarterly MDS dated [DATE], indicated he had intact cognition, required extensive assistance of two staff for bed mobility and total assistance for transfers and toileting. The MDS identified a stage II pressure ulcer, a stage III pressure ulcer and a stage IV pressure ulcer, all present on admission. R5's care plan dated 11/16/18, identified a pressure ulcer to the coccyx and right hip. The care plan directed staff to assess and monitor wound healing and report improvement or decline to physician. A comprehensive assessment of R5's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. In addition, a reassessment was not completed when the pressure ulcers had worsened to determine if care plan interventions were appropriate. Review of R5's TAR dated (MONTH) 2019, identified the following wound treatments: Right ischial tuberosity and coccyx, cleanse with VASHE moistened gauze, cover and secure every day. The TAR indicated wound treatment had not been completed 2/1/19, 2/2/19 and 2/3/19. During wound observation on 2/5/19, at 10:56 a.m. surveyor asked permission to observe wound care. R5 stated, At least it will get done. R5 stated he thought his treatment was scheduled twice daily but stated it has not happened. R5 further stated the care in the facility was poor and sometimes he did not get out of bed until three or four in the afternoon and stated he did not get repositioned. At 11:01 a.m. RN-A completed R5's wound care. R5 had a large stage IV pressure ulcer on his coccyx. Slough was present in the wound bed and the edges were rolled with some necrotic tissue present. The surrounding tissue was red, macerated and contained some small open areas. R5's right ischial tuberosity contained approximately 80% slough with some necrotic tissue at the edges. R5's Wound Assessment Details Report was reviewed and identified the following: 1/16/19, Pressure ulcer to coccyx, stage IV 100% bright beefy red tissue, wound edges none. 6 cm x 6.5 cm x 3.55 cm. A correlating photo depicted 40% slough in wound bed and rolled edges. 1/23/19, Pressure ulcer to coccyx, stage IV. Tissue type 100% bright red beefy tissue. Moderate amount of drainage, peri-wound normal, wound edge none. 6 cm x 6.5 cm x unknown depth. Tunneling was identified 2 cm at 2:00 and 2.5 cm at 5:00. A correlating photo depicted slough in wound bed, rolled edges and maceration of the surrounding tissue. 1/30/19, Pressure ulcer coccyx, stage IV. Tissue type 100% bright beefy red. Moderate drainage, 6 cm x 6.5 cm x unknown. Tunneling was identified 2 cm at 2:00 and 2.5 cm at 5:00. 2/6/19, coccyx ulcer stage IV, 8 cm x 9 cm x 2 cm. 100% pale pink granulation tissue in wound bed, moderate purulent drainage. undermining 2.10 cm at 8:00 to 10:00 and tunneling 2 cm at 2:00 and 2.5 cm at 5:00. There was no reassessment of the pressure ulcer despite worsening condition. 1/16/19, right trochanter, stage II pressure ulcer acquired in facility. 2 cm x 2.5 cm x 2.3 cm bright red beefy tissue. Small amount of bloody drainage present. 1/23/19, right trochanter, stage II pressure ulcer acquired in facility. 2 cm x 2.5 cm x 2.3 cm bright red beefy tissue. Small amount of bloody drainage present. 1/30/19, right trochanter, stage II pressure ulcer facility acquired. 2 cm x 2.5 cm x 2.3 cm bright red beefy tissue in wound bed. Scant amount of drainage present. 2/6/19, right trochanter stage III pressure ulcer worsened and was measured as 6.2 cm x 6.5 cm x 4.2 cm. Beefy red tissue 50%, slough 50%, undermining 2.6 cm at 4:00. There was no reassessment of the pressure ulcer despite worsening condition. R6's annual MDS dated [DATE], indicated she had intact cognition, required extensive assist of two staff for bed mobility and total assist for transfers and toileting. The MDS further indicated she had a stage IV pressure ulcer acquired at the facility. R6's care plan dated 11/12/18, identified a self care deficit related to [MEDICAL CONDITION] and a pressure ulcer to the sacrum. The care plan directed staff to offload and reposition every two hours while in bed and assess weekly and as needed and report improvement or decline to the physician. A comprehensive assessment of R6's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. R6's TAR dated (MONTH) 2019, identified the following wound treatment: Wound dressing change sacrum, cleanse wound and surrounding tissue with normal saline or wound cleanser, cover with [MEDICATION NAME] and cover every day. The TAR indicated the treatment had not been completed 2/1/19, 2/2/19 and 2/3/19. On 2/4/19, at approximately 2:30 p.m. the assistant director of nursing (ADON) completed R6's wound care. R6 had a pressure ulcer on her sacrum. The ADON described the wound as having rolled edges, undermining, 15-30% red beefy tissue and 80% pale pink. R6 also had several small open areas to her labia. A review of R6's Wound Assessment Details Report identified the following wounds: 1/23/19, sacral ulcer stage IV acquired in facility. Pale pink non-granulating tissue 10%, Bright beefy red tissue 90%. 4.8 cm x 7.2 cm x .01 cm. Light drainage, surrounding tissue red. 1/30/19, sacral ulcer stage IV. Pale pink non-granulating tissue 10%, Bright beefy red tissue 90%. 4.8 cm x 7.2 cm x .01 cm. Light drainage, surrounding tissue red. 2/5/19, sacrum active stage IV 4 cm x 8 cm x 1 cm. Bright red beefy tissue 100%, light drainage present. Undermining .8 cm from 6:00 to 9:00. During interview on 2/4/19, at 12:58 p.m. R6 stated she had been in the facility for [AGE] years. R6 stated the facility did not have enough staff and stated because there was a pool agency staff nurse working that day she had not had her wound treatment done. She stated generally when an agency nurse was working the dressing changes did not get done. R6 further stated staff only repositioned her once per shift. During interview on 2/5/19, at 11:46 a.m. the administrator and RN consultant were present. The RN consultant stated the physician should have been notified if wounds were deteriorating or increasing in size. The administrator stated now that it had come to the facility's attention that there were gaps in their processes they would be reviewing the process for wound assessment. During interview on 2/5/19, at 3:02 p.m. the medical director stated there were times when she would personally look at wounds with the nurses and stated when a resident had a wound she was concerned about she would look at it. The medical director stated the facility used to have a wound doctor involved but he no longer came to the facility. The medical director stated she had never seen R1 in the facility. Regarding R2, the medical director stated he had an episode where she thought he might be going septic and ran some tests. She stated when R2's blood tests came back she got really concerned and started him on IV antibiotics for possible osteo[DIAGNOSES REDACTED]. She stated R3 had a lot of wounds. She stated the wet to dry dressing for the wound on R3's iliac crest was not her order and stated we don't do wet to dry dressings. The medical director stated she was led to believe the DON had a really good handle on the wounds. During interview on 2/6/19, at 8:57 a.m. the administrator stated the facility identified they were being reactive rather than proactive related to skin and stated they started a plan that included education and audits. The administrator stated the facility would be reviewing each wound as an interdisciplinary team and if changes occurred would be updating the physician. The administrator stated this was new as of the previous day. During a subsequent interview on 2/6/19, at 10:13 a.m. the medical director stated the wound assessment system was set up so that once a picture of the wound was taken, the entire assessment had to be completed before moving on to the next patient. The medical director indicated the photos were being taken, but the updated assessment information was not being entered. The immediate jeopardy was removed on 2/6/19, at 3:30 p.m. when the facility implemented the following: all wounds were reassessed by the certified wound care nurse along with the medical director. The medical director reviewed all wounds and treatments with some recommendations. All residents with wounds had care plans reviewed and updated and the facility wound team was enhanced to include the director of nursing, assistant director of nursing, charge nurse, registered dietician and the medical director every other week. A facility policy titled, Skin Management Guideline dated 11/28/17, indicated it was the practice of the facility to identify and evaluate residents who's clinical conditions increase the risk for pressure ulcers, to implement preventative measures and to provide appropriate treatments modalities for wounds. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: Consult with the physician of nurse practitioner, re-evaluate turning and repositioning programs, evaluate interventions and re-evaluate and modify the plan of care, document any changes or concerns in the nurses notes and consult with the physician if the ulcers have not shown progress or if the wound is deteriorating or increased in size.

Based on observation, interview and document review, the facility neglected to accurately complete assessments of pressure related areas to reflect changes and/or deterioration of the wounds, implement care plan interventions to provide wound care as ordered, and reassess and implement changes to the plan of care when pressure ulcers deteriorated for 6 of 6 residents (R1, R2, R3, R4, R5, R6) reviewed for pressure ulcers. In addition, the facility failed to provide wound care, timely repositioning and failed to update the physician regarding wound status. R1, R3, R4 and R5 sustained actual harm due to infection and/or worsening of the pressure ulcers. The immediate jeopardy began on 1/10/19, when R1 was hospitalized following a clinic visit related to deterioration of his wound and subsequent infection. It was determined a systemic deficient practice occurred related to inappropriately assessing pressure ulcers as having healthy tissue or intact skin, when in fact the weekly photographs of the pressure ulcers depicted ulcers with necrotic (dead) tissue present. This resulted in the worsening of pressure ulcers for 4 residents. The administrator, regional director of clinical services and clinical consultant were informed of the immediate jeopardy on 2/5/19, at 4:24 p.m. While the Immediate Jeopardy was removed, non-compliance remained at the lower scope and severity of a G. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated he required extensive assistance with bed mobility, total assistance with transfers and toileting and used an indwelling Foley catheter to manage urinary incontinence. The MDS indicated R1 was always incontinent of bowel and identified a stage II pressure ulcer (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister), two stage III pressure ulcers (Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible) and a stage IV pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), all present on admission to the facility. R1's care plan dated 1/3/19, identified impaired cognitive function and an alteration in bowel continence. The care plan did not identify R1's pressure ulcers and lacked evidence of interventions to prevent worsening of existing ulcers or prevention of new ulcers. A comprehensive assessment of R1's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. The care plan did not identify R1's pressure ulcers and lacked evidence of interventions to prevent worsening of existing ulcers or prevention of new ulcers. A Twin City Physician's Skilled nursing note dated 12/28/18, indicated R1 had wounds on the sacrum, right ischial tuberosity (known informally as the sit bones) and bilateral heels. Review of R1's treatment administration record (TAR) dated (MONTH) 2019, identified the following orders: Sacral Wound: cleanse wound, pack with VASHE soaked Kerlix, cover and secure with tape. The TAR lacked evidence of treatment orders for R1's heel ulcers and the right ischial tuberosity. The TAR further indicated R1's sacral wound treatment had not been completed 1/7/19 and 1/8/19. Review of R1's Wound Assessment Details Reports identified the following wounds: 1/2/19, Pressure ulcer to sacrum, stage IV. Tissue type described as bright beefy red 100%. Size 9 centimeters (cm) x 5 cm x 4 cm. A correlating photo of the wound identified slough and eschar in the wound bed. 1/9/19, Pressure ulcer to sacrum stage IV. Tissue type described as bright beefy red 100%. The assessment did not have a correlating photo. Review of R1's facility Progress Note dated 1/10/19, indicated R1 went to a clinic appointment in the morning. Facility received a call from the clinic around 3:30 p.m. that he was admitted to the hospital for an infection in his coccyx wound. R1's medical record lacked evidence the physician was updated regarding the changes in R1's wound. During interview on 2/4/19, at 3:11 p.m. the director of nursing (DON) reviewed R1's physician orders [REDACTED]. The DON stated the nurses would not have known what treatment to administer to the wounds. During interview on 2/4/19, at 6:12 p.m. the registered nurse (RN) consultant for the facility viewed the photo of R1's wound dated 1/2/19. The RN consultant described the wound as some slough, some eschar but stated she would not stage the wound. The RN consultant stated the DON did all the wound rounds and could give more information, During a subsequent interview on 2/4/19, at 6:13 p.m. the DON viewed the photo of R1's wound and stated the wound was a stage IV and contained necrotic tissue (eschar). The DON stated it was a significant change from the previous week but she had not notified the physician. The DON further stated the physician only looked at the wounds if requested by the facility. During interview on 2/5/19, at 3:02 p.m. the medical director stated she had never seen R1 in the facility. R2's admission/readmission MDS dated [DATE], indicated he had intact cognition and was independent with all activities of daily living. The MDS further indicated he had two venous/arterial ulcers. R2's care plan dated 1/18/19, identified a self care deficit and indicated he was independent with activities of daily living. The care plan lacked evidence of interventions related to his ulcers or interventions for prevention of new ulcers or worsening of existing ulcers. On 2/4/19, at 6:06 p.m. R2 approached surveyor and stated, they (facility) are not taking care of my wounds. R2 stated his treatment had not been done for the last four days. Review of R2's TAR dated (MONTH) 2019, identified the following orders for wound care: Change the dressing daily, apply [MEDICATION NAME] to wound, cover and wrap. The order lacked location(s) of the wound. R2's wound treatment had not been signed as completed on 2/2/19, 2/3/19 or 2/4/19. R2's wound care was observed on 2/5/19, at 9:39 a.m. with RN-A. RN-A stated R2 only had one wound, located on the left foot. RN-A removed the bandages on R2's left foot which were saturated with wound drainage and stated, it looks like these haven't been done in a while. RN-A described the wound on R2's left foot as approximately 2 cm hole with dry edges. R2's right lateral foot was wrapped in Kerlix which was removed to reveal an additional wound. RN-A described the wound as a 1 cm hole. At 9:50 a.m. the DON entered R2's room. The DON described the wound on R2's right foot as a dry scab, center of circle not intact and containing some slough. Review of R2' s Wound Assessment Details Reports identified the following wounds: 1/23/19, vascular wound to bottom of left foot. 100% pale pink non-granulating tissue. Wound measured 2.2 cm x 2.2 cm, depth unknown. 1/30/19, bottom of left foot, superficial wound 2.2 cm x 2.2 cm x unknown. 2/5/19, bottom of left foot, 2.2 cm x 2.5 cm x .3 cm pale pink non granulating tissue with light drainage. 1/23/19, vascular wound to right lateral foot 100% intact skin. No assessment was completed on 1/30/19. 2/5/19, right lateral foot 1.6 cm x 2.0 cm x .3 cm. pale pink non- granulating tissue. On 2/5/19, at 9:12 a.m. the DON stated R2 was on an antibiotic [MEDICAL CONDITION] but did not know the cause of [MEDICAL CONDITION]. The DON reviewed R2's TAR and stated his wound care was last done on 2/1/19, and stated it was supposed to be done daily. During interview on 2/5/19, at 3:02 p.m. the medical director stated R2 had an episode where she thought he was becoming septic and ordered lab tests. The medical director stated when the results of the lab tests came back she became really concerned and started him on an IV antibiotic for probable [DIAGNOSES REDACTED]. R3's Admission MDS dated [DATE], indicated he had intact cognition, required extensive assistance for bed mobility and total assistance for transfers and toileting. The MDS indicated R3 had an indwelling catheter, was always incontinent of bowel and identified two stage IV pressure ulcers present on admission. R3's care plan dated 1/10/19, identified a self care deficit related to [MEDICAL CONDITION] and sacral and lower extremity wounds. The care plan directed staff to complete weekly assessments, photos and measurements and assess and monitor wound healing weekly. A comprehensive assessment of R3's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. In addition, a reassessment was not completed when the pressure ulcers had worsened to determine if care plan interventions were appropriate. R3's TAR dated (MONTH) 2019, identified the following wound orders: Left foot third toe sore - cleanse with normal saline daily and apply [MEDICATION NAME] dressing and wrap. Ulceration of sacrum - [MEDICATION NAME] to ulceration of sacrum and bilateral lower extremities, cover and wrap. Ileac Crest, cleanse with wound cleanser and apply saline wet dressing and cover two times daily. An Order Summary Report indicated the treatment was ordered on [DATE], following surveyor inquiry. Review of the TAR indicated that none of R3's wound treatments had been completed 2/1/19, 2/2/19 and 2/3/19. On 2/5/19, at 10:19 a.m. a wound observation was completed with RN-A. R3's toes had multiple dark areas with dry skin. On R3's left calf, two open areas were present. The upper wound contained large amounts of drainage and slough was present in the wound bed. The lower area contained approximately 30% slough. R3's second and fifth toes on his right foot had black nails. The second toe knuckle area was gray in color and contained slough, eschar and purulent drainage. A wound on R3's right shin contained purulent drainage. R3's right ischial tuberosity wound had a deep wound bed containing 100% dark gray slough. At 10:20 a.m. R3 stated it had been a while since his treatments had been done. R3 stated, I spent the whole weekend asking and they never got done. He stated no reason had been given. R3 further stated he had been in the facility for about a month and it had been a while since a physician had looked at his wounds. A review of R3's Wound Assessment Details Report identified the following: 1/23/19, left lower leg back, vascular ulcer 10 cm x 3.5 cm x unknown. Bright red beefy tissue 100%. 1/30/19, vascular ulcer left lower leg back, 100% red beefy tissue. 10 cm x 3.5 cm x unknown depth. No drainage present and wound edges intact. 2/5/19, left lateral lower leg distal, active stage II pressure ulcer 3.3 cm x 1.1 cm x .10 cm. 100% bright red/pink tissue, scant drainage. 2/5/19, left lateral lower leg proximal, active stage II pressure ulcer 6.9 cm x 3.5 cm x .2 cm. Bright pink/red tissue 100% of wound bed. 1/30/19, right iliac crest stage IV, 100% bright beefy red tissue in the wound bed, 3.1 cm x 1.5 cm x 2.5 cm. A correlating photo of the wound depicts gray slough in the wound bed. 2/5/19, right ischial tuberosity, unstageable pressure ulcer with 40% pink/red tissue and 60% slough present in wound bed. light drainage present. 4 cm x 2.3 cm x 2.1 cm. 2/5/19, right inner ankle pressure ulcer stage II. Pink/red tissue in wound base, 2.3 cm x 2.6 cm x .1 cm. 1/30/19, right lower leg front, vascular 100% bright red wound bed 6.5 cm x 3.01 cm x unknown. 2/5/19, right lower leg front stage II pressure ulcer. Pink/red tissue 100% 7 cm x 2.1 cm x 0 cm. R3's medical record lacked evidence of assessment of his toes. The medical record further lacked evidence of physician updated related to wound progress or deterioration. During interview on 2/5/19, at 3:02 p.m. the medical director stated she was aware R3 had a lot of wounds. The medical director stated the dressing for R3's iliac crest was not her order and stated, we don't do wet to dry dressings. R4's Significant Change MDS dated [DATE], indicated she was severely cognitively impaired, required extensive assistance for bed mobility and transfers and identified one stage II pressure ulcer present on admission. R4's care plan revised on 2/5/19, following surveyor inquiry, identified an unstageable pressure ulcer to the left heel. The care plan directed staff to float heels off the bed and provide heel boots when in bed and up in wheel chair. A comprehensive assessment of R4's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. In addition, a reassessment was not completed when the pressure ulcers had worsened to determine if care plan interventions were appropriate. R4's TAR dated (MONTH) 2019, identified the following wound orders: Cleanse area to left heel with wound cleanser twice daily, pat dry, apply Santyl ointment, foam heel dressing and wrap. R4's TAR dated (MONTH) 2019, was requested but not received. During observation on 2/5/19, at 11:36 a.m., RN-A completed R4's dressing change. R4's wound had a foul odor that could be smelled while covered and with heel protector in place. RN-A removed a bandage from R4's left heel that was dated 2/1/19. R4's dressing was saturated with wound drainage. R4's heel was open and contained approximately 90% slough in the wound bed. Review of R4's Wound Assessment Details Report identified the following: 1/16/19, left heel pressure ulcer stage II, 100% intact skin. 3 cm x 2.75 cm x unknown. A correlating photo of the wound depicted 100% black eschar. 1/23/19, left heel pressure ulcer, blister stage II. Intact skin 100%, no drainage, measuring 3 cm x 2.75 cm. A correlating photo of the wound depicted eschar and slough in the wound bed. 1/30/19, left heel stage II 100% intact skin. no drainage, edges distinct and intact. 3 cm x 2.74 cm x unknown depth. A correlating photo of the wound depicted 80% yellow slough in the wound bed 2/5/19, left heel ulceration facility acquired, Pink/red tissue 60% slough 40%. 1.2 cm x 4 cm x unknown depth, unstageable. R4's medical record lacked evidence of physician updated related to the status of the wound. On 2/5/19, at 10:13 a.m. the RN consultant viewed a picture of R4's wound dated 1/30/19. The correlating assessment identified the wound as 100% intact skin. The RN consultant described the wound in the photo as slough, stated she could see pink tissue in the base of the wound then stated, I would call it necrotic tissue. The RN consultant further stated while reviewing the assessments of R4's wounds, that changes had occurred in (MONTH) and again in late January. She stated the physician should have been updated to determine if new orders were needed. R5's quarterly MDS dated [DATE], indicated he had intact cognition, required extensive assistance of two staff for bed mobility and total assistance for transfers and toileting. The MDS identified a stage II pressure ulcer, a stage III pressure ulcer and a stage IV pressure ulcer, all present on admission. R5's care plan dated 11/16/18, identified a pressure ulcer to the coccyx and right hip. The care plan directed staff to assess and monitor wound healing and report improvement or decline to physician. A comprehensive assessment of R5's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. In addition, a reassessment was not completed when the pressure ulcers had worsened to determine if care plan interventions were appropriate. Review of R5's TAR dated (MONTH) 2019, identified the following wound treatments: Right ischial tuberosity and coccyx, cleanse with VASHE moistened gauze, cover and secure every day. The TAR indicated wound treatment had not been completed 2/1/19, 2/2/19 and 2/3/19. During wound observation on 2/5/19, at 10:56 a.m. surveyor asked permission to observe wound care. R5 stated, at least it will get done. R5 stated he thought his treatment was scheduled twice daily but stated it hasn't happened. R5 further stated the care in the facility was poor and sometimes he didn't get out of bed until three or four in the afternoon and stated he did not get repositioned. At 11:01 a.m. RN-A completed R5's wound care. R5 had a large stage IV pressure ulcer on his coccyx. Slough was present in the wound bed and the edges were rolled with some necrotic tissue present. The surrounding tissue was red, macerated and contained some small open areas. R5's right ischial tuberosity contained approximately 80% slough with some necrotic tissue at the edges. R5's Wound Assessment Details Report was reviewed and identified the following: 1/16/19, Pressure ulcer to coccyx, stage IV 100% bright beefy red tissue, wound edges none. 6 cm x 6.5 cm x 3.55 cm. A correlating photo depicted 40% slough in wound bed and rolled edges. 1/23/19, Pressure ulcer to coccyx, stage IV. Tissue type 100% bright red beefy tissue. Moderate amount of drainage, peri-wound normal, wound edge none. 6 cm x 6.5 cm x unknown depth. Tunneling was identified 2 cm at 2:00 and 2.5 cm at 5:00. A correlating photo depicted slough in wound bed, rolled edges and maceration of the surrounding tissue. 1/30/19, Pressure ulcer coccyx, stage IV. Tissue type 100% bright beefy red. Moderate drainage, 6 cm x 6.5 cm x unknown. Tunneling was identified 2 cm at 2:00 and 2.5 cm at 5:00. 2/6/19, coccyx ulcer stage IV, 8 cm x 9 cm x 2 cm. 100% pale pink granulation tissue in wound bed, moderate purulent drainage. undermining 2.10 cm at 8:00 to 10:00 and tunneling 2 cm at 2:00 and 2.5 cm at 5:00. 1/16/19, right trochanter, stage II pressure ulcer acquired in facility. 2 cm x 2.5 cm x 2.3 cm bright red beefy tissue. Small amount of bloody drainage present. 1/23/19, right trochanter, stage II pressure ulcer acquired in facility. 2 cm x 2.5 cm x 2.3 cm bright red beefy tissue. Small amount of bloody drainage present. 1/30/19, right trochanter, stage II pressure ulcer facility acquired. 2 cm x 2.5 cm x 2.3 cm bright red beefy tissue in wound bed. Scant amount of drainage present. 2/6/19, right trochanter stage III pressure ulcer 6.2 cm x 6.5 cm x 4.2 cm. Beefy red tissue 50%, slough 50%, undermining 2.6 cm at 4:00. The medical record lacked evidence of physician updated related to the status of R5's wounds. R6's, annual MDS dated [DATE], indicated she had intact cognition, required extensive assist of two staff for bed mobility and total assist for transfers and toileting. The MDS further indicated she had a stage IV pressure ulcer acquired at the facility. R6's care plan dated 11/12/18, identified a self care deficit related to [MEDICAL CONDITION] and a pressure ulcer to the sacrum. The care plan directed staff to offload and reposition every two hours while in bed and assess weekly and as needed and report improvement or decline to the physician. A comprehensive assessment of R6's risk factors related to pressure ulcers, including causal factors, nutritional status, skin condition, incontinence or other areas that could hinder improvement of the pressure ulcers had not been completed. R6's TAR dated (MONTH) 2019, identified the following wound treatment: Wound dressing change sacrum, cleanse wound and surrounding tissue with normal saline or wound cleanser, cover with [MEDICATION NAME] and cover every day. The TAR indicated the treatment had not been completed 2/1/19, 2/2/19 and 2/3/19. On 2/4/19, at approximately 2:30 p.m. the assistant director of nursing (ADON) completed R6's wound care. R6 had a pressure ulcer on her sacrum. The ADON described the wound as having rolled edges, undermining, 15-30% red beefy tissue and 80% pale pink. R6 also had several small open areas to her labia. A review of R6's Wound Assessment Details Report identified the following wounds: 1/23/19, sacral ulcer stage IV acquired in facility. Pale pink non-granulating tissue 10%, Bright beefy red tissue 90%. 4.8 cm x 7.2 cm x .01 cm. Light drainage, surrounding tissue red. 1/30/19, sacral ulcer stage IV. Pale pink non-granulating tissue 10%, Bright beefy red tissue 90%. 4.8 cm x 7.2 cm x .01 cm. Light drainage, surrounding tissue red. 2/5/19, sacrum active stage IV 4 cm x 8 cm x 1 cm. Bright red beefy tissue 100%, light drainage present. Undermining .8 cm from 6:00 to 9:00. During interview on 2/4/19, at 12:58 p.m. R4 stated she had been in the facility for [AGE] years. R6 stated the facility did not have enough staff and stated because there was a pool agency staff nurse working that day she had not had her wound treatment done. She stated generally when an agency nurse was working the dressing changes did not get done. R6 further stated staff only repositioned her once per shift. During interview on 2/5/19, at 11:46 a.m. the administrator and RN consultant were present. The RN consultant stated the physician should have been notified if wounds were deteriorating or increasing in size. The administrator stated now that it had come to the facility's attention that there were gaps in their processes they would be reviewing the process for wound assessment. During interview on 2/5/19, at 3:02 p.m. the medical director stated there were times when she would personally look at wounds with the nurses and stated when a patient had a wound she was concerned about she would look at it. The medical director stated the facility used to have a wound doctor involved but he no longer came to the facility. The medical director stated she was led to believe the DON had a really good handle on the wounds. The immediate jeopardy was removed on 2/6/19, at 3:30 p.m. when the facility implemented the following: all wounds were reassessed by the certified wound care nurse along with the medical director. The medical director reviewed all wounds and treatments with some recommendations. All residents with wounds had care plans reviewed and updated and the facility wound team was enhanced to include the director of nursing (DON) assistant director of nursing, charge nurse, registered dietician and the medical director every other week. In addition, the interim DON was designated to monitor the completion of all treatments daily Monday through Friday. A facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/17 was reviewed. The policy identified neglect as: The failure of the facility, it's 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.

Based on interview and document review the facility failed to notify the physician of a significant clinical changes for one of four (R1) residents reviewed for wound care. Facility nursing staff failed to notify R1's physician when R1's right knee wound changed color and shape, increased in swelling and drainage, and the wound dehisced. Findings include: R1's medical record was reviewed. R1's [DIAGNOSES REDACTED]. A nurse's note dated 05/03/18, at 10:20 p.m., indicated R1 had knee surgery and was admitted to the facility. A skin assessment dated [DATE], by RN-H indicated R1's right knee had redness and swelling. A drawing of R1's right knee indicated an incision closed with sutures or steri-strips. A nurse's note dated 05/04/18, at 12:59 p.m., indicated R1 had significant increased pain in her right knee and her pain medication was not effective. A nurse's note dated 05/04/18, at 11:18 p.m., indicated R1's right knee had no signs of infection but drained a small amount of fluid. A nurse's note dated 05/05/18, at 10:09 a.m., R1's right knee the wound was open and described as: wound bed was pink with 90 percent granulation and a moderate amount of serosangious (bloody) drainage. A weights and vitals summary indicated on 05/06/18 at 1:00 a.m., R1's temperature was 98.7, and on 05/07/18 at 11:23 a.m. it was 102.4. R1's medical record did not indicate other temperatures during her stay at the facility. A nurse's note dated 05/06/18, at 2:05 p.m., indicated R1's right knee wound was open with bloody drainage. A nurse's noted dated 05/07/18, at 9:10 a.m., indicated staff reported bloody drainage from R1's right knee during interdisciplinary team rounds. R1's right knee wound was open, had uneven edges, slough was present in the wound, and the wound was pink. Staff reported R1 had a temperature of 106.0. Staff notified R1's nurse practitioner (NP), who was in the building. The NP assessed R1's right knee. Staff sent R1 to the hospital. Hospital records dated 05/07/18, indicated the resident came to the hospital [MEDICAL CONDITION]: fever, nausea, vomiting, and a right knee infection. R1's right knee wound had significant dehiscence with purulent drainage, and necrosis. Staff admitted R1 and treated her with antibiotics. R1 went to the operating room four times in eight days for debridement and cleaning of her right knee wound. During an interview on 06/26/18, at 2:15 p.m., registered nurse (RN)-D stated she cared for R1 on 05/06/18, during the day shift and changed R1's right knee dressing. RN-D stated R1's right knee incision was slightly open and drained bloody colored fluid. R1 was in pain all the time. RN-D stated she did not call R1's physician although she informed RN-I, nurse management. During an interview on 06/26/18, at 3:26 p.m., licensed practical nurse ( LPN)-G stated he cared for R1 on 05/05/18 and changed her right knee dressing. On 05/05/18, R1's right knee showed no signs of infection and R1 did not have a fever. LPN-G stated he cared for R1 on 05/07/18, and R1 had a fever. R1 told LPN-G she had a fever for the past 24 hours. LPN-G stated he notified R1's physician, R1's physician assessed R1, and sent R1 to the hospital. During an interview on 07/02/18, at 10:04 a.m. LPN-H stated that on 05/04/18, she cared for R1 and changed R1's right knee dressing. R1's right knee incision was closed and had some drainage of clear fluid. During an interview on 07/02/18, at 3:06 p.m., RN-I stated she worked on 05/05/18, and 05/06/18, as the manager on duty. RN-I stated she did not look at R1's right knee wound on either day. During an interview on 07/03/018, at 10:03 a.m., R1 stated she went to the facility after surgery on her right knee. On 05/05/18, she had a fever and asked staff to take her temperature but they refused. On 05/06/18, when the facility staff changed the right knee dressing the wound looked rotten. It had changed shape and color. R1 stated on 05/06/18, she felt sick to her stomach and could not eat. R1 had a very high temperature on 05/07/18, and went to the hospital. During an interview on 7/5/18, nurse practitioner NP-(J) stated he saw R1 on 05/07/18, and sent R1 to the hospital. R1's right knee appeared swollen and dehisced (open) with multiple areas of slough (yellow brownish dead tissue) in the wound. R1 showed NP-J a photograph of her wound from 05/03/18 and the photograph showed a normally healing post-surgical incision with intact steri-strips and no swelling. A nurse told NP-J that R1 had a fever for several days but he could not recall the nurse's name. NP-J stated he could not verify the fever in R1's chart. A policy dated 11/28/17, indicated staff will immediately report changes in a resident's condition to the attending physician or delegated physician. Changes in resident condition include a deterioration in health or clinical complications.

Based on interview and document review, the facility failed to ensure timely medical care was provided for a resident who experienced a fall with subsequent cognitive and behavioral changes, and significant physical symptoms for 1 of 2 residents (R12) whose closed records were reviewed. This resulted in actual harm for R12 who was hospitalized following a fall and died [DATE]. In addition, the faclity failed to ensure [MEDICAL CONDITION] was appropriately assessed and treated for [REDACTED]. Findings include: R12 had a fall in his room as noted by the Occurrence Report dated [DATE]. The activity section indicated R12 was in the bed prior to the fall. The report depicted, CNA (certified nursing assistant) found him on floor next to his bed on Left side, bed in low, he was throwing pillows at staff and being very unusual behavior. He had ripped off bandaids on the floor, hip drsg (dressing) almost off, heel drsg in place. Unable to tell if small areas bleeding were new or where he had ripped off bandaids. Area on left outer wrist replaced bandaide and a large drsy (sic) placed on Left side of head. The section for Resident statement noted R12 to be very confused per usual. The section for executive director and director of nursing to sign noted, The IDT (interdisciplinary team) Met and reviewed the fall MD (medical doctor) notified and UA (urine analysis) ordered Care Plan Updated. The report reflected R12 sustained an excoriated area on the left side of his head. The Neurological Assessment Flowsheet dated [DATE], noted R12 had 16 opportunities for SpO2 levels to be conducted. Of the 16 opportunities only seven readings were recorded either on the neuro sheet or in the Progress Notes. Two of the readings were below the recommended levels. The readings were 91% and 94%. The medical record lacked evidence of the residents, breathe sounds, if the lungs were clear, if the resident was short of breathe, if the breathing was labored when R12 had oxygen saturation levels below 95%. The medical record lacked evidence of the physician being notified of the low SpO2 levels to determine if supplemental oxygen was needed for R12. The facility did not comprehensively re-assess R12's change in mental status after R12 was found on the floor and he hit his left side of his head. The occurrence log dated [DATE], indicated R12 had a fall at 5:05 a.m. The report noted R12 fell to the ground. The untitled sheet which contained a column for Office of Health Complaints (OHFC) project number sheet was reviewed for entries on [DATE], and R12's fall was not called in to OHFC. The Common Entry Point (CEP) Reporting Log was reviewed for the date of [DATE], and no report was made to CEP on [DATE], regarding R12's fall. Further review of the medical record indicated the facility did not comprehensively assess R12's altered mental status changes and the facility failed to identify the concurrent use of antibiotics, anticoagulants. The medical record reflected the following: R12's care plan for mood and behavior symptoms dated [DATE], respiratory care plan, and anticoagulant assessment care plan both dated [DATE], indicated the resident use [MEDICATION NAME] (blood thinner) for treatment of [REDACTED]. In addition, R12's care plan noted the resident had [MEDICAL CONDITION] [MEDICAL CONDITION] and dementia. Interventions included for staff to monitor for signs and symptoms of anticoagulant complications and to inform the physician anytime antibiotics are ordered as antibiotics have the potential to affect anticoagulation status. The respiratory care plan indicated R12 received oxygen as ordered (but the signed physician's orders [REDACTED]. The record indicated R12 had been admitted to the Veteran's Administration (VA) hospital from the nursing home on [DATE]. According to the History and Physical (H&P) from the VA hospital, R12 had been initially hypoxic with an oxygen saturation level of 85% using room air which had improved with application of three liters of oxygen. The H&P also indicated R12 had been admitted following mental status changes, fever, desaturation, and decreased urine output and indicated, Nurse from NH (nursing home) did mention that this is commonly his issue when he becomes sick from any source. The H&P indicated a possible disposition [MEDICAL CONDITION]. R12's a physician's orders [REDACTED].*Continues on 5 mg (milligrams)(of [MEDICATION NAME]) daily. *Currently taking [MEDICATION NAME] 750 mg daily x 7 days (started [DATE]). Hold re., (check mark) Thursday. The record further indicated R12 had utilized [MEDICATION NAME] for treatment of [REDACTED]. A Laboratory Results sheet printed on [DATE], at 8:03 a.m. revealed a high INR at 3.48 (the laboratory's reference range was identified as 2.40). Further review of the resident's Laboratory Results indicated an INR of 2.07 on [DATE], and 2.4 on [DATE]. On [DATE], the INR result was recorded as 2.92. The resident's [MEDICATION NAME] ([MEDICATION NAME] generic equivalent- blood thinner) had been decreased to 4 mg and a recheck of the INR was scheduled for the following Thursday. On [DATE], the Quarterly Nursing Data Collection and Assessment sheet identified R12 as being alert, speech was clear but sometimes slurred, had no difficulty breathing or shortness of breath with exertion, sitting, at rest or lying flat. On [DATE], R12's Compressed Behavior Report noted R12 had demonstrated symptoms of behaviors and had wandered on [DATE]. On [DATE], an antibiotic was again ordered for R12 however, the notes failed to reflect whether the physician had been reminded the resident was still receiving [MEDICATION NAME]. In addition, subsequent notes dated [DATE] and [DATE], also failed to reflect physician notification of this. On [DATE], a Progress Note documented by a nurse, indicated R12 had even and non-labored respirations, no shortness of breath or congestion. The physician's orders [REDACTED]. The order sheet also indicated R12 was taking [MEDICATION NAME] 5 mg one tablet PO daily. The record indicated the last INR had been drawn on [DATE], and had measured 2.62 (per the Laboratory Sheet, the parameters for [MEDICAL CONDITION] was to keep the INR between 2.0 and 3.0). In addition, physician orders [REDACTED]. R12 had no supplemental oxygen ordered. The [DATE] Treatment Administration Record (TAR) noted R12's SpO2 (oxygen saturation) levels to be from 91% to 98%. The 11:00 p.m.-7 a.m. shift (labeled as C) indicated R12's SpO2s as 95 to 98%. The day shift (labeled as A) identified the SpO2 as 94 to 98%, and the evening shift (labeled as B) indicated R12's SpO2 to be below 95% 19 times out of 28 days. The April Medication Administration Record (MAR) and TAR did not indicate R12 received oxygen that month. The medical record lacked evidence of the residents, breathe sounds, if the lungs were clear, if the resident was short of breathe, if the breathing was labored when R12 had oxygen saturation levels below 95%. R12's target behavior sheet dated [DATE], noted R12 had symptoms of [MEDICAL CONDITION] which started on [DATE]. The facility indicated R12 had one to one staff assist and that was not effective. The Progress Note was void of any documentation that the facility called the physician for the altered mental status in which non-pharmacological interventions was ineffective. R12's Summary Behavior Program for [DATE], noted R12 had symptoms of [MEDICAL CONDITION]. The report directed staff to notice if R12 had inability to focus on task at hand or conversation being had, illogical flow of ideas, switching from one topic to the next, starring into space, being easily startled, loss of energy, wanting to stay in bed or lay down more often, falling asleep in his chair or during periods of activity, etc. The intervention was staff were to notify nurse if symptoms of [MEDICAL CONDITION] have been observed, allow resident an opportunity to rest. The report further noted R12 was hard of hearing and to make sure his hearing was not a factor in symptoms of [MEDICAL CONDITION]. There were no comments about R12 being on both [MEDICATION NAME] and [MEDICATION NAME]. On a Laboratory Results sheet printed on [DATE], at 2:08 p.m. an INR was noted to be 5.73 (HH). On [DATE], the nurses' notes reflected, The NP called back. The only order given was for a UA/UC and monitor resident. He is on neuros and vital signs. He has still not been coherent and himself. Dressing changes done. Lab called also to report a critical INR of 5.73. Call was made to MD. Left a message. The note was unclear if the NP was fully made aware of the resident's change in mental status. The VOHRA (name of company) wound MD saw R12 in [DATE], and noted R12 had sustained a left head wound which measured 0.6 by 0.9 centimeters (CM) and there was light sero-sanguinous drainage. The intervention was to keep a clear occlusive dressing in place. A letter to the facility dated [DATE], indicated the VA hospital had placed the facility on hold for their for new VA contracts for over six months. Those concerns included; turn-over in key leadership staff; hiring, training, retention of quality nursing assistants and nurses; infection control; and wound care staff. These concerns remain and are even heightened at this time with the recent departure of the administrator, DON (director of nursing), social work and business office manager. The letter further remarked, the VA staff have communicated concerns during their recent on-site visit which included wound care, cleanliness of the rooms, and INR monitoring - concern was based on chart findings in what should be standard care following those findings. A Progress Note dated [DATE], noted R12 to be outside with his family. R12 had an emesis and was able to cough and clear his airway on his own power. The writer questioned aspiration and noted R12 was not coughing. It was unclear if lung sounds were performed to determine if the lungs were free from from wheezing, crackles, diminished breath sounds, etc. The temperature was 99.3 and RA O2 sats were 94%. The writer indicated they would monitor R12's condition. A progress note on [DATE], noted R12 to be free of cough and emesis. It was unclear if lung sounds were performed to determine if the lungs were free from from wheezing, crackles, diminished breath sounds, etc. A Progress Note dated [DATE], at 8:15 a.m. indicated the facility called the MD about the INR and Also he (R12) is not his normal self today. VS (vital signs) T (temperature) 97.4 P (pulse) 90 R (respirations) 16 B/P (blood pressure) ,[DATE]. Was not able to get O2 (oxygen) reading due to his hands shaking. Resident just does not look like his normal self. Behavior is different. An entry on [DATE], noted the nurse practitioner (NP) ordered a STAT (immediately) INR. On [DATE], at 3:15 p.m. a note depicted R12 to be alert per baseline and not in any pain. The last entry on [DATE], at 4:30 p.m. noted R12 left for the VA hospital. A Progress Note dated [DATE], indicated R12 was admitted to the hospital on [DATE]. Under the note, the entire page and the second page was crossed off which noted hospitalized [DATE]. Again, the facility did not comprehensively re-assess R12's change in mental status. A resident concern form dated [DATE], was noted for R12. The nature of the concern was R12's condition of the wound and cleanliness of his room. Staff indicated they reviewed the wound assessment and Physician Notes. The form went to indicated R12 had a recent change in treatment and that the wound had shown improvement as a result of a turning and repositioning schedule being implemented. R12 had been educated to refrain from lying on the wound area to enable healing. The note further remarked that R12 was hospitalized prior to the completion of the concern form. However, the form was void of any follow up for the monitoring of the INR monitoring. On [DATE], the VOHRA MD saw R12 and noted the wound measured 0.6 by 0.5 cm. The wound still light ser- sanguineous drainage. The intervention was to apply skin prep (a liquid film-forming dressing that, upon application to intact film to help reduce friction) daily. Review of R12's Vital Sign - Individual Resident Flowsheet for May of 2016 noted R12 to have oxygen saturation levels ranging from 95% to 98%. However, on [DATE], the O2 level was 91% and on [DATE], the level was 92%, which according to the Clinical Use of Pulse Oximetery Pocket Reference Guide dated 2010, a SpO2 of 92% or less (at sea level) suggests hypoxemia, in a patient with acute respiratory illness (e.g., influenza) or breathing difficulty (e.g., an asthma attack), an SpO2 of 92% or less may indicate a need for oxygen supplementation, and in a patient with stable chronic disease (e.g., [MEDICAL CONDITION]), an SpO2 of 92% or less should prompt referral for further investigation of the need for long-term oxygen therapy. There was no oxygen reading documented on the sheet for [DATE] and on [DATE], the reading was 94%. The medical record lacked evidence of the physician being noted of the low oxygen levels to determine if R12 could have benefited from supplemental oxygen use. The VA hospital admission H&P dated [DATE], indicated R12 was admitted to the VA hospital. The VA H&P indicated R12 had several admissions to the hospital in past per the family and per the VA computerized patient reporting system for altered mental status in the past year. The VA lab report imbedded in the H&P noted R12 had a low hemoglobin (9.6 - The normal HGB level for males is 14 to 18 grams per deciliter. HGB c) and a low red blood cell count (3.48 - Male: 4.7 to 6.1 million cells per microliter (cells/mcL). RBCs contain hemoglobin, which carries oxygen to your body's tissues). On [DATE], R12's VA medical record noted the following: On [DATE], [MEDICATION NAME] dose was 5 mg and R12 was stared on Bactrim on [DATE], p.m. On [DATE], the INR was 5.73 and the [MEDICATION NAME] was held. On [DATE], the INR was 2.28 and R12 was given 2.5 mg of [MEDICATION NAME], on [DATE], R12 was given 2.5 mg of [MEDICATION NAME]. On [DATE], the INR was 4.32 and the [MEDICATION NAME] was held on that date and the date of [DATE]. On [DATE], the INR was 2.46 and the [MEDICATION NAME] was held *RN states unable to contact on-call MD on Sat (Saturday) Last days of Bactrim therapy. On [DATE], no INR was drawn, *RN states unable to contact on-call MD on Sun (Sunday). The NH Progress Notes noted the INR was drawn lat and the results were 1.80. The note further commented they were awaiting the MD's return call. On [DATE], the INR was 1.51 and [MEDICATION NAME] was ordered at 3 mg. On [DATE], INR was 1.35 ** 4.5 mg ordered for 5 pm nut not given at NH; admit to Minneapolis VAMC; NH (nursing home) recheck INR on ,[DATE]. The VA assessment plan noted, INR subtherapeutic likely related to several held doses at NH prior to admit related to subtherapeutic INR and inability to obtain order from on call NH MD. Subtherapeutic INR at NH is likely related to drug interaction with Bactrim therapy started on [DATE] -- which can lead to significant increases in the INR. Bactrim course was completed on [DATE]. Pt's [MEDICATION NAME] dosing history from the month of April is not available at this time so assess [MEDICATION NAME] regimen prior to Bactrim start. A Progress Note dated [DATE], noted on [DATE] (implied late entry although not noted as such), R12 was seen by the wound doctor and both wounds have shown improvement. The note went onto state that the VA nurse requested R12 be sent to the VA hospital for wound evaluation on [DATE]. The wound vac was removed and a wet to dry dressing was applied to the wound for transport. (The note date of [DATE], contraindicated the Physician order [REDACTED]. According to the facility's documentation it could not be determined when R12 was sent to the hospital. The [DATE] (,[DATE] through [DATE]), TAR sheet noted R12's oxygen levels ,[DATE] shift was either 96 or 97%, the am shift noted nine levels were documented and of the nine documented three levels were below 95%, and the pm shift noted nine levels were documented and of the nine documented only three levels were above the 95%, with the lowest being 91%. The [DATE] MAR and TAR did not indicate R12 received any oxygen that month. The medical record lacked evidence of the physician being noted of the low oxygen levels to determine if R12 could have benefited from supplemental oxygen use. On [DATE], at 10:58 a.m. caretaker-A and family member (F)-B was interviewed and noted after the resident fell he was not himself. He had nasal drainage which brown in color, repeated different words on different days, such blue one day, Help Me, help me the next day and also repeated How are doing on another day. The caretaker indicated R12's hand was shaking so bad that he could not hold a cigarette. (The facility assessed the resident on [DATE], as being able to hold his own cigarette). Both caretaker-A and F-A indicated they did inform the staff however, each time they visited R12 there was a different staff on duty and they did know if the concerns were followed up on. On [DATE], at 10:05 a.m. a licensed practical nurse (LPN)-A was interviewed regarding education of antibiotic and [MEDICATION NAME] use. She indicated there had been no training since she had been here hired as of [DATE]. On [DATE], at 10:40 a.m. a registered nurse (RN)-A was interviewed and indicated she had worked with R12. RN-A indicated she knew of the antibiotic and [MEDICATION NAME] use and could give universal side effects but could not give specific side effects and what to monitor for when they both used to together. On [DATE], at 2:43 p.m. RN-F, field director of education and training verbally stated, No do not believe it has been done. It has not been assigned by Relias. It was verified by looking at a RN educational file who had been here since [DATE], and there was no education on [MEDICATION NAME] or antibiotic use. RN-F looked at the modules educational library and there was one course on dangerous medication and insulin and nothing on antibiotics. RN-F came here in March. No education modules on [MEDICATION NAME] and antibiotics. I know what she (the surveyor as told to the IDON) is talking about as I have been on [MEDICATION NAME] and you do not mix certain antibiotics. On [DATE], at 2:43 p.m. RN-G, field director of education and training noted there was no training in the paper educational files. The interim director of nursing (IDON) checked as well no training in the paper files. On [DATE], at 2:50 p.m. the IDON called the old administrator, regarding the VA letter for our response. 2:52 p.m. Any education on training for antibiotics and [MEDICATION NAME] together and the answer was she does not recall any education that was done. IDON checked all three manila folders and a stack of rubber-banded papers. No training could be located for R12. On [DATE], at 2:55 p.m. per RN-E, unit manager, confirmed there had not been any education with staff done for [MEDICATION NAME] and antibiotics combined use. On [DATE], at 11:20 a.m. the medical director was interviewed. She indicated she had not been made aware of the altered mental status in R12 after his fall on [DATE] and on [DATE]. She acknowledged she should have been made aware. She reviewed the nurse's notes and indicated she wished there had more documentation to review. On [DATE], at 3:00 p.m. NP-A was interviewed and acknowledged she had ordered a urine culture on [DATE], but was not specifically made aware nor did she remember if she was informed of R12's change in mental status on [DATE], and also on [DATE]. When asked if she had been made aware of the family's and caretaker's concern of R12's shakiness and repetitive words she indicated No. When asked if she should have been made aware of the R12's condition she stated, Yes. The IDON was interviewed on [DATE], at 2:49 p.m. she indicated the facility was aware of the R12's altered mental status on [DATE], and that the nursing staff had called the physician on [DATE], and an UA was ordered. On [DATE], at 3:45 p.m. both licensed practical nurse-B and nursing assistant-B were interviewed. They both knew who R12 was but could not describe what cares had been provided to R12. The facility utilized a ,[DATE], Signs and Symptoms A's when to notify the physician tool. The section for Altered Mental Status directed the staff to call immediately for an abrupt significant change in cognitive function from usual with or without altered level of consciousness or for non-immediate when the symptoms were identified as persistent change from usual cognitive function with no other criteria met for immediate notification. Drugs.com noted the interaction between [MEDICATION NAME] and [MEDICATION NAME] to be one a major interaction. Using [MEDICATION NAME] together with [MEDICATION NAME] may increase the risk of bleeding, especially if you are elderly or have kidney or liver impairment. You may need more frequent monitoring of your [MEDICATION NAME] time or INR by your doctor to safely use both medications. Call your doctor promptly if you experience any unusual bleeding or bruising, swelling, vomiting, blood in your urine or stools, headache, dizziness, or weakness during treatment with these medications. The facility's ,[DATE], Notification of Resident Change in Condition policy indicated facility clinicians will immediately inform the physician and resident's legal representative when there is a significant change in physical, mental, or psychosocial status. According to the policy, documentation was to be completed in the nursing progress notes the time notification was given. A policy for monitoring oxygen saturations levels was requested and the facility indicated they have no policy. The facility did not re-assess R12's altered mental status after R2 fell on [DATE], and hit his head, had behavioral changes, had displayed altered mental status when the resident was noted to be on [MEDICATION NAME] and [MEDICATION NAME] simultaneously, the facility did not act upon the family and caretaker information for the change in mental status of R12's shakiness and of the repetitive words after R12 fell , and the facility did not re-assess R12 on [DATE], when he again had altered behavioral changes. R12 was not re-assessed after his oxygen saturations level fell below 95%. R12 was harmed as R12's physician was not informed of the altered mental status changes. R31 had a significant event with sever [MEDICAL CONDITION] (fluid build up) of her legs leading to fluid weeping from her legs. Medication orders that may have contributed to the [MEDICAL CONDITION] were not correctly documented for proper physician notification. On [DATE] 10:29 a.m. Family Member (FM)-C was interviewed and explained the course of events leading up to the [MEDICAL CONDITION]. FM-C explained, at the time of admission, [DATE], R31 was walking, eating, and alert. FM-C believed R31 was to have her legs elevated at all times due to the [MEDICAL CONDITION]. However, when FM-C came daily to visit she would find R31 with her legs down. FM-C stated, it was a struggle at the facility to get a recliner that worked properly to keep the legs up. On [DATE], FM-A came for her daily visit and found R31 sitting in the recliner with legs down. R31's legs were very swollen, her pant's legs and socks were wet and there was a puddle of fluid on the floor by her feet. R31 was also confused. FM-C become upset and quickly notified the staff of the situation. FM-C requested information to file a formal complaint regarding the facilities lack of attention to keeping R31's feet elevated. On [DATE], at 7:18 a.m., Nursing Assistant (NA)-C was observed assisting R31. NA-C asked R31 if she would like to put her feet up. R31 initially declined, but, then agreed to put feet up with encouragement from NA-C. The Comprehensive Admission Data collection and Assessment, dated [DATE], indicated no [MEDICAL CONDITION] present. A nursing noted, dated [DATE], indicated R31 had 2+ [MEDICAL CONDITION] (a situation in which the swelling is severe enough to leave a dent in the skin for 10 to 15 seconds when pressed with the finger). On [DATE], a nursing note again identified the 2+ [MEDICAL CONDITION]. The medical administration record (MAR) for April indicated 2+ [MEDICAL CONDITION] from [DATE] through [DATE]. The initial admit progress note, [DATE], completed by R31's medical doctor (MD) indicated no [MEDICAL CONDITION]. The progress note included 2 [DIAGNOSES REDACTED]. The plan was to continue to monitor. The admission Minimum Data Set (MDS) assessment dated [DATE], and the 14 day MDS dated [DATE], did not identify [MEDICAL CONDITION] as an active diagnosis. A care conference was held on [DATE]. Social services documentation from the care conference meeting indicated nursing was to followu up on bi-lateral (both sides) lower [MEDICAL CONDITION] On [DATE], the [MEDICAL CONDITION] was noted as bilateral [MEDICAL CONDITION] of all four extremities and R31 had wheezing. The level of [MEDICAL CONDITION] was not identified. The primary medical doctor (MD) was notified by phone. The physician's telephone orders, dated [DATE], indicated a [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] was not addressed. On [DATE] a telephone order was completed for 1 gram of sodium to be given daily for seven days and a fluid restriction for seven days, for a [DIAGNOSES REDACTED]. On [DATE], a nursing note indicated 1+ [MEDICAL CONDITION] of the lower extremities and R31 was encouraged to keep feet elevated. On [DATE] a nursing note indicated R31 had a weight gain of over 2 pounds in 2 days with ongoing 2+ [MEDICAL CONDITION] and NP-L was notified. The MAR for May, 2016 had an order for [REDACTED]. There was no corresponding signed physician's telephone order in the record. A telephone order, dated [DATE], indicated a [DIAGNOSES REDACTED]. On [DATE], a nursing note indicated 2+ bilateral [MEDICAL CONDITION] with encouragement to keep legs elevated. A nursing note on [DATE], indicated, writer called physician but did not indicate the purpose for the call. The nursing notes lacked any description of the events on [DATE], as reported by FM-C. The nursing notes lacked description of R31 having fluid weeping from her legs, or FM-C reporting the incident to staff. The record also lacked any on going tracking of the level of [MEDICAL CONDITION] and/or fluid weeping from the legs after [DATE]. NP-L's visit note of [DATE] indicated R31 was seen for a change of condition. R31 was in reclining chair alert only to stimuli which was a significant change to previous level of consciousness. R31's legs were swollen, but not pitting, weeping moderate amounts of fluid. NP-L did discontinue the sodium pill, wrote orders to keep resident in bed with lower extremities elevated, and increased a medication to help relieve fluid build up. The note indicated FM-C reported R31 said she was ready to die. On [DATE] at 2:10 p.m., Registered Nurse (RN)-C said, If her legs are down they will swell up. NP-L was interviewed on [DATE], at 12:30 p.m. and explained the events of [DATE]. NP-L stated FM-C found R31 with swollen legs and fluid weeping from the legs. NP-L made a visit that day and found the resident to have a significant change in condition. Medication was increased to remove excess fluid with good results and R31 had since been more alert. NP-L stated every time she saw R31 there was [MEDICAL CONDITION] and would be surprised if R31 had not had [MEDICAL CONDITION] when admitted . When asked about administering sodium to someone with [MEDICAL CONDITION], NP-L verified it could worsen the [MEDICAL CONDITION], but was more concerned with the low sodium levels than increased [MEDICAL CONDITION]. NP-L verified she had not notified the MD about the weeping legs and had discontinued the sodium. On [DATE], at 10:00 a.m., the primary MD was interviewed. She verified the sodium could have contributed to the [MEDICAL CONDITION] and said, It now makes more sense now about her drastic change in her legs with the extra sodium. The MD stated R31's sodium levels could have been low due to the [DIAGNOSES REDACTED]. R72 had chronic pain without adequate assessment, documentation, and implementation of non-pharmacological interventions. On [DATE], at 7:30 a.m. R72 was observed calling out for help. LPN-B asked if R72 was in pain and he replied, Yes. LPN-B then offered to get something for pain. At 8:00 a.m. LPN-B returned to assess pain in shoulders and knee. LPN-B asked R72 to rate the pain. R72 could not rate the pain but could say yes to when and where it hurt during the assessment while LPN-B gently moved R72's arms and legs. At 8:36 a.m. R72 was observed sitting in his wheelchair in the hall way. He winced, pointed to his shoulder and stated he had pain. On [DATE], at 9:41 a.m. R72 was lying in bed. He grimaced while the surveyor spoke to the resident. When asked if he was experiencing pain he replied, Well, yes. When asked where the pain was, R72 placed his hand on the right side of his neck and stated, Right here--in my neck. He then moved his hand up on his head behind his right ear and stated, And up here. It always hurts. RN-D was informed of R72's complaints of pain and RN-D stated he did sometimes complain of pain. R72 was prescribed scheduled [MEDICATION NAME] and maybe he didn't get it yet or it didn't kick in yet, but said she would check on it. On [DATE], at 10:30 a.m. treatment sheets revealed the resident could have been administered Ben Gay topical pain cream but it had not been administered during the month of ,[DATE]. A pain assessment was completed on, [DATE]. The assessment lacked input from R72. The resident interview section of the assessment was blank. The instructions were to attempt the interview, but if the resident was unable to communicate answers, skip to the PAIN section for residents with dementia or non-interviewable residents. The PAIN section indicated R72 had repeated calling out, loud moaning or groaning and crying, and facial grimacing. The assessment lacked a description by the nurse of observed pain location, history, or frequency. The follow up plan was to notify the nurse practitioner. The care plan for R72 indicated a problem with persistent chronic pain. The goal was for R72 to report pain relief within ,[DATE] minutes of receiving pain medication or treatment; no complaints of pain when questioned; no vocalization of pain; no non-verbal signs of pain; no decline in activity; non-pharmacological measures used and no increase in behaviors. Interventions included monitor and record effectiveness of medication, assess for verbal and non-verbal signs and symptoms of pain unrelieved by treatments, and comfort measures of position change and relaxation techniques. An order dated [DATE], for [MEDICATION NAME] (a pain medication) changed from 50 milligrams (mg) three time daily as needed (PRN) to a scheduled dose of 25 mg every morning, 50 mg at bedtime and a dose of 50 mg available twice daily PRN. However, the Medication Administration Record (MAR) showed the PRN [MEDICATION NAME] had been used only once between [DATE] to [DATE]. On [DATE], the [MEDICATION NAME] was increased to 50 mg 3 times per day with 50 mg available as needed 2 times per day. However, the PRN [MEDICATION NAME] had not been given to R72 from [DATE] to [DATE]. The MARs for both,[DATE] and ,[DATE] lacked documentation of the pain

Based on interview and document review, the facility failed to implement interventions to prevent and/or minimize recurring skin breakdown for 1 of 3 residents (R12) reviewed for pressure ulcers. This resulted in actual harm for R12 who acquired two pressure ulcers while in the facility, one of which progressed to a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), and resulted in the resident being hospitalized . Findings include: R12's Skin Integrity Assessment: Prevention and Treatment Care Plan dated 7/22/15, and current, indicated R12 had a left ankle and right hip wound. Interventions included air mattress on the bed, gel cushion in wheelchair, heels floated, pillow between legs, treatments as ordered. R12 was to be turned and repositioned every two hours. Upon admit to the facility R12 was noted to have moisture associated skin damage (MASD) buttocks and groin. According to a skin assessment conducted when R12 was readmitted from the hospital on [DATE], R12 had a sacral ulcer that measured 1.0 by 1.0 centimeter (cm). The wound bed was described as pink and red with no drainage noted. Although no stage was identified, the wound was identified as a pressure ulcer. Skin assessment notes on 2/1/16, indicated the wound had decreased in size to 1.0 by 0.5 by 0.3 in depth with no hip involvement noted at that time. The facility conducted a Tissue Tolerance (TT) Assessment (assessment of the skin's ability to endure the effects of pressure without adverse effects) on 2/19/16. The assessment noted R12 was evaluated after having been in a lying position for two hours. At that time his skin was observed to be red. The TT assessment indicated the lying time was decreased to one and a half hours and the resident's skin was then observed to be pink to clear. The sitting portion of the assessment was not completed, so it could not be determined how long R12's tissue could tolerate pressure when the resident was sitting. The summary section was void of any documentation on the back page of the form. However, as noted above, the care plan for skin care indicated that R12 was to be turned and repositioned every two hours. A Care Area Assessment for skin dated 2/23/16, indicated R12 had a history of [REDACTED]. A Minimum Data Set ((MDS) dated [DATE], also indicated R12 had MASD and that R12 was always incontinent of bowel. The facility utilized a PUSH Tool (a tool that compares total scores measured over time to provide an indication of improvement or deterioration in pressure ulcer healing). The coccyx PUSH Tool dated 3/2/16, indicated the wound area measured less than 0.3 cm by 0.3 cm with granulation and the ulcer had a light exudate. The Skin Grid sheet also dated 3/2/16, indicated the wound measured 0.9 cm by 0.4 cm by 0.2 cm with serous drainage and identified the wound as a stage 3 (Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). Due to this inconsistent wound documentation, the actual measurements of the ulcer could not be determined. On 3/22/16, the PUSH tool indicated the coccyx ulcer had increased in size to 0.3 to 0.6 cm by 0.3 to 0.6 cm with granulation present, and the ulcer was described as having a light exudate. The Skin Grid worksheet, also dated 3/22/16, noted the wound to 1.0 cm by 0.3 cm by 0.2 cm with serous drainage and described the ulcer as a stage 3. Due to this inconsistent wound documentation, the actual measurements of the ulcer at that time could not be determined. On 3/29/16, the Skin Grid worksheet indicated R12's coccyx ulcer was healed. The March 2016 Medication Administration Record (MAR) and Treatment Administration Record (TAR) identified only one circled treatment, depicting the resident had not received the treatment by facility staff, or that the resident had refused. The one circled treatment was from 3/1/16 when the physician progress notes [REDACTED]. The interdisciplinary Progress Notes from March 2, 2016 at noon, through March 29, 2016 at 4:30 p.m., were reviewed and lacked any documentation to indicate the resident had refused treatment to the ulcers. The VOHRA wound MD note dated 3/29/16, indicated R12's coccyx area had healed. However, the note indicated R12's right hip and left ankle had deteriorated due to the resident being non-compliant. The notes further indicated the right hip had been debrided and the physician had explained the procedure and reasons for it to the resident on 2/16/16. The medical record documentation lacked any evidence of R12 refusing wound care. A Skin assessment dated [DATE], indicated R12 had an open area on the right hip with a dressing applied. There was no measurement included on the 4/6/16 Skin Assessment. In addition, the Skin Assessment indicated R12 had an abrasion to the left ankle. There were no measurements of the abrasion. Finally, the Skin Assessment indicated the sacral area was noted to have a, scar over a bony prominence. Notes from the VOHRA wound MD dated 4/6/16, indicated no changes to the resident's skin issues on the hip or ankle. R12's primary physician's Progress Note dated 4/13/16, indicated the coccyx wound was healed. The note also depicted a wound check had been conducted on 4/6/16 on R12's left ankle and right hip however, there was no further description of the wounds. There were no further Progress Notes noted in the medical record from R12's primary physician or nurse practitioner (NP) regarding the ulcers. Per an interview with the interim director of nursing (IDON) on 5/29/16, at 3:45 p.m. she stated she was going to call the primary physician to get the Progress Note from his last visit to R12. (That notes faxed to the facility at 4:49 p.m. on 5/29/16 were dated 4/13/16.) A Progress Note from the VOHRA wound MD dated 4/13/16, indicated R12's right hip had improved and had decreased necrotic tissue. The left ankle had no change. A Progress Note from the VOHRA wound MD dated 4/20/16, indicated R12's right hip had deteriorated due to a decline in R12's status, but still had decreased necrotic tissue. The Progress Note further indicated R12's left ankle had deteriorated due to the resident's being non-compliant. However, the medical record documentation lacked evidence of the non-compliance or refusals of wound care. A Skin assessment dated [DATE], indicated R12 was noted to have abrasions and skin tears on both feet in between the toes. However, no further assessment, nor treatment had been established. In addition the Skin Assessment indicated R12 had pressure ulcers to the right hip and coccyx. The open areas between the toes were not identified on the current plan of care. Nursing Progress Notes from 4/21/16, were void of any documentation about the areas between the toes being open. The 4/21/16 Nursing Progress Notes also indicated the coccyx ulcer treatment had not been provided as ordered during the day shift as the resident had been up in the chair since 7:00 a.m. however, the Progress Notes indicated the treatment had been done on the evening shift. On 4/27/16, documentation on the Skin Grid form indicated the right hip had tunneling/undermining at the 5 o'clock area and measured 1.2 cm. The area was described as measuring 6.0 cm by 4.0 cm by 0.5 cm. In addition the left ankle ulcer was described as measuring 2.3 cm by 2.5 cm by 0.2 cm and was identified as a Stage 4. Nursing Progress Notes from 4/28/16, indicated the morning skin treatments had not been done however, the MAR for 4/28/16, had been signed off to indicate the treatment had been completed during the evening shift. The Progress Notes from 4/21/16 through 5/11/16, failed to identify the areas between R12's toes as being open, or as skin tears. In additions the notes did not indicate any refusal of care by R12. The VOHRA wound MD note dated 5/4/16, indicated R12's right hip had deteriorated due to R12 being non-compliant with wound care and the left ankle had no change. However, the medical record documentation lacked evidence of any non-compliance including refusals of the wound care. There were nothing in the wound MD's notes to indicate any treatment had been initiated for the open areas between R12's toes. The VOHRA wound MD note dated 5/10/16, indicated R12's right hip and left ankle had improved. However, the wound MD did indicate in his notes that R12 had incontinence associated [MEDICAL CONDITION] which had improved. Although R12 had orders for [MEDICATION NAME] ointment to be applied every shift, and as needed after each incontinence episode, the March through May 2016 TARs lacked documented evidence of the ointment being used after each incontinence episode. The April 2016 MAR and TAR indicated the daily wound orders were not completed two times. The May 2016 MAR and TAR noted three of the daily hip wound orders were circled, which indicated the wound treatment was not done. Neither the April or May MAR or TAR included any treatments for the areas between R12's toes even though the TAR for April indicated R12's skin was checked for impairment on 4/6, 4/14, 4/20, and 4/27/16. The May TAR noted the May 4th skin check had not been completed at all. The staff were to document a + to identify any new areas or a - to indicate no new areas. The TAR was void of any identification of a + or a -. R12's open areas /skin tear areas between the toes were not identified on the facility April and May 2016 TARs after being identified on 4/21/16. R12 was admitted to the Veteran's Administration (VA) hospital on [DATE]. Upon request by the surveyor, a History and Physical (H&P) dated 5/10/16 was obtained and reviewed. The H&P indicated R12's hospital admission skin assessment included: right hip presenting with an unstageable ulcer, non-tender necrotic tissue and possibly palpable acetabulum (a concave surface of the pelvis, the head of the femur meets with the pelvis at the acetabulum) with the appearance of a recently removed wound vac, with Stage II ulcers (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) between multiple toes bilaterally, (stage) II-III ulcer on the sacral area, granulation tissue and moist ulcer on left medial malleolus, bandaged, no necrotic tissue, stage III. The resident's hospitalization laboratory results indicated R12 had low [MEDICATION NAME] measuring 2.4 (the normal range is 3.4 to 5.4 grams per deciliter (g/dL) and the hemoglobin was 9.6 (the normal HGB for a male is 13.8 to 17.2 g/dL). The VA physician had documented: ? (Questionable) Neglect: We will have SW (social worker) look into his case further. This hip wound never should have gotten as far as it did. R12 was to have a wound consult on 5/11/16. Skin Grid documentation dated 5/11/16, while the resident was hospitalized , indicated R12's right hip had tunneling/undermining at the 5 o'clock area and measured 2.4 cm. The right hip wound measured 6.5 cm by 4.2 cm by 0.8 cm. The area had increased in size since measurements 4/27/16. The left ankle had decreased to 1.8 cm by 1.8 cm by 0 depth. The VA Wound Consultation Sheet dated 5/11/16, noted R12 had wounds between the 4th and 5th toes on the right foot, and had red and inflamed areas on the buttocks and groin folds. The VA Wound Assessment further indicated the right hip was unstageable and irregular shaped. The area was identified as measuring 4.5 cm by 7.7 cm by 1.5 cm. with moderate purulent drainage. The left ankle was identified as having presented as Stage 2 with 80% granulation, with serous fluid present, and as measuring 1.6 cm by 2 cm and shallow. The coccyx wound was identified as unstageable, with 90% adherent tissue and 10% granulation. The area was described as measuring 1.5 cm by 1.5 cm by 0.3 cm with a scant amount of serous drainage. The buttocks was described as having [DIAGNOSES REDACTED] and a rash. Treatments were ordered for all of the areas including the coccyx ulcer which was identified as having been packed with a gauze dressing. On 6/1/16, a NA (nursing assistant) Detail Report was printed. A question for the NA to answer was Did you see a new skin problem? Although the report sheet did not depict which areas of the body the skin was checked for, the answers from 4/27 through 5/10/16, were documented as No. On 5/29/16, at 10:40 a.m. RN-A was interviewed and she stated she'd taken care of R12 while he was in the facility. RN-A commented that while R12 had a turning and repositioning schedule for his back and left side only, R12's coccyx had healed. She further stated R12 had used a wound vac on his right hip for a pretty deep pressure ulcer. When asked whether she'd had training on how to care for R12's wound using the wound vac she stated, Not here. On 6/1/16, at 3:37 p.m. the interim director of nursing (IDON) and nurse consultant RN-B were interviewed. RN-B stated staff were supposed to perform skin checks weekly. She proceeded to explain that staff were to put a + or a - in the box on the TAR which indicated 'yes' there was a skin problem or 'no' there was not. The IDON added that she'd applied the wound vac to R12's hip on 5/9/16, the day before R12 left for the VA Hospital. The IDON said she was uncertain whether R12's coccyx area had been open or not at the time she'd applied the wound vac to his hip. In addition, the IDON stated neither of the nurses who had signed the TARs were still working in the facility. On 6/1/16, at 3:45 p.m. licensed practical nurse (LPN)-B and nursing assistant NA-B were interviewed. They both knew who R12 was but could not describe what skin care had been provided to R12. On 6/2/16, at 12:12 p.m. the NP on call for the resident's primary MD, returned a call the surveyor had placed to the MD. The NP stated she had not seen R12's wounds for a long time because the facility had a wound doctor who made rounds. The NP further confirmed neither she nor the MD had received a call from the facility regarding R12's coccyx wound having re-opened. The facility's Procedure for Pressure Ulcer Prevention/Treatment effective July 2015, directed the staff to review and revise Skin Integrity Assessment: Prevention and Treatment Care Plan to reflect interventions to heal pressure ulcers and stabilize, reduce or remove underlying risk factors. R12 was harmed as he was readmitted back to the VA with a new pressure ulcer on the coccyx, between his toes and a right hip ulcer where the bone was palpable.