Every finding on record at Transitional Care Unit

Based on observation, staff interview, review of the dishwasher sanitation logs, review of the manufacturer instructions and review of facility policy, the facility failed to ensure accurate dishwasher chemical sanitation to prevent foodborne illness. This had the potential to affect all four residents of the facility. The facility census was four. Findings include:Observation on 04/13/26 at 8:53 A.M. of the kitchen dishwasher operation with the Dietary Manager (DM) #114 revealed the dishwasher utilized chemical sanitation. Continued observation revealed the wash cycle water temperature was 120 degrees Fahrenheit (F) and the rinse cycle water temperature was 120 degrees F. The chemical sanitation testing strips used had a color key with corresponding parts per million (ppm) numerical indicators for the presence of specific chemicals, bacteria and pollutants. The color options were for 0 ppm, 200 ppm, 400 ppm, 600 ppm, 800 ppm and 1000 ppm. A placard observed on the dishwasher revealed wash and rinse water temperatures should be at a minimum 120 degrees F and 50 ppm chlorine for sanitation.Review of the dishwasher sanitation log from March 2026 through 04/13/26 revealed chlorine was documented daily to read 100 ppm.Interview on 04/13/26 at 8:57 A.M. with DM #114 confirmed the chemical test strips utilized by dietary staff did not have a reading correlating to 100 ppm. Furthermore, DM #114 verified the chemical test strips used to ensure adequate sanitation did not measure the chlorine ppm as indicated by the manufacturer.Review of the manufacturer guidelines for the dishwasher revealed to set the sanitizer concentrations to 50 ppm (Notice: Do not exceed 100 ppm). Monitor chlorine levels by using test strips.Review of the undated facility policy titled, Cleaning and Maintenance of Work Areas and Equipment, revealed employees must check the wash and rinse cycles to ensure they were running to correct temperatures and test the chlorine sanitizer ppm.

Based on record review and staff interviews the facility failed to provide discharge notification to the Ombudsman. This affected two (#1 and #8) of three residents reviewed for discharge. The facility census was four.Findings include:1. Review of medical record for Resident #1 revealed an admission date of 03/20/26. Diagnoses included wound dehiscence, osteoarthritis of the spine, anxiety, morbid obesity, and peripheral artery disease. Resident #1 discharged to home with home health services on 04/04/26.Review of the electronic medical record (EMR) revealed no evidence the Ombudsman was notified of the 04/04/26 discharge.2. Review of medical record for Resident #8 revealed an admission date of 3/18/26. Diagnoses included acute pancreatitis, depression, pancreatic cyst and obesity. The resident was discharged home on [DATE].Review of the EMR revealed no evidence the Ombudsman was notified of the 03/24/26 discharge.Interview on 04/13/26 at 3:55 P.M. with Clinical Manager (CM) #99 verified the facility did not have evidence the Ombudsman had been provided discharge notification for Resident #1 or Resident #8's planned discharges. CM #99 stated if a discharge was planned, notifications were not sent to the Ombudsman.Interview on 04/14/26 at 10:10 A.M. with the Administrator confirmed if a discharge was planned, the facility did not send a discharge notification to the Ombudsman.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure non-pressure ulcer wounds were thoroughly documented and further failed to ensure physician treatment orders were obtained. This affected one (#2) of two residents reviewed for wounds. The facility census was four.Findings include:Review of medical record for Resident #2 revealed an admission date of 03/26/26. Diagnoses included septic bacteremia, atrial fibrillation, hypertension and hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment, dated 04/08/26, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required set up assistance for eating, maximum assistance for toileting hygiene and bed mobility and was dependent for transfers. Resident #2 had a surgical wound. Review of the admission assessment dated [DATE] revealed Resident #2 had a small incision to the left hand and a small incision to the left wrist with sutures. No further description of the wounds was documented.Review of the physician orders revealed no orders for wound treatment.Observation on 04/13/26 at 10:23 A.M. revealed Resident #2 was awake and seated in her recliner. A two by (x) two kerlix bandage wrapped with cotton gauze was observed to her left wrist. Concurrent interview with Resident #2 revealed she had an infection in her left wrist. Resident #2 stated the doctor lanced her hand and the infection was drained, then they cut her outer wrist and washed out the infection. Resident #2 stated she had stitches to her wrist, which were previously removed by nursing staff and her hand was healing well.Interview on 04/13/26 at 3:55 P.M. with Clinical Manager (CM) #99 revealed the facility did not do weekly measurements of wounds, aside from pressure ulcer wounds.Interview on 04/14/26 at 9:44 A.M. with Registered Nurse (RN) #113 revealed the treatment for Resident #2's left wrist wound was to apply mupirocin ointment (topical antibiotic), cover with a two x two gauze pad, cover with kerlix and secure with tape. RN #113 was unable to locate the physician order in the electronic medical record (EMR) and stated she was unsure where the specific treatment order came from. RN #113 explained she had gotten the information for wound care during the nursing report and stated she removed tape, kerlix and a two x two gauze pad when she went in to provide wound care for Resident #2's left hand and wrist. RN #113 stated the wrist wound sutures were removed and the area was closed and the hand wound was almost closed.Observation on 04/14/26 at 9:48 A.M. with RN #113 of Resident #2's left wrist and left hand wounds revealed an approximately 1.0 centimeter (cm) light scar to her left outer wrist and an approximate length of 0.6 cm x a width of 0.1 cm healing wound to her left hand.A follow-up interview on 04/15/26 at 9:28 A.M. with CM #99 verified there were no wound measurements or description of the wounds on Resident #2's left hand and wrist on the admission assessment. CM #99 confirmed the wound assessment documented sutures to the left wrist but there was no numerical value given for the sutures.Review of the undated facility policy titled, Transitional Care Unit Skin Assessment, Wound Care Prevention and Treatment, revealed upon admission of any resident, a thorough skin assessment would be completed by the admitting nurse and findings would be documented on the admission note. The policy also revealed treatment orders would be obtained by the assigned nurse and entered into the electronic medical record.

Based on observation, staff interview, and operational requirement review, the facility failed to ensure routine monitoring and record keeping of the wash and rinse cycle requirements for the dishwasher to ensure the dishes were properly sanitized and disinfected. This had the potential to affect the one resident residing in the facility at the time of the survey. The facility census was one. Findings include: Observation on 07/31/23 at 9:05 A.M. of the dishwasher operation revealed the wash cycle was 122 degrees Fahrenheit (F), the rinse cycle was 128 degrees F, and the test strip results were 100 parts per million. Observation on 07/31/23 at 9:09 A.M. of the temperature/sanitizer log revealed there was an area to document the wash temperature, rinse temperature and strip parts per million (PPM) and initials. There was no temperatures logged for the wash or rinse cycles for April, May, June or July 2023. This was verified with Kitchen Coordinator #10. Interview on 08/01/23 at 7:29 A.M. with Dietary Manager #14 revealed he was unaware the temperatures needed to be monitored and recorded for the dishwasher. He stated staff education would be provided to ensure temperatures were taken and recorded moving forward. Review of the dishwasher operational requirements revealed the wash and rinse cycle each required 120 degrees F temperature minimum.

Based on observation, resident and staff interview, and medical record review, the facility failed to follow up on recommendations from the physician. This affected one (#56) of four reviewed. The census was four. Findings include: Review of Resident #56's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a physician order dated 02/09/20 revealed Resident #56 was ordered a basic metabolic panel (BMP) blood test. Review of results of the BMP revealed Resident #56's blood glucose was elevated measuring 126 milligrams per deciliter (mg/dL). The facility laboratory set a normal range for blood glucose levels between 74 and 99 mg/dL. Review of a physician visit progress note dated 02/09/20 revealed the physician identified Resident #56 with a focused problem area of type two diabetes mellitus with [MEDICAL CONDITION] and documented Resident #56 would be placed on rapid blood glucose finger checks (Accu-Cheks) with insulin coverage. The progress note was signed by the physician on 02/09/20 at 11:54 [NAME]M. Review of Resident #56's medical record between 02/10/20 and 02/12/20 revealed no further blood glucose laboratory values and no finger stick blood glucose levels were obtained, no physician orders were initiated for Accu-Cheks or insulin, and no additional progress notes were documented related to the physician's recommendation for Accu-Cheks with insulin coverage. Review of a progress note dated 02/12/20, written by Registered Nurse (RN) Clinical Coordinator #100, revealed the physician was contacted for clarification of his recommendation on 02/09/20 for Resident #56 to have Accu-Cheks and insulin, and the physician verified he wanted Resident #56 on a medium dose sliding scale insulin with Accu-Cheks before meals and at bedtime. Observations on 02/10/20 at 7:52 [NAME]M., at 10:49 [NAME]M., at 2:21 P.M.; on 02/11/20 at 1:03 P.M., 2:39 P.M., and at 3:52 P.M.; and on 02/12/20 at 8:24 [NAME]M. revealed Resident #56 was calm and free from distress. Resident #56 did not display any lethargy or signs of an altered mental state, and her overall health condition remained unchanged. Interview on 02/11/20 at 4:02 P.M. with Resident #56 stated she had no concerns about the current status of her health and verified she had not experienced any significant changes with her health since she was admitted to the facility. Interview on 02/12/20 at 9:49 [NAME]M. with RN Clinical Coordinator #100 verified the physician intended to start Resident #56 on Accu-Cheks with insulin coverage, but forgot to initiate an order for [REDACTED].

Based on observations, staff interview, and review of the manufacturer's recommendations/facility policy, the facility failed to ensure food was properly labeled and stored, and dishes were sanitized in a manner to prevent contamination. This had the potential to affect two (#107 and #108) of two residents who reside in the facility. Findings include: Observations on [DATE] at 8:52 A.M. with Food Service Director (FSD) #300, revealed the walk-in freezer contained multiple food items that were expired. The food were as follows: diced chicken (two packs) opened and repackaged in gallon size zip lock bags dated [DATE]; corn beef wrapped in aluminum foil dated [DATE]; pastrami (two packs) wrapped in aluminum foil dated [DATE]; one unidentified food item wrapped in aluminum foil, unlabeled and undated; apple corn bread stuffing opened and repackaged in gallon size zip lock bags dated [DATE], ham wrapped in aluminum foil and undated; and one bag of frozen peas, opened and undated. In the reach in freezer there was an opened and undated package of English muffins, and toast was repacked in a zip lock bag dated [DATE]. In the walk-in refrigerator there were multiple opened and repackaged containers including: chili sauce dated [DATE]; two opened and repackaged containers of tomato paste dated [DATE]; pesto sauce opened, repackaged and undated; ketchup opened and repackaged dated [DATE]; and oyster sauce opened and repackaged dated [DATE]. In the service area reach-in refrigerators there were three opened and undated packages of cheese. Interview with FSD #300 during the time of the observations, verified all the items noted above were opened and expired or undated. FSD #300 stated he needs to work on dating food. FSD #300 stated the facility practice was to discard opened food after seven days in the refrigerator. Regarding foods in the freezer, FSD #300 stated he discards foods after three or four months but was unsure of the facility policy for the length of time things can be stored in the freezer. FSD #300 further verified the frozen foods noted above should have been discarded. FSD #300 stated the items in the walk-in refrigerator should have been labeled with the manufacturer's expiration date. He also verified both Resident #107 and Resident #108, were served meals from the kitchen. Continued observations revealed the kitchen three-sink dishwashing system was in use. FSD #300 obtained a test strip to check the sanitizer. He dipped the strip in the third sink and held it in the water for the manufacturer's recommended ten seconds. He removed the strip from the water and compared the strip to the package. The strip did not change color. The sanitizer was not at the recommended 200 parts per million (ppm) for effective sanitizing. Interview at the time of the observation revealed FSD #300 verified the dietary staff were currently washing dishes in the three sinks dish system. FSD #300 stated the three sink dish system used Quaternary solution for dish sanitizing. FSD #300 verified the Quaternary solution did not meet the minimum of 200 ppm for effective dish sanitation. Further interview with FSD #300 on [DATE] at 10:02 A.M., stated the facility policy does not address dating opened food. Review of the facility policy titled, Food Storage, revised ,[DATE], revealed foods must be protected from contamination, spoilage and other damage during storage. Foods stored in refrigerators should be covered, labeled and dated. All frozen foods should be labeled and dated. Review of the manufacturer's instructions revealed the Quaternary solution must be 200 ppm concentration for effective dish sanitizing. Review of the Quaternary test strip instructions, revealed the proper testing method was to dip a test strip in the water and hold it for ten seconds. Remove the strip from the water and immediately compare the color.

Based on observations, staff interview, review of the coded announcement sheet and review of facility policy and procedures, it was determined the facility failed to ensure overhead paging was utilized for emergency situations only to maintain a homelike environment for the residents. This affected two (#107 and #108) of two residents who reside in the facility Findings include: On 12/26/18 at 8:23 A.M., during entrance/initial tour to the facility, a coded announcement was heard over the intercom system throughout the facility/unit where residents were residing. The code was announced as follows: Attention code agency is now in affect at the facility. We would like to welcome the Ohio Department of Health. This code was repeated five times over the intercom system. On 12/26/17 at 9:12 A.M., interview with the Administrator verified the intercom system was only to be used for emergency situations. She verified the operator at the front was the person who made the announcement. On 12/27/18 at 11:56 A.M., interview with Operator #35 verified she made the coded agency announcement as described above on 12/26/18. She verified it was repeated five times throughout the facility utilizing the intercom system. She further verified paging announcements were usually for emergency situations only. Review of the code announcement instruction sheet revised 03/21/18, documented a Code Agency was among other codes for various emergency situations. Further review documented instructions to have surveyor have a seat in the lobby, contact the Administrator and other facility staff at an extension provided, and then to announce Attention. code agency is now in affect at facility. We would like to welcome the (agency name) to our facility. Further instruction documented to repeat twice at 10 second intervals three times. Review of the policy and procedures with a subject matter of unnecessary noise reduction dated (MONTH) (YEAR), documented the facility will reduce noise levels by limiting overhead paging for matters of urgent public safety or urgent clinical operations. The overhead paging will not be used as a convenience or unnecessarily.

Based on observation, staff interview, and review of facility policies, the facility failed to ensure dishes were properly sanitized using the hot water dish machine and the facility failed to ensure opened foods were dated when they were opened. This had the potential to affect two of two residents currently in the facility. Findings include: Observations during initial kitchen tour 08/08/2016 at 9:15 A.M. conducted with Dietary Shift Leader (DSL) #100 revealed in the dry goods storage pantry there were four opened pasta bags and one opened bag of white rice. All were undated. Interview with DSL #100 at the time of the observation on 08/08/16 at 9:15 A.M. verified the pastas and rice were opened and undated. She verified the facility policy was for all opened foods to be dated when they are opened. Observation on 08/08/16 at 9:23 A.M. in the dairy cooler revealed there were four opened and undated bags of shredded cheese and one opened and undated package of sliced cheese. Interview with DSL #100 at 9:33 A.M. verified the cheeses were opened and undated. In the produce cooler there was one bag of diced onions opened and undated. The bag was a dated with a best by date of 08/05/16 stamped on the bag by the producer. DSL #100 verified it was expired. She stated the facility used the best by on produce as the date upon which produce was no longer used by the facility kitchen. Interview on 08/08/16 at 9:50 A.M., Director of Food Services (DFS) #101 verified the policy was to date all produces when they are opened. He verified all fresh produce was to be used by the best by date. Observation of the hot water dish machine on 08/08/2016 at 9:48 A.M. with DSL #100 revealed a staff member loading dirty dishes and began running them through the dish machine. Observation of the temperature gauges for the wash and rinse cycles revealed the wash temperature reached 150 degrees Fahrenheit (F) and the rinse temperature reached 174 degrees F. Interview with DSL #100 at the time of the observation verified the rinse temperature was 174 degrees F based on the gauge reading. However she denied using the gauge reading as the benchmark for the rinse temperature requirement. She stated the required temperature for the rinse cycle was 160 degrees F and the facility used test strips to verify the minimum rinse cycle temperature of 160 degree F was obtained. DSL #100 placed a test strip in one of the dirty dish trays and ran it through the dish machine. Several trays of dishes moved through the dish machine while DSL #100 waited for the test strip to come out. Monitoring of the temperature gauge for the rinse cycle revealed the temperature remained at 174 degrees F. When the test strip came out of the dish machine DSL #100 removed the strip and stated the required temperature of 160 degrees F was obtained based on the color change of the test strip. Comparison between an unused test strip and the used test strip revealed there was no change in the color of the used test strip. The dish machine was continually running during the conversation regarding the test strip. The rinse cycle temperature still remained at 174 degrees F. Multiple trays of dishes were run through the dish machine from 9:48 A.M. to 10:04 A.M. when the rinse cycle temperature gauge finally reached 180 degrees F. Dietary Worker (DW) #102 was removing dishes from the clean side and during the observation. She was emptying the dishes from the racks and returning them to the clean dishes storage areas. On 08/08/2016 at 10:04 A.M. DW #102 verified she was removing the dishes from the dish machine and returning them to service. She stated the rinse temperature must be over 160 degrees F. She verified the facility used test strips which tested the dish machine rinse temperature for 160 degrees F. On 08/08/2016 at 10:10 A.M. Interview with DFS #101 verified the dish machine was a hot water sanitizing system. He stated the minimum temperature was 185 degrees F. He verified the test strips used only indicated a temperature reached at 160 degrees F and the test strips were what the facility was using to test the dish machine temperature. Review of the facility policy titled Food Storage, revised 07/16, revealed foods must be protected from contamination and spoilage. For dry foods and refrigerated foods, once the foods are opened the remaining products should be covered or resealed, labeled and clearly dated. Review of the facility policy titled Cleaning and Maintenance of Work Areas and Equipment, revised 7/20/16, revealed eating utensils and dishes will be washed in the dish machine. The morning dishwasher should use test strips to verify the temperature is at the desired level of 150 degrees F for the wash and 180 F degrees for the rinse.

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure timely notice was given to residents prior to discharge from skilled service. This affected three (#8, #27, and #41) of three residents who were reviewed for discharge from skilled services in the past six months. The facility identified 47 residents who received skilled services in the past six months. The facility census was two. Findings include: Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] . [DIAGNOSES REDACTED]. Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the medical record for Resident #41 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Interview with the Administrator on 08/09/16 at 6:30 P.M. revealed Resident #8, #27, and #41 received Medicare skilled services while here. She further verified there was no documentation of a Notice of Medicare Provider Non-Coverage being provided to them prior to discharge from the facility . She further verified the residents did complete their therapy at the facility and should have received the Notice of Medicare Provider Non-coverage. Review of facility policy titled Discharge Notice Medicare Notice of Medicare Provider Non Coverage Notice, dated 04/2015, revealed the resident was to receive an Advance Beneficiary notice of Notice of Medicare Provider Non Coverage notice at least 48 hours prior to the completion of the Medicare skill need. It further revealed if the resident chose to leave the facility before the medical of therapy plan was completed, it was not necessary to give the notice.

Based on medical record review, observations, resident interview, staff interview and review of facility policies, the facility failed to obtain appropriate treatment orders and failed to provide ongoing assessment for a pressure ulcer. This led to actual harm when Resident #59's right inner ankle pressure ulcer increased in size, developed drainage, and was noted to progress to an unstageable pressure ulcer. Additionally, the facility failed to assess and implement the use of a pressure reducing cushion to the chair for Resident #61, who had existing pressure ulcers on the bilateral buttocks. This affected two (#59 and #61) of three residents reviewed for pressure ulcers. The facility identified two residents as currently having pressure ulcers. The facility census was nine. Findings include: 1. Review of the medical record revealed Resident #59 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review the of history and physical, dictated by the orthopedic physician on 10/20/15, documented the resident to have an ulceration to the right medial ankle region, which was healed. Also documented was the plan to continue the right leg immobilizer brace for treatment of [REDACTED]. The orthopedic physician documented he would follow the resident on a daily basis. Review of inter-agency transfer orders, dated 10/22/15, documented Resident #59 was alert and oriented with a primary [DIAGNOSES REDACTED]. His physician ordered treatments consisted of a pressure reducing Hill-Rom mattress, 24 inch knee immobilizer to the right leg, elevate and apply ice to the right leg, and a sequential compression device to the left leg. Orders also included [MEDICATION NAME] ointment to wounds in the gluteal area, cover the gluteal wounds with an [MEDICATION NAME] dressing, and change the dressing every three days. The section addressing wound care documented the resident had pressure ulcers present on the bilateral gluteal areas. The nutritional assessment on the intra-agency transfer form indicated the presence of pressure ulcers on the bottom right ankle and heel. Review of the Interdisciplinary Assessment, dated 10/22/15, documented Resident #59 had [MEDICAL CONDITION] to his right lower leg. Also documented by Registered Nurse (RN) #85 was the presence of two open areas to the Resident's right inner ankle. The first area was identified as a reddened, circular area which measured two centimeters (cm) in diameter. The second area was identified as a one cm circular, reddened, open area. Documentation included a description of a four cm raised, dry, flaky, scabbed area on the right lower leg. RN #85 documented she cleaned the area and applied a Vaseline, non-adherent dressing. The assessment identified the resident to have a Braden score of ten making him at high risk for developing pressure areas. Review of the interdisciplinary plan of care, dated 10/22/15, documented Resident #59 was provided wound care education. The plan of care did not address the pressure ulcer to the resident's right inner ankle, including any interventions to treat the area, promote healing, and prevent further breakdown of the area. Review of the resident assessment data point history dated 10/22/15, revealed Resident #59 had a large scab to his inner, right ankle. On 10/23/15, 10/24/15 and 10/25/15, the right inner ankle was documented to have a large, healing scab with no drainage noted. There was no documentation on 10/26/15 and 10/27/15 of the area being observed, assessed or treated. Review of the medical record, including the 24 hour assessment, treatment administration record, and nurses notes, from 10/22/15 through 10/26/15, lacked any documentation of measurements being obtained or any dressing changes being completed to Resident #59's right inner ankle. Review of the physician orders from 10/22/15 to 10/26/15, lacked any documentation of orders put in place to treat Resident #59's pressure ulcer to his right ankle. Review of physician progress notes [REDACTED].#59's right inner ankle pressure area. Observations on 10/27/15 at 10:00 A.M., revealed Resident #59 was sitting in his recliner. He was observed to have a right leg immobilizer in place, which extended from his thigh to his right foot. A dry and intact dressing was observed in place to his right heel. His leg was elevated with ice packs in place on the immobilizer. The resident's heels were observed to be elevated with a pillow, enabling the heels to float in the air. Interview on 10/27/15 at 11:30 A.M., Registered Nurse (RN) #37 stated she had not worked with Resident #59 since his admission. She stated the resident had a stage II pressure ulcer to his left posterior calf and previously had open areas to his buttocks, which were now healed. She stated preventive dressings were in place for his heels. RN #37 stated she was unaware of any pressure ulcers to the resident's right inner ankle and she had not received any report of any other pressure areas present. Observation of Resident #59's skin was made on 10/27/15 at 11:38 A.M. with RN #37. The dressings were removed to the resident's bilateral heels, with no pressure areas observed. The skin was intact and blanchable. Observation of the resident's buttocks and coccyx revealed no open areas were present. RN #37 removed the resident's immobilizer to the right right leg which revealed a Kerlix and non-adherent pad wrapped around the lower, right inner ankle. Brown drainage was observed on the outer aspect of the Kerlix dressing. RN #37 then unwrapped the dressing, which was noted to have a large amount of foul smelling exudate present. There were two unstageable pressure ulcers that were almost touching. The combined areas measured a total of 6.75 centimeters (cm) in length, with the top of the area having a width of 3.5 cm, and the bottom area having a width of 2 cm. The area above the right inner ankle measured 4.25 cm in length, the width at the top of the area measured 1.75 cm, and the bottom width measured 1.5 cm. The areas appeared to be dark purple in color with an undefined border and maceration present. Interview on 10/27/15 at 11:35 A.M. with Resident #59, stated he had the wound to his right inner ankle area when he was at home. He stated he got it from wearing an appliance in his shoes. He denied any pain at the site during the assessment and dressing change. Additional interview on 10/27/15 at 11:40 A.M. with RN #37, stated she was not previously aware Resident #59 had a wound to the right inner ankle area. She also stated she notified the orthopedic physician who told her he was under the assumption the wound clinic was taking care of the area. Interview on 10/27/15 at 12:38 A.M. with Clinical Nurse Leader (CNL) #47, stated she followed Resident #59 when he was admitted to the acute care hospital in the same building. She stated the orthopedic physician and physician assistant were following the resident's pressure ulcers. She verified there was no current orders for monitoring and treatment of [REDACTED]. She further verified there was no acute care plan in place to address the care of the pressure ulcer. She stated he had a pressure relieving mattress at the time of admission. She stated the wound was chronic in nature and verified she hadn't observed the area since the resident was admitted to the facility Review of orthopedic physician telephone order dated 10/27/15 at 12:50 P.M., noted an order to keep the right leg immobilizer loose while in bed. An order on 10/27/15 at 1:05 P.M., noted to wrap the resident's right lower leg with two four by four dressings and a Kerlix wrap. An order dated 10/27/15 at 5:30 P.M., documented to consult wound care for right medial ankle chronic pressure ulcer. Review of wound physicians progress note dated 10/28/15, documented Resident #59 had eschar covered areas on his right lower leg. The note documented the areas as unstagable pressure ulcers and recommended use of the [MEDICATION NAME] agent, Santyl, to be added to the right lower leg eschar areas. The note indicated the resident was to be assessed at the wound clinic on 11/02/15. Observation was made on 10/28/15 at 9:28 A.M. of Wound Nurse #46 performing Resident #59's dressing change to his right inner ankle area. The old dressing, which was removed, was not observed at this time. The area was noted to have some bloody drainage present on a clean towel underneath the resident's leg. Wound Nurse #46 measured the area to be 6.7 cm in length by 5 cm in width, with a depth of 0.2 cm depth and an undefined border. The wound bed contained eschar and slough which obscured the view of the wound bed. No odor was noted at this time. Interview on 10/28/15 at 9:28 A.M. with Wound Nurse #46, stated she was at the facility to assess Resident #59's wound due to an order for [REDACTED]. She stated the wound was unstagable at this time. She stated an order was received to start applying Santyl ointment and place a dry dressing over the ulcer, with an additional order to be assessed at the wound clinic on 11/02/15. Interview on 10/28/15 at 3:30 P.M. with RN # 85, stated she worked when Resident #59 when he was admitted . She stated she assessed the resident as having open areas with scabs and obtained measurements at that time. She stated she did not stage the area or notify the physician to receive orders for a treatment. She stated her and another nurse decided to place vaseline on the area with a non-adherent dressing and wrap it in a Kerlix dressing until the physician came in the next day. She stated she did not put an acute care plan in place regarding the care of the open area because she was not sure if it was a pressure ulcer. Interview on 10/28/15 at 4:00 P.M. with the Director of Nursing (DON), stated Orthopedic Physician Assistant #66 was monitoring the wound daily and nursing was changing the dressing. She then verified there was no documentation of measurments of the right inner ankle pressure ulcer. She also verified there was no evidence a treatment order had been received by the physician. She further verified there was no documentation of a dressing change documented since 10/22/15, to the right inner ankle pressure area. Interview on 10/29/15 at 10:35 A.M. with Orthopedic Physician Assistant #66, stated he did not remove Resident #59's dressing to his right, inner ankle region from 10/22/15 to 10/26/15 to monitor the wound. He assumed the surgeon was treating and monitoring the resident's wounds since the surgeon was taking care of the pressure areas to his buttocks. Orthopedic Physician Assistant #66 stated he was not notified of any changes of the wound until 10/26/15. He stated at that time, he assessed the wound to have an area of pink viable skin under the previous scab, with two outer areas that appeared dark in color surrounding the area. He described the area to have an hour glass shape. He stated at that time, he made a wound consult and ordered a dressing change. Review of a statement provided by the facility dated 10/29/15, and written by RN #49, documented Resident #59 had open, black, scabbed, necrotic areas, with no dressing in place at the time of admission. Old brown drainage was noted to be sticking to the to the immobilizer. She further documented on 10/22/15, she observed RN #85 place a Vaseline non-adherent dressing with a gauze to the right ankle, and wrapped the gauze with a Kerlix dressing. Review of facility policy titled, Wound Care Prevention and Treatment,, revised August 2015, documented pressure ulcers were to be entered during initial assessment, on the interdisciplinary admit data and on a pressure wound assessment and care form. The policy reveals the nurse was to document measurements on Monday, Wednesdays and Fridays, and or with each dressing change. The policy also noted the staff were to document the treatment type and changes on the treatment record. If a wound was necrotic, notify the physician for possible debridement. On 10/29/15 at 1:40 P.M., an interview with the DON stated the facility did not have any standing protocol for nurses to treat wounds with greater than 25% necrotic tissue present. She stated they were to notify the physician for further orders. 2. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #61's Interdisciplinary Assessment, dated 10/23/15, documented a Braden Scale Score of 15 (a score of 16 or less indicated the resident was at risk for pressure ulcer development). The Interdisciplinary Assessment documented the resident was admitted with two open areas on the buttocks with an [MEDICATION NAME] dressing intact. Review of Pressure Wound Assessment and Care form dated 10/24/15, documented Resident #61 had a Stage II pressure ulcer on the right buttocks measuring one centimeter (cm) in length by one cm wide, with a less than 0.01 cm depth, and a Stage I pressure ulcer on the left buttock identified to measure pinpoint. According to the Pressure Wound Assessment and Care dated 10/24/15, the care included turning the resident every two hours, a pressure reducing Hill-Rom mattress, and an [MEDICATION NAME] dressing to the area. Review of Resident #61's care plan dated 10/23/15, revealed the presence of a right hip incision, open area on the buttock, bruises and abrasions. Interventions included: monitoring the incision, dressing applied as ordered, monitoring for drainage amount, color and odor, barrier cream as ordered, heels propped, turn every two hours, and the use of a Hill-Rom mattress. There was no documentation as to whether a pressure reducing cushion for the chair was assessed or considered. Further review of Resident #61's Pressure Wound Assessment and Care form dated 10/27/15, documented the left buttocks area increased in size to measure a half cm long by a half cm wide, and was now a stage II pressure ulcer. The assessment contained no documentation of a change in the resident treatment to the area and no assessment regarding the need for a pressure reducing device for the resident's chair. Observation on 10/26/15 at 12:03 P.M. and on 10/27/15 at 9:05 A.M. and 12:00 P.M., revealed Resident #61 was sitting in a recliner in his room. Resident #61 was not seated on any type of cushion. Interview on 10/27/15 at 12:00 P.M. with Resident #61, stated he was more comfortable when sitting up in the recliner verses laying in bed. He stated he spends most of his time throughout the day in the recliner. Observation on 10/28/2015 at 1:56 P.M., revealed Resident #61 to be sitting in his recliner in his room. There was no cushion noted in place to the residents recliner. Observation on 10/28/2015 at 3:52 P.M. noted RN #85 and State tested Nurse Aide (STNA) #67 assisted Resident #61 to bed from his recliner. RN #85 and STNA #67, provided Resident #61 with incontinent care following an incontinent bowel movement. Resident #61's foam dressing on the buttocks was soiled and needed changed. RN #85 removed the soiled foam dressing and cleansed the right and left buttocks with soap and water. During the observation, Resident #61 did complain of minimal discomfort to the buttocks when touched. RN #85 measured the left buttocks to be 1.5 inches long by one inch wide (3.81 cm by 2.54 cm). The left buttock pressure ulcer was noted to be a Stage II open area. The right buttock was a Stage II open area measuring two cm in diameter. RN #85 did not measure a depth of the right buttock pressure ulcer during the assessment. RN #85 proceeded to apply the [MEDICATION NAME] foam dressing to the right and left buttocks. Interview at the time of the observation on 10/28/15 at 3:52 P.M. with RN #85 and STNA #67, confirmed Resident #61 did not have a pressure reducing cushion in place to the recliner. Interview on 10/28/15 at 3:59 P.M. with the DON, confirmed Resident #61 was admitted on [DATE] with a Stage I pressure ulcer on the left buttocks and a Stage II pressure ulcer on the right buttocks. The DON confirmed the left buttock pressure ulcer progressed to a Stage II pressure ulcer on 10/27/15. The DON confirmed there was no documentation or evidence Resident #61 was assessed for the use of a pressure reducing cushion to the chair. The DON confirmed Resident #61 liked to spend time out of the bed in the recliner and a pressure reducing device or cushion to the chair would be beneficial. Review of the facility policy and procedure titled, Wound Care Prevention and Treatment, revised 08/2015, revealed a Braden Scale of 16 or less indicated a high risk for pressure ulcers and pressure ulcer prevention procedures should be implemented. The policy identified the coccyx and buttocks as pressure points.

Based on medical record review, observations, resident interview, staff interview and review of a facility policy, the facility failed to assess a residents non-pressure related skin condition upon admission. This affected one (#61) of one resident reviewed for non-pressure related skin conditions, out of seven total residents observed for skin conditions non-pressure related. Facility census was nine. Findings include: Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #61's Interdisciplinary assessment dated [DATE] revealed the resident had the following [MEDICAL CONDITION] present at admission: a right hip incision, dried abrasions with scabs on the left shin, right elbow, and right knee, a dried scab to the right heel, and two open areas on the buttocks. The assessment does not indicate the resident had any skin tears, or skin impairments to her right hand. Review of an assessment titled Nursing 24 H Assessment, dated 10/26/15, identified a two centimeter skin tear on the resident's right hand with no treatment identified. Additionally, there was no physician orders for a treatment to the skin tear on Resident #61's right hand. Observation on 10/26/15 at 12:03 P.M. revealed Resident #61 was sitting in a recliner. Resident #61 was observed with a foam dressing covering the right hand dated 10/22/15, the day prior to admission. There was bruising noted on the hand. Interview at the time of the observation, Resident #61 stated there was a cut on the skin of her hand. Observation on 10/27/15 at 9:05 A.M. revealed Resident #61 was sitting in a recliner in his room with a foam dressing covering the right hand which was dated 10/26/15. Interview on 10/26/15 at 12:54 P.M., Registered Nurse (RN) #37 stated the foam dressing Resident #61 had on his right hand was a [MEDICATION NAME] foam dressing which was used to treat skin tears. RN #37 stated the facility does not obtain specific orders for these dressing changes and the dressing changes are not tracked on the treatment record. RN #37 confirmed Resident #61's right hand skin tear was not assessed upon admission. Review of facility policy titled Physical Assessment, revised 06/2014 indicated the physical assessment is a critical component of the overall nursing assessment process and during the physical assessment the nurse will inspect the patient's skin for scars, [MEDICAL CONDITION], wounds and/ or irritation. Review of facility policy titled Wound Care Prevention and Treatment, revised 08/2015, revealed a skin tear is a separation of the epidermis from the dermis. The policy noted if a skin tear is present on the initial assessment, the area should be assessed and documented on the Interdisciplinary Admit Data and staff should implement a treatment card for change of [MEDICATION NAME] every seven days.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to notify the physician of the presence of a wound upon admission and failed to notify the physician when the wound developed necrotic areas. This affected one (Resident #59) out of three resident reviewed for pressure ulcers. This had the potential to affect two residents identified by the facility as having pressure ulcers. The facility census was nine. Findings include: Review of medical record revealed Resident #59 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the inter-agency transfer orders, dated 10/22/15, documented Resident #59 was alert and oriented with a primary [DIAGNOSES REDACTED]. His treatments ordered consisted of a specialty mattress, 24 inch knee immobilizer to the right leg, elevate and apply ice to the right leg, and sequential compression device to the left leg. The section addressing wound care documented the resident had pressure ulcers to the bilateral gluteal areas. The nutritional assessment on the intra-agency transfer form indicated the presence of pressure ulcers on the bottom right ankle and heel. Review of the Interdisciplinary Assessment, dated 10/22/15, documented Resident #59 had [MEDICAL CONDITION] to his right lower leg. Also documented by Registered Nurse (RN) #85 was the presence of two open areas to the Resident's right inner ankle. The first area was identified as a reddended circular area which measured two centimeters (cm) in diameter. The second area was identified as a one cm circular, reddened, open area. Documentation included a description of a four cm raised, dry, flaky, scabbed area. RN #85 documented she had cleansed the area and applyied a Vaseline non-adherent dressing. The assessment identified the resident to have a Braden score of ten making him at high risk for developing pressure areas. Review of patient assessment data point history documented on 10/22/15, revealed Resident #59 had a large scab to his inner right ankle. On 10/23/15, 10/24/15 and 10/25/15 the right inner ankle was documented to have a large, healing scab with no drainage noted. There was no documentation on 10/26/15 and 10/27/15 of the area being observed, assessed or treated. Review of physician orders [REDACTED].#59 pressure area to his right ankle. Review of physician progress notes [REDACTED].#59's right inner ankle pressure area. Observation of Resident #59's skin was made on 10/27/15 at 11:38 A.M. with RN #37. RN #37 removed the resident's immobilizer to the right right leg which revealed a Kerlix dressing and non-adherent pad wrapped around the right inner ankle. Brown drainage was observed on the outside of the Kerlix dressing. RN #37 unwrapped the dressing, which was noted to have a large amount of foul smelling exudate present. There were two unstageable areas which were almost touching. The combined areas measured a total of 6.75 centimeters (cm) in length, with the top of the area having a width of 3.5 cm, and the bottom area having a width of 2 cm. The area above the right inner ankle measured 4.25 cm in length, the width at the top of the area measured 1.75 cm, and the bottom width measured 1.5 cm. The areas appeared to be dark purple in color with an undefined border and maceration present. Interview on 10/27/15 at 12:38 A.M., Clinical Nurse Leader (CNL) #47 stated she followed Resident #59 when he was admitted to the acute care hospital in the same building. She stated the orthopedic physician and physician assistant were following the resident's pressure ulcers. She verified there was no current orders for treatment of [REDACTED]. She stated he had a pressure relieving mattress at the time of admission. She stated the wound was chronic in nature and verified she hadn't seen it since the resident was admitted to the facility. Interview on 10/28/15 at 3:30 P.M., RN # 85 stated she worked when Resident #59 was admitted . She stated she assessed the resident as having open areas with scabs to the right inner ankle and obtained measurements at that time. She stated she did not stage the areas or notify the physician to receive orders for a treatment. She stated her and another nurse decided to apply a Vaseline non-adherent dressing with a Kerlix dressing wrap to the open area until the doctor came in the next day. Interview on 10/29/15 at 10:35 A.M., Orthopedic Physician Assistant #66 stated he did not remove Resident #59's dressing to his right, inner ankle region from 10/22/15 to 10/26/15 to monitor the wound. He assumed the surgeon was treating and monitoring the resident's wounds since they were taking care of the pressure areas to his buttocks. Orthopedic Physician Assistant #66 verified he was not notified of any changes of the wound until 10/26/15. He stated at that time he assessed the wound to have an area of pink viable skin under the previous scab, with two outer areas, that appeared dark in color, surrounding the area. He described the area to have an hour glass shape. He stated at that time he made a wound consult and ordered a dressing change. Review of facility policy titled Wound Care Prevention and Treatment, revised August 2015, documented if wound is necrotic to notify the physician for possible debridement. On 10/29/15 at 1:40 P.M. interview with Director of Nursing stated the facility did not have any standing protocol for nurses to treat wounds with necrotic tissue present. She stated they were to notify the physician for further orders.