Every finding on record at University Village Retirement Community

Based on observation, record review, and interview, the facility failed to ensure meals were palatable for three (#22, 47 and #54) of three residents who were reviewed for food palatability. The staff engagement coordinator identified 71 residents who received nourishment from the kitchen. Findings: A Food and Nutrition Services policy, revised October 2017, read in part, Food and nutrition services staff will inspect food trays to ensure that the .food appears palatable and attractive, and it is served at a safe and appetizing temperature. On 12/02/24 at 11:05 a.m., a hotbox arrived to the satellite kitchen for the [NAME] hall. Food was removed from the hotbox and placed on the steam table. On 12/02/24 at 11:11 a.m., DA #1 was observed to obtain temperatures of the food. The carrots and green beans were observed to be under holding temperature at 128 degrees Fahrenheit. The food temperatures were not obtained again prior to plating at 11:30 a.m. On 12/02/24 at 11:49 a.m., Resident #22 stated lunch was cold. On 12/02/24 at 2:17 p.m., Resident #54 stated the food was not hot in dining room. On 12/02/24 at 3:29 p.m., Resident #47 stated the food was good, but sometimes it was not hot. On 12/03/24 at 3:50 p.m., DA #2 was observed to plate food. The DA was not observed to obtain temperatures of the food. DA #2 stated they were plating the hall trays to serve them first. They stated food temperatures were taken in the kitchen. On 12/04/24 at 2:42 p.m., a test tray was received from the hall cart. The food was observed to be without flavor and not served at a palatable temperature. On 12/04/24 at 3:53 p.m., the DM stated temperatures of the food were taken once the food was cooked. They stated food was then panned and placed in the hotbox before taken to the satellite kitchens, where the temperatures should be obtained again prior to serving.

Based on observation, record review, and interview, the facility failed to ensure foods were served in a sanitary manner in two of two dining areas. The staff engagement coordinator identified 65 resident who ate food in the dining rooms. Findings: A Food Handling policy statement, revised July 2014, read in part, Food will be .served so that the risk of foodborne illness is minimized. On 12/02/24 at 11:17 a.m., in the satellite kitchen on [NAME] hall, DA #1 was observed to pour ice from a large scoop into multiple glasses and used their gloved hand to guide the ice into the cups. DA #1 was observed to have touched multiple objects prior to guiding the ice with their gloved hand without doffing and sanitizing between. On 12/02/24 at 11:32 a.m., DA #3 was observed to deliver meals to two residents without changing their gloves or sanitizing their hands. DA #3 was observed to touch the counter, residents, and themselves between meals. They placed the drinks on the table by handling the top rim of the cup. On 12/02/24 at 12:05 p.m., a family member of a resident eating in the dining room on [NAME] hall requested the resident's food be heated in the microwave. On 12/02/24 at 12:05 p.m., DA #3 doffed their gloves, left the dining room and entered the satellite kitchen, while not wearing a hair net, rinsed their hands in the sink, dried their hands, and re-entered the dining room and donned gloves. On 12/03/24 at 4:41 p.m., CNA #2 and CNA #3 repositioned a female resident in their geri-chair. On 12/03/24 at 4:42 p.m., CNA #2 handed a drink to a resident. They were not observed to sanitize their hands after repositioning the female resident in their chair. CNA #2 was observed to leave the dining room to find the other aide. On 12/03/24 at 4:46 p.m., CNA #3 passed a tray without being observed to sanitize their hands between. On 12/03/24 at 4:50 p.m., CNA #4 entered the dining room and they did not sanitize their hands before delivering a tray to a male resident. CNA #4 was then observed to serve another resident a meal plate and had not sanitized their hands. On 12/03/24 at 4:52 p.m., CNA #4 was observed to cut the food for a resident and did not sanitize their hands. On 12/04/24 at 2:27 p.m., CNA #5 stated they sanitized before and after but not in-between passing meal trays. They stated they wore gloves to make sure they are not touching food. CNA #5 stated the cups were placed by the top of the cup due to ease of handling. On 12/04/24 at 4:20 p.m., the DON stated staff were to pick cups up from the side. They stated staff do wear gloves for passing meal trays, but were to change the gloves if they touched residents or anything.

Based on record review and interview, the facility failed to ensure arbitration agreements contained language which indicated a neutral arbitrator would be utilized and the arbitration would take place at a venue convenient to both parties for three (#20, 38, and #120) of three sampled residents who were reviewed for arbitration agreements. The administrator identified 56 residents who had signed an arbitration agreement. Findings: The admission packet contained the following document which read in part, 8. Arbitration .such Dispute be settled by arbitration, which shall be conducted in Tulsa County, OK in accordance with [company name withheld] Rules of Procedure for Arbitration. The arbitration agreement did not indicate a neutral arbitrator would be utilized. 1. Resident #20 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or Respite Care Agreement revealed the resident signed an arbitration agreement on 02/13/24. 2. Resident #38 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or Respite Care Agreement revealed the resident's representative signed an arbitration agreement on 05/28/24. 3. Resident #120 had diagnoses which included unspecified dementia. Review of the Skilled Nursing Facility Agreement revealed the resident signed an arbitration agreement on 12/02/24. On 12/04/24 at 5:09 p.m., the administrator stated they were relatively new to the facility and would need to consult with a staff member who had been employed longer to gather information about the arbitration agreement. On 12/05/24 at 10:05 a.m., the administrator stated they did not know why the arbitration agreement did not include language that a neutral arbitrator would be utilized or that the selection of a venue would be convenient to both parties.

Based on record review and interview, the facility failed to ensure records were accurate for one (#21) of five sampled residents who were reviewed for unnecessary medications. The administrator identified 74 residents who resided in the facility. Findings: Resident #21 had diagnoses which included anxiety, depression, and atrial fibrillation. A physician's order, dated 02/19/24, documented staff were to monitor Resident #21 for side effects related to antidepressant medication and to chart in the progress notes if they documented yes that the resident had side effects. A physician's order, dated 02/19/24, documented staff were to monitor Resident #21 for side effects related to anticoagulant medication and to chart in the progress notes if they documented yes that the resident had side effects. A physician's order, dated 10/14/24, documented staff were to monitor Resident #21 for side effects related to antianxiety medication and to chart in the progress notes if they documented yes that the resident had side effects. The October 2024 TAR documented the following side effect monitoring results: a. from 10/14/24 through 10/31/24, Resident #21 had side effects related to antianxiety medication use 22 times out of 53 opportunities; b. from 10/01/24 through 10/31/24, Resident #21 had side effects related to anticoagulant medication use 23 times out of 93 opportunities; and c. from 10/01/24 through 10/31/24, Resident #21 had side effects related to antidepressant medication use 25 times out of 93 opportunities. The November 20104 TAR documented the following side effect monitoring results: a. from 11/01/24 through 11/30/24, Resident #21 had side effects related to antianxiety medication use 24 times out of 90 opportunities; b. from 11/01/24 through 11/30/24, Resident #21 had side effects related to anticoagulant medication use 18 times out of 90 opportunities; and c. from 11/01/24 through 11/30/24, Resident #21 had side effects related to antidepressant medication use 20 times out of 90 opportunities. The December 2024 TAR documented the following side effect monitoring results: a. from 12/01/24 through 12/04/24, Resident #21 had side effects related to antianxiety medication use three times out of ten opportunities; b. from 12/01/24 through 12/04/24, Resident #21 had side effects related to anticoagulant medication use two times out of ten opportunities; and c. from 12/01/24 through 12/04/24, Resident #21 had side effects related to antidepressant medication use two times out of ten opportunities. Review of the progress notes did not reveal documentation the resident had experienced side effects related to antianxiety, anticoagulant, or antidepressant medication use. On 12/04/24 at 12:24 p.m., LPN #1 stated the charge nurses monitored for medication side effects. They stated they documented on the TAR and if they documented yes to the question about side effects, they were to document in a progress note. LPN #1 stated Resident #21 had not experienced any medication side effects. They reviewed the electronic clinical record and stated they had documented yes to indicate they had monitored for side effects not to indicate the resident had experienced medication side effects. On 12/04/24 at 3:28 p.m., the DON stated the TARs were monitored for medication side effects by the ADON, consultant nurse, pharmacist, and themselves. They stated Resident #21 had not experienced any medication side effects. On 12/04/24 at 4:03 p.m., the DON stated they had reviewed the TARs for Resident #21 and stated they had noticed the documented side effects for antianxiety, anticoagulant, and antidepressant medications. They stated they needed to provide education to ensure accurate documentation of medication side effect monitoring.

Based on observation, record review, and interview, the facility failed to ensure catheter tubing was maintained to prevent infection for two (#2 and #27) of two residents who were reviewed for catheter infection prevention. The staff engagement coordinator identified six residents who had catheters. Findings: The Catheter Care, Urinary policy, dated August 2022, read in part, Be sure catheter tubing and drainage bag are kept off the floor. 1. Resident #2 had diagnoses which included obstructive bladder. On 12/02/24 at 3:22 p.m., Resident #2 was observed to be in bed with their catheter tubing on the fall mat. On 12/03/24 at 8:52 a.m., Resident #2 was observed in their wheelchair in their room with their catheter tubing on the floor. On 12/04/25 at 10:13 a.m., Resident #2 was observed in their bed with their catheter bag and tubing on the floor. On 12/04/24 at 10:27 a.m., CNA #1 covered Resident #2, lowered the bed, and placed the fall mat. The resident's catheter tubing was observed to touch the fall mat. 2. Resident #27 had diagnoses which included neurogenic bladder. A Physician's Order, dated 08/19/24, documented to maintain and monitor suprapubic catheter with bedside drainage bag and cover with dignity bag. A Care Plan, revised 11/13/24, documented Resident #27 was at risk for urinary tract infection related to a history of UTIs and suprapubic catheter. On 12/02/24 at 3:35 p.m., the catheter tubing was observed to hang below the wheelchair of Resident #27 and touch the floor. On 12/04/24 at 4:18 p.m., CNA #1 stated the catheter bag and tubing were always below the bladder and they placed it on the side of the bed. They stated the catheter bag and tubing should not be on the floor. On 12/04/24 at 4:20 p.m., the DON stated the catheter bag should be placed on the bed frame and below the bladder to maintain infection control. They stated staff were educated to not lay the catheter bag on the floor and they would need to implement a way to keep the tubing off the floor.

Based on record review and interview, the facility failed to ensure arbitration agreements contained language residents and/or resident representatives could rescind the agreement within 30 days of signing and signing the agreement was not a condition of admission for three (#20, 38, and #120) of three sampled residents who were reviewed for arbitration agreements. The administrator identified 56 residents who had signed an arbitration agreement. Findings: 1. Resident #20 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or Respite Care Agreement revealed the resident signed an arbitration agreement on 02/13/24. 2. Resident #38 had diagnoses which included congestive heart failure. Review of the Health Center Long Term Care or Respite Care Agreement revealed the resident's representative signed an arbitration agreement on 05/28/24. 3. Resident #120 had diagnoses which included unspecified dementia. Review of the Skilled Nursing Facility Agreement revealed the resident signed an arbitration agreement on 12/02/24. Review of the admission packet revealed an arbitration agreement. The arbitration agreement was not observed to contain language granting the resident and/or the resident representative the right to rescind the agreement within 30 days of signing it. The arbitration agreement did not contain language the resident and/or the resident representative was not required to sign the arbitration agreement as a condition of admission to the facility or as a requirement to continue to receive care at the facility. On 12/04/24 at 5:09 p.m., the administrator stated they were relatively new to the facility and would need to consult with a staff member who had been employed longer to gather information about the arbitration agreement. On 12/05/24 at 10:05 a.m., the administrator stated they did not know why the arbitration agreement did not include language the resident and/or resident representative could rescind the agreement within 30 days of signing or why the arbitration agreement did not inform the resident and/or the resident representative of their right not to sign the agreement as condition of admission to the facility.

41220 Based on observation, record review, and interview, the facility failed to ensure medications were secured in locked medication carts for two (#1 and #2) of seven medication carts observed. The administrator identified 72 residents resided in the facility. Findings: A Storage of Medications policy, dated 10/2024, documented drugs and biologicals used in the facility were stored in locked compartments. On 12/03/24 at 3:08 p.m., medication cart #1 on bluebird hall, outside of room [ROOM NUMBER], was observed to be unlocked. No staff were in view of the cart . On 12/03/24 at 3:17 p.m., medication cart #2, located in the hallway outside of room [ROOM NUMBER], was observed to be unlocked. On 12/03/24 at 3:18 p.m., RN #1 removed a medication from medication cart #1 and went into room [ROOM NUMBER]. The cart remained unlocked. On 12/03/24 at 3:20 p.m., RN #2 was observed to move medication cart #2 to several different rooms, remove medication and enter the room, leaving the cart in the hallway unlocked and unattended each time. On 12/03/24 at 3:32 p.m., RN #1 returned to the unlocked cart to chart. When asked about the unlocked cart, RN #1 locked the cart and stated the medication cart should be locked when not in use. On 12/03/24 at 3:35 p.m., the DON stated medication carts should be locked when unattended. On 12/03/24 at 3:42 p.m., the DON locked medication cart #2.

Based on observation, record review, and interview, the facility failed to ensure privacy was provided during urinary catheter care for one (#2) of two sampled residents who were reviewed for urinary catheters. The staff engagement coordinator identified six residents who had urinary catheters. Findings: The Catheter Care, Urinary policy, dated August 2022, read in part, Provide privacy. Resident #2 had diagnoses which included obstructive and reflux uropathy. A physician's order, dated 09/06/24, documented the resident had an indwelling urinary catheter and staff were to provide catheter care every shift. On 12/04/24 at 10:13 a.m., CNA #1 and LPN #1 were observed to provide catheter care to Resident #2 with the resident's roommate in the room in their bed. The privacy curtain was observed to be open and not closed between Resident #2 and their roommate during the catheter care. On 12/04/24 at 2:07 p.m., CNA #1 stated they were to close the privacy curtains during personal care, but had not noticed Resident #2's roommate was in the room. On 12/04/24 at 2:18 p.m., LPN #1 stated they were to close the privacy curtains during care, but was in a rush and had not closed it during the catheter care for Resident #2. On 12/04/24 at 3:32 p.m., the DON stated staff were to close privacy curtains during personal care.

Based on record review and interview, the facility failed to inspect a hospice supplied bed for safety prior to use by a resident for one (#1) of three sampled residents reviewed for bed safety. The administrator identified 68 residents resided at the facility. Findings: A facility policy titled Bed Safety and Bed Rails, dated March 2023, read in part, Bed frames, mattresses, and bed rails, are checked for compatibility and size prior to use. Resident #1 had diagnoses which included a history of falling. A progress note, dated 10/21/24 at 10:48 p.m., documented the resident was found on the floor next to the bed. The resident's neck was resting on the bed rails and legs were on the ground. On 10/28/24 at 9:58 a.m., Resident #1's representative stated the incident occurred when the headboard separated from the frame of the bed. On 10/28/24 at 10:26 a.m., Maintenance #1 stated they thought they performed bed inspections quarterly and when something malfunctioned. They stated they did not inspect hospice supplied beds when they were brought into the facility. They stated they did not call call them when they set up the beds. They stated when the incident with Resident #1 occurred they did look at the bed, but it was already in the hallway and was broken. On 10/28/24 at 11:34 a.m., Resident #1 stated they recalled the bed incident. They stated their head was never stuck in the bed rail. The stated the bed broke on one side and they slid from the bed and landed on their knees with their head resting against the mattress and bed rail. They stated they would have gotten up, but they had been too weak. They stated there was no injury from that incident they recalled. On 10/28/24 at 12:15 a.m., the ADON stated when the bed had broken the resident's neck had been resting on the side rail on the left side of the bed and their legs were on the floor mat. They stated the resident did have small skin tear on their neck where it rested against the side rail. They stated they were not sure when bed inspections were done, but did know they should be done prior to use by a resident. They stated that was policy.

Based on record review and interview, the facility failed to ensure blood pressure medications were administered as ordered for one (#12) of five sampled residents reviewed for medications. The DON identified 31 residents who had blood pressure medications with parameters. Findings: Res #12 had diagnoses which included hypertensive heart disease with heart failure. A physician order, dated 02/20/23, documented lisinopril (ACE inhibitor) 2.5 mg one time a day. Hold if SBP is less than 100; and metoprolol tartrate (beta blocker) 25 mg give 1/2 tablet two times a day. Hold if SBP is less than 100 and heart rate less than 60. The August 2023 MAR documented lisinopril was held four out of 25 opportunities when the SBP was within parameters. It was documented metoprolol was held four out of 49 opportunities with the SBP and heart rate were within parameters. The September 2023 MAR documented lisinopril was held seven out of 31 opportunities when the SBP was within parameters. It was documented metoprolol was held 10 out of 62 opportunities with the SBP and heart rate was within parameters. On 09/25/23 at 2:14 p.m., the DON was asked to review the resident's MARs for the administration of lisinopril and metoprolol. They were asked the reason why the medications were held when the resident's SBP and/or heart rate was within parameters. On 09/25/23 at 3:32 p.m., the DON stated there was no reason for the medications not being administered when they were within parameters. They stated orders were not followed.

Based on observation, record review, and interview, the facility failed to administer oxygen according to physician orders for one (#213) of four sampled residents reviewed for respiratory care. The Resident Census and Conditions of Residents form, dated 09/22/23, documented 11 residents received respiratory treatments. Findings: Res #213 had diagnoses which included COPD. A physician order, dated 09/19/23, documented Res #213 was to receive continuous oxygen at 2 L per minute via nasal cannula. The order documented to titrate oxygen to maintain oxygen saturation above 90%. On 09/21/23 at 10:04 a.m., Res #213 was observed in their room. Their oxygen concentrator was observed to be on and the resident was receiving oxygen via nasal cannula. The oxygen gauge on the concentrator was set above 5 L. On 09/21/23 at 2:17 p.m., Res #213 was observed in the therapy room with a therapy staff member. The resident was observed without portable oxygen on or nearby. On 09/21/23 at 2:20 p.m., RN #2 was asked if the resident had oxygen on, they stated they did not. The RN was asked to check the resident's oxygen saturation. They stated it was 88-89. The RN was asked if the resident was supposed to have continuous oxygen. The RN stated they were unsure why the resident was not on oxygen. On 09/21/23 at 2:38 p.m., the DON was asked how the facility ensured residents received oxygen as ordered. They stated there should have been a portable oxygen tank in the resident's room to be placed on the wheelchair when the resident left the room.

Based on record review, observation, and interview, the facility failed to ensure: a. staff were COVID tested during outbreak status per policy and procedure; b. staff wore appropriate PPE for COVID posted isolation precaution rooms per policy and procedure; and c. staff washed their hands with glove changes during wound care per policy and procedure. The DON identified six resident who were on isolation precautions for COVID-19 and two residents who were receiving wound care. Findings: The facility policy, titled Coronavirus Disease (COVID-19) - Testing Staff, documented in part .outbreak is defined as any single new onset of COVID-19 infection in a resident or a single case of infection in any staff . All staff in the unit (or in the facility), regardless of vaccination status, are tested immediately (but not sooner than 24 hours after the exposure) and, if negative, again 48 after the exposure, and a final test 48 hours after second test. If additional cases are identified, testing will continue every 3-7 days (in addition to room restriction and full PPE use for care of exposed residents) until there are no new cases for 14 days . A facility Isolation - Categories of Transmission-Based Precautions policy, dated September 2022, documented in part .Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection .or has a laboratory confirmed infection . A facility wound care policy, dated October 2010, documented in part .Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly . 1. On 09/25/23 the DON identified residents who tested positive for COVID-19 on 09/18/23 through 09/22/23; and staff who tested positive for COVID-19 from 09/18/23 through 09/25/23. On 09/26/23 at 11:41 a.m., an interview was conducted with the IP regarding COVID-19 testing. The IP stated the facility was in outbreak status. The IP stated the residents and staff were tested based on signs and symptoms of COVID-19. The IP stated on 09/18/23 a resident tested positive for COVID-19. The IP stated all staff were tested for COVID-19 the same day. The IP stated the facility had not conducted any formal testing of staff since the initial staff testing on 09/18/23. The IP state the facility had not followed their policy regarding COVID-19 testing for prevention and control. On 09/26/23 at 12:49 p.m., the administrator was asked about COVID-19 testing. They stated they were informed it was up to the facility to determine if contact tracing or routine testing was completed. They stated the facility relied on a contact at acute diseases to guide their testing and precautions. 2. A sign posted on the door of a resident documented in part .transmission precautions .full PPE required: gloves, disposable isolation gown, mask, face shield . On 09/26/23 at 12:30 p.m., CNA #1 was observed in an isolation room. The CNA was observed collecting a meal tray from the resident's bedside table. The CNA was not wearing gloves, a gown, or face shield. The CNA exited the room and placed the meal tray on a rolling cart. The CNA was asked what PPE was required to enter the resident's room. They stated they were informed PPE was only required if providing direct patient care. On 09/26/23 at 12:49 p.m., the DON was asked what PPE was required when entering an isolation room. They stated the staff should wear a mask, gloves, eye protection, and a gown. They were asked if the PPE should be donned for any staff entering the room, they stated that all staff should follow the signs posted on the door. 3. Res #212 had diagnoses which included history of right femur fracture and disruption of external surgical wound. A physician order, dated 09/20/23, documented to cleanse wound to right hip incision site with normal saline, dress with silver alginate and border gauze every shift for dehiscence. On 09/22/23 at 09:21 a.m., RN #2 was observed performing wound care for Res #212. The nurse was observed performing hand hygiene and donning gloves prior to removing the existing dressing. The nurse discarded the existing dressing and removed their gloves. The nurse did not perform hand hygiene prior to donning clean gloves. On 09/22/23 at 09:31 a.m., RN #2 was asked when hand hygiene should be performed during wound care. The RN stated they should have used the alcohol based hand rub and gestured to the bottle of hand sanitizer on the treatment cart. The RN stated they did not perform hand hygiene during wound care. On 09/22/23 at 10:35 a.m., the DON was asked when hand hygiene should be performed during wound care. They stated hand hygiene should be performed before care, after care, and when changing gloves.

Based on observation, record review, and interview. the facility failed to ensure a resident had a physician order to self-administer a nebulizer treatment for one (#16) of one sample resident reviewed for self-administration of medications. The Resident Census and Conditions of Residents report, dated 09/22/23, documented 11 residents who received respiratory treatments. Findings: Res #16 had diagnoses which included COPD. A physician order, dated 05/03/23, documented levalbuterol HCL (breathing treatment) inhalation mobilization solution 1.25 mg/ml. One vial inhale orally via nebulizer three times a day. On 09/21/23 at 1:06 p.m., the resident was observed laying in their bed with a nebulizer treatment being administered through the mask over their nose and mouth. There was no staff present in the room or outside of the resident's door. There was no documentation the resident had a physician's order to self-administer a nebulizer treatment. On 09/21/23 at 1:17 p.m., RN #1 was observed going into the resident's room where they shut the nebulizer treatment off. On 09/21/23 at 1:20 p.m., RN #1 and RN #2 were asked what was the protocol for administering nebulizer treatments. They stated Res #16 received a breathing treatment every eight hours. They were asked if it was protocol to stay with a resident while their treatment was being administered. They shook their heads yes. They were asked if Res #16 had a physician order to self administer their breathing treatment. RN #2 stated, No.

Based on observation, record review, and interview, the facility failed to notify the physician of a surgical wound change for one (#212) of one sampled residents reviewed for surgical wounds. The DON identified three residents who had surgical wounds. Findings: Res #212 had diagnoses which included history of right femur fracture and disruption of external surgical wound. A wound specialist note, dated 09/05/23, documented the surgical wound to the right trochanter had been treated for two weeks, and was documented to have steri-strips in place. The note documented the surgical sites to the right lateral upper leg and right inferior lower leg had healed. A skilled nurse note by RN #2, dated 09/07/23 at 11:45 a.m., documented in part .wound dressing changed; sanguineous drainage noted on old dressing, 2/3 of surgical incision skin open, Steri-strips changed . A transfer to hospital summary, dated 09/09/23 at 11:35 a.m., documented the resident was sent to the hospital for neurological evaluation related to new onset left hand weakness. A nurse note, dated 09/09/23 at 10:20 p.m., documented the resident was admitted to the hospital for conditions including wound dehiscence. An admission evaluation, dated 09/13/23 at 8:01 p.m., documented the resident readmitted to the facility. The note documented the right hip incision had dehisced. A 5-day comprehensive assessment, dated 09/20/23, documented the resident was cognitively intact, required extensive assistance with ADLs, and had a surgical wound. On 09/22/23 at 09:21 a.m., RN #2 was observed performing wound care for Res #212. The nurse was asked about the history of the wound. They stated the resident had a hip fracture repair and the wound dehisced at the hospital. On 09/22/23 at 11:50 a.m., RN #2 was asked about the progress note documented on 09/07/23. They stated they were not worried about the wound opening because they were able to re-approximate the wound with steri-strips. They stated they did not notify the physician because it was superficial. On 09/22/23 at 12:02 p.m., the DON was asked about notification of changes to wounds. They stated the nurse should have notified them as soon as the changes were noted. They were informed of the notation on 09/07/23 for Res #212. They stated the physician and DON should have been notified the wound had opened.

On 03/29/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the resident received adequate supervision and assistive devices to prevent accidents. The facility documented interventions for falls which were not initiated or inconsistently applied. The multiple falls resident #2 incurred resulted in fractured cervical vertibrae and a closed head injury. On 03/29/22 at 3:15 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. At 3:24 p.m., the administrator was notified of the IJ situation. On 03/30/22 at 3:51 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: .1. A binder has been constructed to stay with Resident #2 at all times that will document all care and services provided, who provided the care and services and what date and time provided. This has been implemented as of 19:00 [7:00 p.m.] on Tuesday, March 29th .2. Every careplan for every resident that has had a fall since January 1, 2022 has been reviewed, and we have ensured all fall interventions are in place and current as of 10:00 [a.m.] on Wednesday, March 30th .3. Staff have either been in-serviced about the fall intervention binders and requirement to review and sign them before shifts in person or by phone if unable to come in person. This includes nursing staff, housekeeping staff, maintenance staff and dining services staff .4. One binder has been placed at each nurses' station and attached to the counter so that it cannot be removed .a. The DON and Resident Care Director will be responsible for the content placed in the binder and ensuring it matches any residents' care plans and any interventions in place .b. All staff will be educated about the existence of the binders and the requirement that they review and document that they reviewed the information in the binder before beginning their shift every shift .c. The DON will keep a separate monitoring file and do random, daily checks of each shift to ensure staff are reading and documenting that they are reading the binder updates .5. the DON will continue to perform or coordinate daily huddles to update staff about pertinent information related to falls and interventions .6. When a fall occurs the charge nurse will complete an incident report in our EMR which includes a root cause analysis .a. An intervention for the fall will also be put in to place immediately .b. The leadership team, which includes the MDS nurses, DON, Resident Care Director, Administrator, Assistant Administrator, Social Services Director, Therapy Director, Risk Management/Infection Prevention RN and Admission Director, will review the incident reports and interventions every morning and determine if the intervention is appropriate or not .c. The MDS Coordinators will update the residents' care plan accordingly .d. A member of the team will be assigned a red card that shows the resident's name and room number and the intervention that should be in place. It will be that person's responsibility to ensure that the intervention is in place appropriately .e. Once the intervention is in place appropriately, the red card will be returned to the next meeting for purposes of tracking and monitoring .f. The DON and/or Resident Care Director will update the desk binders to communicate to staff any pertinent fall interventions .7. A weekly fall committee meeting will also occur once weekly to include the same leadership group mentioned above .a. In this meeting we will go over all falls since the previous meeting and ensure that the interventions are still in place and working and document accordingly . The IJ was lifted, effective 03/31/22 at 4:00 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm at a pattern. On 03/31/22 and 04/04/22, interviews were conducted with facility staff, including nursing staff and therapy staff, regarding education and in-service information pertaining to the Immediate Jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent accidents for two (#2 and #6) of four sampled residents reviewed for falls. This resulted in resident #2 diagnosed with a neck fracture after a fall, a closed head injury after another fall, and resident #6 diagnosed with a fractured hip after a fall. The risk manager identified 108 documented resident falls from January 2022 through March 2022. Findings: Resident #2 admitted to facility on 11/12/21 with diagnoses which included abnormality of gait, history of falls, and an acute fracture of the left radius bone from a recent fall. An incident report, dated 11/19/21 at 11:46 a.m., documented an unwitnessed fall in the bedroom. No injuries were documented. Per incident report, the resident stated she was reaching for something on her bed but could not recall what she was reaching for. The resident was assisted to the recliner and common items placed within reach. The resident was provided the call light and encouraged to call for assistance when getting up or when something was needed. The incident report was reviewed by the risk manager and a fall intervention initiated to place signage in the resident's room to remind the resident to call for assistance. The careplan, dated 11/19/21, documented, .Falls: the Res. is at risk for falls r/t functional decline with risk for complications .Goal: I will not have major injuries r/t falling through the review date . Careplan interventions included: to keep any personal belongings that resident may need on the bedside table and to include the resident's phone to be within reach at all times; to keep the call light in reach and answer the call light in a timely manner; and for the therapy department to evaluate and treat the resident. An incident report, dated 12/03/21 at 11:27 p.m., documented an unwitnessed fall in the bedroom. No injuries were documented. The incident report documented the resident was found in her room, sitting on her buttocks next to her bathroom. Per incident report, the resident stated she had been walking with her walker to the bathroom when she lost her balance and sat on her bottom. The incident report documented the resident was wearing pajamas and non-skid socks. Per incident report, the resident was educated on the use of the call light and was able to return demonstration of the use of the call light. The resident was also instructed on calling for help before getting up. The incident report was reviewed by the risk manager and documented, .Reviewed, agreed with above and will cont education to resident about not using walker unless staff assisting . The careplan, dated 12/06/21, documented the following additional fall intervention: .I was educated on how to use the call light and I demonstrated how to use it . An incident report, dated 12/17/21 at 3:14 a.m., documented an unwitnessed fall in the bedroom. No injuries were documented. The incident report documented the resident was found sitting on the floor next to her bed. Per incident report, the resident stated she was trying to get up out of bed when she fell on her bottom. The report documented the resident was educated on the use of the call light and was able to demonstrate its use. The incident report was reviewed by the risk manager and she documented she would educate the staff and add a task to the electronic medical record to check on the resident between 3:00 a.m. and 4:00 a.m. and to toilet the resident, if awake. The careplan, dated 12/17/21, documented the following additional fall intervention: .Please check for bathroom assistance between 3-4am when I'm awake . An incident report, dated 12/18/21 at 1:16 p.m., documented an unwitnessed fall in the bedroom. Per incident report, the resident was found outside of the bathroom, laying on her left side. The incident report documented, .Head assessed and knot noted to back left of head . Per incident report, the resident did not use the call light and stated she ambulated to the bathroom to fix her dentures. After the fall, the resident complained of a headache. The incident report was reviewed by the risk manager and she documented, .further investigation showed resident not wearing non skids [socks] or shoes at time of fall. Will educate and give reminders to staff on assuring that resident has non skids [socks] or shoes on at all times . An incident report, dated 12/19/21 at 6:52 a.m., documented an unwitnessed fall in the bedroom. Per incident report, the resident was found lying on her back near her bed. The report documented the resident stated she had hit her head. Per incident report, the resident was wearing silk socks and attempted to ambulate to the bathroom without using the call light to request assistance. The incident report was reviewed by the risk manager and she documented, .will follow up on the urine specimen for potential infection, if negative other avenues of possible infection, also instructed staff on keeping resident in common area when up out of bed . An incident report, dated 12/19/21 at 6:30 p.m., documented an unwitnessed fall in the bedroom. Per incident report, the resident was found lying on her back near her bed. The incident report documented the resident stated she had hit her head. The report documented the resident was wearing silk socks and attempted to ambulate to the bathroom without using the call light to request assistance. The incident report was reviewed by the risk manager and she documented, .will place a fall mat at bedside when in bed, will also consider a different room where resident is more visible from hallway . There was no documentation of a resident room change. The careplan, dated 12/20/21, documented the following additional interventions: a floor mat was to be placed next to the resident's bed; keep the resident in the common area when awake and out of bed; and to make sure the resident wore non-skid socks or shoes. An incident report, dated 12/22/21 at 9:45 p.m., documented an unwitnessed fall in the bedroom. No injuries were documented. The incident report documented the resident was found on the floor, sitting on her buttocks. The report documented the resident stated she was going to the bathroom and fell . Per incident report, the resident was instructed to use the call light for assistance. The incident report was reviewed by the risk manager and documented the addition of a task to the electronic medical record for staff to check on the resident between 9:00 p.m. and 9:30 p.m., and to offer the resident toileting and other activities of daily living assistance before bedtime. An incident report, dated 12/31/21 at 7:19 p.m., documented an unwitnessed fall in the bedroom. No injuries were documented. The incident report documented the resident was found sitting on her buttocks in the bathroom of her room. She was wearing pajamas and non-skid socks. Per incident report, the resident stated she was walking to the bathroom without her walker, lost her balance and sat on her buttocks. The report documented the resident was instructed to use the call light and was able to demonstrate its use. She was also instructed to call for help before getting up. The incident report was reviewed by the risk manager and she documented signage was placed in the room to remind the resident to call for assistance and not to try getting up alone. The careplan, dated 12/31/21, documented the additional fall intervention, .She was educated on the use of the call light and demonstrated the use of the call light. She was also educated on calling for help before getting up. Signage placement multiples for reminding resident to call for assistance, not to try alone . An incident report, dated 01/11/22 at 9:30 p.m., documented an unwitnessed fall in the bedroom. No injuries were documented. The incident report documented the resident was lying on her abdomen with her head pointed toward the wardrobe and her feet pointed toward the bed frame. Per incident report, the resident stated she started from the recliner and went to answer the phone. The incident report was reviewed by the risk manager and she documented, .will educate staff to assure all personal items in reach for resident . An incident report, dated 01/12/22 at 5:00 p.m., documented an unwitnessed fall in the bedroom. The incident report documented the resident was found lying on her abdomen with her head pointed toward the recliner and her feet pointed toward the bed. The incident report documented, .w/c [wheelchair] noted to be L side of resident in the unlocked position, no socks or shoes noted to be in place, call light was not activitated, neuros noted to be WNL of resident, no new skin conditions noted, ROM noted to be WNL to QLE, body noted to be in its natural alignment, unable to determine residents pain rating d/t resident stating at times she was fine and at other times she could feel a pain in her hip, when asked resident what she was attempting to do resident first stated, 'I was trying to go to the bathroom' and later stated 'I slid out of my wc', [sic] when taking VS earlier in the shift resident was noted to be in recliner, when asked if she was in pain resident stated at first, 'Oh no I'm alright, I'll be fine' and later stated, 'Well there is a small pain in my hip' .resident transferred from floor to bed, X-ray to R hip ordered d/t possible pain to R hip, CMA instructed to give PRN pain medication at this time, new intervention: bring resident to nurses station when awake for observation and safety, at this time resident noted to be in bed d/t awaiting x-ray and will be placed into bed to obtain x-ray, non-skid socks put in place, bed in lowest position, fall mat in place . The incident report was reviewed by the risk manager and she documented, .Reviewed, and team agreed with above interventions . An incident report, dated 01/17/22 at 8:22 a.m., documented an unwitnessed fall in the bedroom. The incident report documented, .Resident was found on the floor at 0600 [6:00 a.m.] d/t an unwitnessed fall. Resident was on the floor between her curio cabinet and her recliner. She stated she was trying to get her bathrobe. Resident stated that she fell and hit her head and neck. Resident c/o neck and head pain .Upon assessment noted oval shaped bruise forming on upper spine and marble size knot forming on the back of her neck on the left side. Resident then started to c/o of [sic] neck, head, and back pain. EMSA was called at 0628 .Neuro checks started until EMSA arrived. EMSA arrived and transported resident to [hospital name withheld] @ 0640 . The incident report was reviewed by the risk manager and she documented, .Reviewed, upon return resident will be changed to a more centrally located room with easier view of activity from hallway/door . There was no documentation of a resident room change. The careplan, dated 01/18/22, documented the following additional interventions: the bed was to be positioned in low position at all times when the resident was in the bed and the resident was to be brought to the nurses' station when awake for observation and safety. An incident report, dated 01/24/22 at 11:20 p.m., documented an unwitnessed fall in the bedroom. The incident report documented, .This nurse was notified by Med aid that patient was found lying on floor. This nurse assessed resident in room and seen resident on floor supine position c/o pain in Right hand/wrist. This nurse assessed skin noticied no abnormalities except bruising to left Upper extremity. This nurse assisted by CNA assisted with resident transfer from floor to wheelchair. Patient did not tolerate transfer .Resident stated 'I was just trying to get up and i fell .' The incident report was reviewed by the risk manager and she documented, .Reviewed, staff was re-educated that resident to be in common area within view whenever awake or alone . An update to the careplan, dated 01/25/22, documented the following additional intervention: Staff were to perform frequent checks while the resident was in bed. A handwritten entry also documented, .staff re-educated to bring res to common area . An incident report, dated 01/25/22 at 4:00 p.m., documented an unwitnessed fall in the bedroom. The incident report documented, .at approx 1600 [4:00 p.m.] this nurse was alerted to residents room by admin, upon entering room resident noted to be sitting on bottom in bathroom with left side of body facing toward toilet and back resting against wall of shower, walker noted to be on far side wall of bathroom, it appeared resident had tried to use walker to self ambulate .resident c/o head pain, speech noted to be slightly slurred, pupils PERRL but sluggish, all other neuros were WNL .when asking resident what she was attempting to do resident stated, 'I was getting up to do something', [sic] when asking resident what something she was attempting to do resident stated, 'I don't know' .resident transferred from floor to w/c and brought to nurses station, at nurses station resident c/o of [sic] head pain again, scalp re-checked, resident then had small raised area to back of head that was slightly warm .911 activated d/t possible head injury . The incident report was reviewed by the risk manager and she documented, .Reviewed, upon return large ceiling tile signage placed for reminding resident to call for assistance . An update to the careplan, dated 01/26/22, documented the following additional intervention: .brought to nurses station, Res. sent to ER. Room change . On 01/27/22, resident #2 room was changed. The discharge summary for a local hospital, dated 01/27/22, documented the resident sustained multiple neck fractures. It documented, .Complex oblique fracture through the body of C2. Fractures of spinous process of C3 [cervical vertebra 3] and C4 [cervical vertebra]. Sacral decubitus ulcer, present on admission . An update to the careplan, dated 01/27/22, documented the following additional intervention: .Call dont fall sign . An incident report, dated 01/28/22 at 1:30 p.m., documented an unwitnessed fall in the bedroom. The incident report documented, .this nurse called to residents [sic] room. resident noted on her back on floor next to recliner. head to toe assessment conducted. bruises noted to right forehead and left hand. c/o headache. resident stated 'I was going to the bathroom' .unwitnessed fall with head injury, resident sent out to [hospital name omitted] . The incident report was reviewed by the risk manager and she documented, .Reviewed, ongoing intervention was in place to keep resident in common area at all times she is alone or awake in room, staff involved, verbally counseled about following precaution placed on resident . An update to the careplan, dated 01/31/22, documented the following additional intervention: .one on one at all times . A handwritten entry documented, .staff involved counseled on keeping res in common area . There were no incident reports for resident #2 related to falls for the month on February 2022. An incident report, dated 03/16/22 at 8:30 p.m., documented an unwitnessed fall in the bedroom. No injuries were documented. The incident report documented the resident was found on her back on the fall mat. Per incident report, the resident did not know why she fell or what she was doing to fall. There was no documentation the risk manager reviewed the incident report. An incident report, dated 03/17/22 at 8:30 p.m., documented an unwitnessed fall in the bedroom. No injuries were documented. The incident report documented the resident was found on her back on the floor atop the fall mat with arms and legs extended. Per incident report, due to the resident's confusion, she was not able to explain the reason for the fall. The incident report documented the resident was wearing non-skid socks, the wheelchair was locked and approximately three feet from the resident, the call light was in reach, and the bed was at the appropriate height. The incident report was reviewed by the risk manager and she documented, .Reviewed, awaiting Bolsters from hospice for resident from prior fall, will task staff not to put to bed earlier than 8pm and to toilet at 8pm and prep for bed . An update to the careplan, dated 03/18/22, documented the following additional intervention: .frequent checks for positioning while in bed .awaiting bolsters from hospice for resident from prior fall, will task staff not to put to bed earlier than 8pm and prep for bed . On 03/23/22, no bolsters were observed on the resident's bed. On 03/23/22 at 2:45 p.m., the resident was observed in the common area near the nurses' station. Resident had a cervical (neck) collar in place. The resident's room was observed to have a fall mat, walker, and bed in low position. There were no bolsters on the bed. On 03/23/22 at 2:49 p.m., CNA #1 stated the resident stayed out in the common room in the recliner between meals. She stated the resident was transferred back to her room using the wheelchair. On 03/23/22 at 2:51 p.m., LPN #1 stated the resident was out in the common area because she was a high fall risk. He stated the resident liked to do thing by herself and had forgotten her own limitations. He stated this was the best way to keep her safe. He stated the resident would ask for assistance when staff were present. On 03/24/22, no bolsters were observed on the resident's bed. On 03/28/22, no bolsters were observed on the resident's bed. On 03/28/22 at 1:52 p.m., resident #2 was observed in bed. There were no bolsters present. On 03/28/22 at 4:32 p.m., the risk manager was interviewed. She stated every incident report was reviewed by their team, consisting of the administrator, Director of Nursing, the risk manager, the admissions director, the two MDS coordinators, the assistant administrator, and therapy. She stated the team came up with interventions by looking at how the fall occurred and/or what caused the fall. She stated if the documentation of the incident was vague, either herself or the assistant administrator would investigate the cause of the fall and determine an appropriate intervention. She was asked how the facility monitored to ensure interventions were implemented. She stated on fridays she would check to see if the interventions were in place. She was asked how the facility monitored to ensure intangible interventions such as staff checking and toileting resident between 3:00 a.m. and 4:00 a.m was conducted. She stated the Resident Care Coordinator added such interventions into the electronic medical record as a task the staff then must document toward. She was asked if anyone was responsible to ensure the interventions were completed. She stated she did not know if the interventions specifically were audited but knew the facility audited documentation and charting. She was asked what was the root cause of falls for resident #2. She stated the resident had a lot of falls at first due to her cognition. She stated, initially the facility did not recognize the resident's decreased cognition. She stated due to the frequency of agency staff use in the facility, interventions were not followed, resulting in repeated falls. She stated, when a fall occured because an intervention was not followed, the staff involved were in-serviced individually on the intervention. She stated facility wide there were 33 total falls in January but the number of falls increased to 43 total falls in February. The risk manager was asked why there was an increase in total resident falls between January and February. She stated the facility had not performed a root cause analysis for falls. She stated she grafted the falls to see if certain staff or shifts were prone to have more falls occur. She stated the 2-10 shift had more falls due to some residents experiencing increased confusion in the evening. She asked what the nurse staffing patterns were for the facility. She stated she was not involved and could not answer that. She stated the facility used a lot of agency nursing staff, especially CNAs, to cover shifts and thought this contributed to the over-all increase in resident falls. The risk manager was asked to review the December 2021 falls for resident #2. She stated the resident was admitted to the facility after contracting COVID and was placed in isolation in a room with a poor view of the resident from the hall. She stated after the resident's first fall, the facility judged the resident's cognition was adequate for signage to be an appropriate intervention. She stated staff were to check on her at specific times, provide assistance with toileting and other activities of daily living. She stated after another fall involving the resident's independent use of a walker, therapy was asked to remove the walker from the room after each session. She stated other interventions added included use of non-skid footwear and a fall mat. The risk manager was asked to review the January 2022 fall for resident #2. She stated the intial fall in January appeared to be from over extending while reaching for personal items so the facility added an intervention to keep personal items within reach, including the resident's phone. She stated after the fall on the 12th, the resident was to be kept in the common areas for observation. She stated the fall on the 17th resulted in a trip to the hospital. She stated the fall occured in the resident's room where the resident was not very visible to the staff in the hall so the facility changed her room. She stated when the resident fell on [DATE], the resident should have been in the common area but instead fell in her room so staff involved were re-educated on the resident's fall interventions. She stated another fall occured on 01/25/22 and a ceiling tile reminding the resident to call for assistance was added to the resident's room. She stated when the resident fell on [DATE], the resident should have been in the common area but instead fell in her room so staff involved were re-educated on the resident's fall interventions. The risk manager stated the resident was kept in the common area in February and did not fall. She was asked to review the falls for March 2022 for resident #2. She stated the last two falls had occured late in the evening and the resident fell out of bed. She stated the facility requested bolsters from hospice. She stated after investigating the two falls, the facility determined the resident had returned to her room and bed too early and the staff was re-educated to keep the resident out in the common area for observation. She was asked when the bolsters were in place on the resident's bed. She stated her flowsheet documented the bolsters were in place on 03/18/22. She was asked where the bolsters were located. She stated she did not know and had not been to the resident's room. She stated the DON had ordered the bolsters from hospice but she did not know when they were received. She was asked about the one on one staffing at all times for resident #2 and where the documentation for one on one staffing would be located. She stated she did not recall the resident being placed on one on one staffing. She was asked if the resident had incurred a fall with major injury. She stated the resident fell and fractured her cervical vertebrae. On 03/28/22 at 5:28 p.m., MDS Coordinator #1 was asked about the intervention for one to one staffing at all times for resident #2. She stated the resident fell and broke her neck. She stated the facility had a fall meeting and staff were supposed to have eyes on the resident at all times. She stated the intervention to staff the resident one on one at all times was the only safe thing to do in her opinion. On 03/29/22, no bolsters were observed on the resident's bed. On 03/29/22 at 10:15 a.m., resident #2 was observed in the common area with her cervical collar in place. The resident was reclined back in a recliner. On 03/29/22 at 11:25 a.m., the resident was observed in her wheelchair in the dining room. On 03/29/22 at 11:25 a.m., LPN #2 was asked what frequent checks meant for a fall intervention. She stated frequent was vague and could mean anything. She stated they checked on all residents every two hours during rounds so frequently to her meant more often, in between rounds, maybe every hour. She was asked what the one on one at all times intervention meant. She stated typically if a resident was placed one on one, they would have a private sitter. She stated one on one meant that someone was physically with the resident at all times. She stated she had provided care to one on one residents in the past. She stated most of the residents determined to be a high fall risk were brought to the common area for observation and every two hours a CNA would reposition the resident and offer to toilet them. On 03/29/22 at 1:37 p.m., the Resident Care Director was asked if the resident had bolsters on her bed. She stated she knew the bolsters were delivered but did not see the bolsters on the resident's bed when she viewed the resident's room on 03/28/22 or 03/29/22. She stated she did not know where the bolsters were. She was asked why the there were so many resident falls in the facility. She stated the facility used a lot of agency staff and the agency staff did not know the residents and were not aware of their needs nor the care planned interventions. She stated while some agency staff constently worked in the facility, in general it was hard to provide consistency in care when agency staff were used. On 03/29/22 at 3:24 p.m., the administrator was informed of the Immediate Jeapardy determination. The administrator and DON were provided a verbal summation of the findings which resulted in the Immediate Jeapardy determination, including the intervention of one on one staffing which was not initiated. The administrator confirmed one on one staffing at all times was not initiated and asked if it were possible to remove the intervention from the care plan for resident #2. On 03/29/22 at 3:45 p.m., the risk manager was asked to provide all documentation related to falls for resident #2. No post fall evaluations were provided. On 03/29/22 at 4:10 p.m., a screen shot of the resident's updated care plan was provided to the surveyor. The screen shot documented the resident's intervention for one on one staffing at all times was marked as completed. The following interventions were added: the fall mat to be placed on the floor by the bed while the resident was in bed; the bolsters to be placed on the bed while resident was in bed for safety; the resident was to be in the common area while awake for frequent visual checks for safety; and toileting scheduled for upon rising, before and after meals, at bedtime, and as needed. On 03/30/22 at 10:30 a.m., the administrator and DON informed the surveyor resident #2 had fallen out of bed in the night. The DON stated staff performed one hour checks on the resident and the bolsters were in place on her bed. She stated despite these interventions, the resident still fell . On 03/30/22 at 12:30 p.m., the risk manager was interviewed. She stated if the incident report was [TRUNCATED]

Based on record review, observation, and interview, the facility failed to prevent the development of pressure ulcers nor provide the care to promote healing of pressure ulcers for one (#2) of three residents whose clinical records were reviewed for pressure ulcer care. The facility census and condition identified 14 residents with pressure ulcers. Findings: Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 11/18/21, documented the resident was always continent of bowel and bladder. The assessment documented the resident's skin was intact. The care plan, dated 12/07/21, documented the resident had the potential for impaired skin integrity and set a goal for her skin to remain intact, free of redness, blisters, and/or discoloration. The interventions included: to administer medications as ordered and monitor/document for effectiveness and side effects; to have a pressure reducing device for her chair and bed; to monitor her nutritional status, serve her diet as ordered, and monitor/record her intake; and to obtain and monitor lab and other diagnostic work as ordered, report the results of the diagnostic work, and follow up as indicated. The skin evaluation, dated 12/21/21, documented the resident had moist mucous membranes with warm, dry skin, and normal skin turgor. It also documented she had moisture associated skin damage and an area of slough on the right buttock measuring 1cm x 1cm x 0.5 cm. No clinical suggestions were documented. A general note attached to the skin evaluation documented, .Continues with Cast to LUE. No swelling noted. Open area to Right buttock measured at 1cm x 1cm x 0.1 new orders to apply [MEDICATION(S)] BID . The wound physician's progress note, dated 12/28/21, documented the resident had pressure ulcers on the sacrum and right buttock which had developed in the facility. The wound physician documented the modifying factors as weakness, congestive heart failure, left radius fracture, and metabolic [CONDITION(S)]. There was no documented treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The skin evaluation, dated 12/28/21, documented the resident had moist mucous membranes with warm, dry skin, and normal skin turgor. It also documented she had an unstageable pressure ulcer on the right buttock measuring 1cm x 0.6cm with a necrotic wound bed including adherent slough. Additionally, the evaluation documented an unstageable pressure ulcer in the sacral area measuring 0.5cm x 0.3cm with a necrotic wound bed including adherent slough. The clinical suggestions included to advise resident to frequently shift weight and raise buttocks while sitting in chair; to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; to administer as needed medications per order; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Continues with Cast to LUE. No swelling noted. [Name of Wound Physician's Group withheld] here to evaluated [sic] open areas to buttocks. New orders received to treat with [MEDICATION(S)] and change drsg every T [Tuesday], TH [Thursday], and sat [sic] [Saturday] . The treatment sheet, dated December 2021, documented the residents dressings to the right buttock and sacrum were changed on 12/30/21, a Thursday. The skin evaluation, dated 01/04/22, documented the resident had moist mucous membranes with warm, dry skin, and normal skin turgor. It also documented she had an unstageable pressure ulcer to the right buttock measuring 0.7cm x 0.5cm with slough for a wound bed. Additionally, the evaluation documented an unstageable pressure ulcer in the sacral area measuring 0.2cm x 0.2cm with slough for a wound bed. The clinical suggestions included to advise resident to frequently shift weight and raise buttocks while sitting in chair; to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; to administer as needed medications per order; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Continues with Cast to LUE. No swelling noted. [Name of Wound Physician Group withheld] here to evaluated [sic] open areas to buttocks. No new orders recieved [sic] areas are decreasing in size . The wound physician's progress note, dated 01/04/22, documented the resident had pressure ulcers on the sacrum and right buttock. The treatment ordered for both wounds was to cleanse with saline, to apply skin prep to the periwound, to apply [MEDICATION(S)] to the wound bed, to cover with a foam bordered dressing, and to change the dressing every Tuesday, Thursday, Saturday and as needed for soilage and saturation. The wound physician recommended a nutritional supplement twice daily and a low air loss mattress to aid in wound healing. The plan of care documented the two wounds were smaller and to continue [MEDICATION(S)] to debride the wound bed. The wound physician documented, .Acute complicated wounds due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment Educated on orders, etiology of wound, and importance of keeping patient re positioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean and dry. Expect wound to heal within 2-8 weeks . The skin evaluation, dated 01/11/22, documented the resident had moist mucous membranes with warm, dry skin, and normal skin turgor. It also documented she had an unstageable pressure ulcer to the right buttock measuring 0.5cm x 0.5cm with slough for a wound bed. Additionally, it documented an unstageable pressure ulcer in the sacral area measuring 0.2cm x 0.1cm with slough for a wound bed. The clinical suggestions included to advise resident to frequently shift weight and raise buttocks while sitting in chair; to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; to administer as needed medications per order; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Continues with Cast to LUE. No swelling noted. [Name of Wound Physician Group withheld] here to evaluated [sic] open areas to buttocks, Continues with current tx orders . The wound physician's progress note, dated 01/18/22, documented the pressure ulcer to the sacrum had resolved. The progress note also documented the resident had an unstageable pressure ulcer on the right buttock. The treatment ordered for the wound was to cleanse with saline, apply skin prep to the periwound, apply [MEDICATION(S)] to the wound bed, cover with a foam bordered dressing, and to change the dressing every Tuesday, Thursday, Saturday and as needed for soilage and saturation. The wound physician recommended a nutritional supplement twice daily and a low air loss mattress to aid in wound healing. The plan of care documented the two wounds were smaller and to continue [MEDICATION(S)] to debride the wound bed. The wound physician documented, .Acute complicated wounds due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment Educated on orders, etiology of wound, and importance of keeping patient re positioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean and dry. Expect wound to heal within 2-8 weeks . The skin evaluation, dated 01/19/22, documented the resident had moist mucous membranes with warm, dry skin, and normal skin turgor. It also documented the resident had an unstageable pressure ulcer to the right buttock measuring 0.3cm x 0.2cm with slough for a wound bed. The clinical suggestions included to advise resident to frequently shift weight and raise buttocks while sitting in chair; to perform dressing changes / treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; to administer as needed medications per order; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Continues with Cast to LUE. No swelling noted. [Name of Wound Physician Group withheld] evaluation area to sacral has resolved. Will continue tx to right buttock area has decreased in sized [sic] . The skin evaluation, dated 01/25/22, documented the resident had moist mucous membranes with warm, dry skin, and normal skin turgor. It also documented she had a stage II pressure ulcer on the right buttock measuring 0.3cm x 0.6cm x 0.1cm with slough in the wound bed. Additionally, it also documented a stage II pressure ulcer in the sacral area measuring 1.0cm x 1.0cm x 0.1cm with slough in the wound bed and maceration around the wound. The tissue was documented as painful. The clinical suggestions included to advise resident to frequently shift weight and raise buttocks while sitting in chair; to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; to administer as needed medications per order; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Patient continues to be seen by [Name of Wound Physician Group withheld] wound NP for areas to her bottom. New orders recieved [sic] to start [MEDICATION(S)] to wound bed every t. th, sat. No other skin issues noted at this time . The wound physician's progress note, dated 01/25/22, documented the pressure ulcer to the sacrum had reopened to a stage II. The progress note also documented the resident had stage II pressure ulcer on the right buttock which was previously smaller. The treatment ordered for both wounds was to cleanse with saline, apply skin prep to the periwound, apply [MEDICATION(S)] to the wound bed, cover with a foam bordered dressing, and to change the dressing every Tuesday, Thursday, Saturday and as needed for soilage and saturation. The wound physician documented the resident received a nutritional supplement twice daily and a low air loss mattress to aid in wound healing. The plan of care documented the two wounds were smaller and to continue [MEDICATION(S)] to debride the wound bed. The wound physician documented, .Chronic complicated wounds due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment Educated on orders, etiology of wound, and importance of keeping patient re positioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean and dry. Expect wound to heal within 2-8 weeks . An incident report, dated 01/25/22 at 4:00 p.m., documented an unwitnessed fall in the bedroom. The resident was sent to a local hospital ER for evaluation. The discharge summary for a local hospital, dated 01/27/22, documented the resident had a sacral decubitus ulcer on admission to the hospital and had sustained multiple neck fractures. The care plan, dated 01/27/22, documented the resident was to receive hospice services for end of life care and documented the goal would be for the resident's comfort would be maintained. The interventions included: to keep the environment quiet and calm; to keep linens clean, dry and wrinkle free; to keep the lighting low and familiar objects near; and to work with nursing staff to provide maximum comfort for the resident. The treatment sheet, dated January 2022, documented the right buttock dressing and sacrum dressing changes were performed every Tuesday, Thursday, and Saturday except 01/20/22 (a Thursday) and 01/27/22 (a Thursday). On 02/02/22, the resident was discharged from skilled therapy and placed on hospice. The skin evaluation, dated 02/02/22, documented the resident had dry mucous membranes and dry cracked, mottled skin with decreased turgor. It documented there was discoloration on the right side of the resident's face and on her left arm and hand. There was no further skin abnormalities documented and no documentation of the previous wounds. The clinical suggestions included to evaluate for pain and discomfort, to encourage resident to ask for assistance with ambulation, and to activate the facility's fall protocol. The wound physician's progress note, dated 02/08/22, documented the pressure ulcer to the sacrum had resolved. The progress note also documented the resident had a stage II pressure ulcer on the right buttock with a pink non granular wound bed. The progress note documented to apply triad cream twice daily to wound and leave open to air. A review of the treatment sheet for February 2022 documented triad cream was applied to the wound on the evening of 02/16/22 and the morning of 02/17/22. Per the treatment sheet, the order for dressing was started on 02/16/22, eight days after the ordered dressing for triad cream was received (02/08/22) and a day after receiving the order for skin prep to the periwound and [MEDICATION(S)] to the wound bed. The triad cream was discontinued after the morning application on 02/17/22. The skin evaluation, dated 02/09/22, documented the resident had dry mucous membranes and dry/cracked skin with decreased turgor. It documented there was discoloration on the right side of the resident's face and on her left arm and hand. The clinical suggestions included to evaluate for pain and discomfort, to encourage resident to ask for assistance with ambulation, and to activate the facility's fall protocol. A general note attached to the skin evaluation documented, Skin intact, continues with fading bruising to face . The care plan, dated 02/10/22, documented the resident had the potential for dehydration and had a goal to be free of symptoms of dehydration and maintain moist mucous membranes, and good skin turgor. The interventions included: to administer medications as ordered and monitor/document for their effectiveness and potential side effects; to monitor for, document, and report any signs or symptoms of dehydration, including: decreased urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakeness, dizziness, fever, thirst, recent/sudden weight loss, and dry/sunken eyes; and obtain and monitor lab and other diagnostic work as ordered, report the results, and follow up as indicated. The care plan also updated the skin integrity interventions to include: to administer treatments as ordered and monitor for effectiveness; to treat pain as per orders prior to treatment/turning etc. to ensure comfort; and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The skin evaluation, dated 02/15/22, documented the resident had dry mucous membranes and fragile skin with decreased turgor. It also documented a stage II pressure ulcer on the right buttock measuring 0.5cm x 0.5cm x 0.1cm with granulation in the wound bed, a clear watery discharge, and painful tissue. The clinical suggestions included to evaluate for pain and discomfort. A general note attached to the skin evaluation documented, .[Name of Wound Physician Group withheld] here resident evaluated has open area, new orders recieved [sic] . The wound physician's progress note, dated 02/15/22, documented the resident had a stage II pressure ulcer on the right buttock with a pink non granular wound bed. The progress note documented to cleanse wound with saline, apply skin prep to periwound, [MEDICATION(S)] to the wound bed and to cover wound with a bordered foam dressing. The care plan, dated 02/17/22, documented the resident was at risk for skin complications related to immobility and functional decline and set a goal for the resident not to have complications related to skin impairement. The interventions included: to administer/monitor/report medications, supplements, treatments as ordered and any resulting side effects; to avoid scratching and keep hands and body parts from excessive moisture; to keep the resident's nails short; to encourage good nutrition and hydration in order to promote healthier skin; to keep skin clean and dry and to use lotion on dry skin; to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces; and weekly skin assessment to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The skin evaluation, dated 02/22/22, documented the resident had dry mucous membranes and fragile skin with decreased turgor. It also documented a stage II pressure ulcer on the right buttock measuring 0.2cm x 0.3cm x 0.1cm with granulation in the wound bed and painful tissue. The clinical suggestions included to evaluate for pain and discomfort. A general note attached to the skin evaluation documented, .[Name of Wound Physician Group withheld] here new orders recieved [sic] to continue current tx orders area is smaller. No other skin issues recieved . The wound physician's progress note, dated 02/22/22, documented the resident had a stage II pressure ulcer on the right buttock with a pink non granular wound bed. The progress note documented to cleanse wound with saline, to apply skin prep to periwound and [MEDICATION(S)] to the wound bed and to cover wound with a bordered foam dressing every Tuesday/Thursday/Saturday and as needed for soilage and/or saturation. The wound physician documented, .Chronic complicated wounds due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment Educated on orders, etiology of wound, and importance of keeping patient re positioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean and dry. Expect wound to heal within 2-8 weeks . A review of the treatment sheet for February 2022 documented skin prep and [MEDICATION(S)] were applied to the peri wound and wound of the right gluteus on 02/19/22 (Saturday), 02/22/22 (Tuesday), and 02/24/22 (Thursday). There was no documentation the dressing was performed on 02/28/22 (Saturday). Per treatment sheet, the ordered dressing was started on 02/19/22 and discontinued on 03/08/22. The skin evaluation, dated 03/01/22, documented the resident had dry mucous membranes and fragile skin with decreased turgor. It also documented a stage III pressure ulcer on the left gluteal measuring 0.5cm x0.5cm x0.1cm with granulation in the wound bed, a clear watery discharge, and painful tissue. The clinical suggestions included to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Right gluteus wound has healed. Resident noted with left gluteal open area. [Name of Wound Physician Group withheld] assessed and new orders recieved [sic] . The wound physician's progress note, dated 03/01/22, documented the resident's pressure ulcer on the right buttock had resolved. The progress note documented a left stage III pressure ulcer located on the left gluteus was acquired on 03/01/22. The progress note documented to cleanse wound with saline, apply skin prep to periwound and [MEDICATION(S)] to the wound bed and to cover wound with a bordered foam dressing every Tuesday/Thursday/Saturday and as needed for soilage and/or saturation. The wound physician documented, .Acute complicated wound due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment .Ensure only 1 flat sheet the length of the bed and 1 disposable pad is used on LAL [low air loss] mattress and avoid cloth pads. Ensure LAL setting is appropriate for weight. Educated on orders, etiology of wound, and importance of keeping patient re positioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean and dry. Expect wound to heal within a few weeks/months. Potential to heal and plan to assess/treat complicating factors to healing (vascular, nutrition, glycemic control, infection, etc.): not diabetic, no S/S of infection, on supplements to assist in wound healing . The care plan, updated 03/05/22, documented the skin integrity interventions to include: nursing to ensure heel boots were in place every shift when in bed or in recliner and to ensure low air loss mattress was inflated and on the correct settings every shift. A review of the treatment sheet, dated March 2022, documented skin prep and [MEDICATION(S)] were applied to the peri wound and wound of the right gluteus on 03/01/22 (Tuesday), 03/03/22 (Thursday), and 03/05/22 (Saturday). There was no documentation the dressing was performed on 03/08/22 (Tuesday). Per treatment sheet, the ordered dressing was started on 02/19/22 and discontinued on 03/08/22, a week after the wound was documented as resolved. The March 2022 treatment sheet documented the resident's left gluteus dressing for skin prep to the peri edges and [MEDICATION(S)] to the wound bed daily was started on 03/09/22, a week after the acquired stage III pressure ulcer was assessed and orders for treatment received (03/01/22). The treatment sheet documented the resident was to receive weekly skin assessment from a licensed nurse to include measuring any open areas or non blanchable redness, every Sunday, starting 03/06/22 and discontinued 03/15/22. The treatment sheet documented the skin assessment was performed 03/13/22. There was no documentation the skin assessment was performed on 03/06/22. The wound physician's progress note, dated 03/08/22, documented an unstageable pressure ulcer on the resident's right gluteus was acquired on 03/08/22. Additionally, the progress note documented a left stage III pressure ulcer located on the left gluteus was acquired on 03/01/22. The progress note documented to cleanse wounds with saline, to apply skin prep to periwounds and [MEDICATION(S)] to the wound beds and to cover wounds with a bordered foam dressing every Tuesday/Thursday/Saturday and as needed for soilage and/or saturation. The wound physician documented, .R buttock wound is reopened - UPI - ordering [MEDICATION(S)] to help decrease bioburden. L buttock S3PI - unchanged - clarified orders; [MEDICATION(S)] to decrease bioburden. Acute complicated wound due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment .Ensure only 1 flat sheet the length of the bed and 1 disposable pad is used on LAL mattress and avoid cloth pads. Ensure LAL setting is appropriate for weight. Educated on wound care orders, etiology of wound, and importance of keeping patient re positioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean and dry. Expect wound to heal within a few weeks/months. Potential to heal and plan to assess/treat complicating factors to healing (vascular, nutrition, glycemic control, infection, etc.): not diabetic, no S/S of infection, on supplements to assist in wound healing . The skin evaluation, dated 03/09/22, documented the resident had dry mucous membranes and fragile skin with decreased turgor. It also documented a stage III pressure ulcer on the left gluteal measuring 0.5cm x0.5cm x0.1cm with granulation in the wound bed, a clear watery discharge, and painful tissue. Additionally, it documented an unstageable right gluteal wound measuring 0.3cm x 0.3cm with a necrotic wound bed and adherent slough. The clinical suggestions included to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Resident has 2 areas open on both buttocks. [Name of Wound Physician Group withheld] following, tx orders in place . The March 2022 treatment sheet documented the resident's right gluteus dressing for skin prep to the peri edges and [MEDICATION(S)] to the wound bed daily was started on 03/09/22. The skin evaluation, dated 03/13/22, documented the resident had dry mucous membranes and fragile skin with decreased turgor. It also documented a stage III pressure ulcer on the left gluteal measuring 0.5cm x0.5cm x0.1cm with granulation in the wound bed, a clear watery discharge, and painful tissue. Additionally, it documented an unstageable right gluteal wound measuring 0.3cm x 0.3cm with slough for a wound bed. The clinical suggestions included to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Resident has 2 areas open on both buttocks. [Name of Wound Physician Group withheld] following, tx orders in place . The skin evaluations for 03/09/22 and 03/13/22 were identical. The wound physician's progress note, dated 03/22/22, documented an unstageable pressure ulcer on the resident's right gluteus which increased in size from the previous assessment to 5.5cm x 2cm. Additionally, the progress note documented a left stage III pressure ulcer located on the left gluteus had increased in size to 0.5cm x 0.6cm and become an unstageable pressure ulcer. The progress note documented to change the dressings daily and to cleanse the wounds with saline, to apply skin prep to the periwound, to apply santyl to the wound bed, and to cover with a border foam dressing. The wound physician documented, .R buttock wound is larger - UPI - changing to santyl to help debride the wound bed. L buttock S3PI is larger and now UPI - changing to santyl to help debride the wound bed. Chronic complicated wounds due to etiology, comorbidities, nutrition, decreased mobility, incontinence, risk of infection or worsening of wound without proper treatment .Ensure only 1 flat sheet the length of the bed and 1 disposable pad is used on LAL mattress and avoid cloth pads. Ensure LAL setting is appropriate for weight. Educated on wound care orders, etiology of wound, and importance of keeping patient re positioned every 2 hours. Check patient frequently for incontinent episodes to keep skin clean and dry .Expect wound to heal within a few weeks / months. Potential to heal and plan to assess/treat complicating factors to healing (vascular, nutrition, glycemic control, infection, etc.): not diabetic, no S/S of infection, on supplements to assist in wound healing - nursing staff is now laying patient down in bed in-between meals - on LAL [mattress] . The skin evaluation, dated 03/23/22, documented the resident had dry mucous membranes and fragile skin with decreased turgor. It also documented a stage III pressure ulcer on the left gluteal measuring 0.5cm x0.5cm with a necrotic wound bed, a clear watery discharge, and painful tissue. Additionally, it documented an unstageable right gluteal wound measuring 5.5cm x 2.0cm with a necrotic wound bed, a clear watery discharge, and painful tissue. The clinical suggestions included to advise resident to frequently shift weight and raise buttocks while sitting in chair; to perform dressing changes/treatments as ordered; to turn, ambulate, move resident at least every 2 hours; to evaluate for pain and discomfort; and to add an informative task to the CNA charting. A general note attached to the skin evaluation documented, .Resident has 2 areas open on both buttocks Tx in place. [Name of Wound Physician Group withheld] following, W?C [sic] cushion in place and resident has LAL mattress . The March 2022 treatment sheet documented the resident's right and left gluteus dressings for skin prep to the peri edges and santyl to the wound beds daily were started on 03/24/22, two days after the wounds were assessed and wound treatment orders received (03/22/22). On 03/28/22 at 1:45 p.m., the resident was assisted to her room and bed by two CNAs. On 03/28/22 at 1:52 p.m., CNA #2 was asked what care was provided to resident #2. She stated the resident was assisted to bed and checked for incontinence. She stated the resident was dry. She stated the resident showered earlier in the day. At 1:52 the resident was observed in bed on her right side with quarter rails up and fall mat on floor. On 03/28/22 at 2:34 p.m., LPN #3 was asked what the resident's wounds looked like. She stated she did not know the resident had a wound. The LPN stated she normally worked weekends on the skilled floor and did not receive any information in report regarding the wound. On 03/28/22 at 2:48 p.m., the surveyor entered the resident's room with the Resident Care Coordinator. The coordinator was asked when the dressing was last changed. She stated she did not know the time but the day shift nurse had applied a clean dressing that morning. The coordinator pulled the resident's pants back to expose the buttocks. There was no dressings present. The coordinator stated, Well she doesn't have anything on it right now. She was asked how the facility monitored to ensure dressings were in place. She stated they did not have anyone checking behind the nurse to confirm the dressing was in place once the nurse charted the dressing completed. She stated the facility held the nurse responsible for the dressings they charted. On 03/28/22 at 2:52 p.m., LPN #3 was observed preparing to apply a new dressing for resident #2. The LPN was observed to gather supplies, including Santyl prescribed to another resident, and place the supplies on a tray before entering the resident's room. She was asked what was the facility protocol for medicated supplies. The LPN stated they were to use the medicated supplies specifically supplied to the resident. The Resident Care Coordinator entered the conversation and asked what was the concern. She was informed the Santyl in the med cup was prescribed to another resident. The coordinator stated she would call and reorder the Santyl from the pharmacy and cover the resident's wounds with a dry dressing to protect the area until the Santyl arrived. She was asked how long the resident went without the dressing. She stated she did not know but would contact the day shift nurse. LPN #3 was observed to close the privacy curtain, to move the wheelchair, to place the wound care tray on the bedside table and to move the table, and to raise the resident's bed. She was observed to wash her hands and to don gloves. She removed gauze from their packaging, opened border dressing, opened skin prep and normal saline. She then removed the resident's sweat pants and brief. She was asked the condition of the resident's brief. She stated she thought the resident was wet. She was asked if the sweat pants were wet. She stated no. She was asked if she was aware the resident did not have a dressing on. She stated no. She stated they just finished shift change and she did not receive the information in report. She was asked if the nurse aide who assisted the resident to bed had informed her there was no dressing in place over the resident's wounds. She stated no. She obtained peri wipes and performed per [TRUNCATED]

Based on observation, interview, and record review, it was determined the facility failed to implement correct hand hygiene infection control for one (#35) of five sampled residents reviewed for wound care. The facility facility wound flow sheet documented 14 residents had wounds. Findings: On 08/20/21 the medical record of resident #35 documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An assessment dated [DATE], documented the resident was moderately impaired for daily decision-making and had a stage two pressure ulcer on admission. The care plan, dated 08/20/21, documented the resident had a pressure ulcer on her left heel. The care plan documented the staff were to monitor the resident's nutritional status, complete wound care as ordered, and document weekly wound assessments. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/08/21 at 10:45 a.m., licensed practical nurse (LPN) #1 and #2 were observed performing wound care. LPN #1 prepared the wound care supplies on a clean field and washed her hands. LPN removed the soiled dressing from the left heel. Without changing her gloves the LPN washed the wound with soaked gauze. The LPN removed her gloves and without performing hand hygiene she applied clean gloves. The nurse applied the Santyl ointment and a dry. The LPN discarded the used supplies and washed her hands. On 10/08/21 at 10:50 a.m., the nurse was asked at what point in the wound care process was hand hygiene to be performed. The LPN stated hands should be sanitized when gloves were changed.

Based on interview and record review, the facility failed to notify the resident's physician of a decline in fluid intake and output for one (#1) of three residents reviewed for hydration. The facility identified 60 residents lived in the home. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The clinical admission evaluation, dated 03/10/21, documented the resident had mild impairment for decision-making, required cueing, could not obey commands, and had [CONDITION(S)]. The assessment documented the resident had weakness, flaccidity, paralysis, and was impaired on one side. The assessment documented the resident had a mechanically altered diet. The record documented the resident's urine was clear, she was incontinent, wore a brief, and had not urinary complaints. The record documented the resident's mucous membranes were dry and skin turgor was decreased. The baseline care plan, dated 03/10/21, documented the resident had difficulty communicating with staff, required one person assistance with eating, was at risk for swallowing and chewing problems, and was incontinent of bowel and bladder. The physician orders, dated 03/10/21, documented the resident was to receive a puree textured heart healthy diet with nectar thick fluids. Skilled nursing notes, dated 03/12/21 at 9:33 PM, documented the resident had scant urine output. The notes did not document the physician was notified. The intake records, dated 03/12/21, documented the resident drank a total of 260 milliliters of fluid for three shifts that day. Skilled nursing notes, dated 03/13/21 at 3:54 PM, documented the resident had decreased fluid intake. The notes did not document the physician was notified. The intake records, dated 03/13/21, did not document fluid intake for the three shifts that day. The intake records, dated 03/14/21, did not document fluid intake for the three shifts that day. The progress notes, dated 03/14/21 at 12:47 PM, documented the on call physician was notified of the resident's blood pressure and sustained elevated heart rate that morning but did not document the physician was notified fluid intake or urine output. The progress notes, dated 03/14/21 at 1:08 PM, documented the on call physician was notified of the resident's blood pressure and heart rate that morning but did not document the physician was notified of the resident's fluid intake or urine output. The skilled nursing notes, dated 03/14/21 at 1:26 PM, documented the resident was lethargic, fluids were encouraged, and urine was clear yellow. The physician orders, dated 03/14/21, documented the staff were to obtain a blood chemistry test and a a complete blood count test for the resident. A laboratory report, dated 3/15/21 at 4:08 AM, documented the ordered laboratory tests were obtained. The progress notes, dated 03/15/21 at 12:30 PM, documented the resident had not been alert and did not respond to stimuli. The note documented the resident would not eat and only drank three sip of mighty shake. The note documented the physician was notified and the resident was assessed by the physician. The note documented the resident was sent to the hospital via emergency services at 12:30 PM. On 05/05/21 at 2:14 PM, the resident's physician stated the staff did not notify her of the resident's poor fluid intake till the morning of 03/15/21. The physician stated had she been notified sooner she would have started intravenous fluids. The physician stated the resident's prognosis was very poor due to her extensive stroke and disease process.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff implemented the correct procedure for transmission based precautions for one (#21) of 24 residents reviewed for infection control. The facility identified one resident was on transmission based precautions. Findings: The facility policy and procedure for transmission based precautions documented a sign should be posted on the door, staff and visitors were to wear personal protective equipment (PPE) when entering an isolation room, remove PPE before exiting, and perform hand hygiene before exiting. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 04/10/19, identified the resident had [MEDICAL CONDITION] and was on contact isolation. The physician orders [REDACTED]. On 04/10/19 at 9:43 PM, the admission summary note documented the resident had diarrhea and an order for [REDACTED].>On 04/16/19 at 8:55 AM, the resident was sitting in his room eating breakfast. The resident was clean, dry, and had no odors. On 04/16/19 at 9:25 AM, the unit coordinator was interviewed regarding an isolation cart outside the resident's room. The unit coordinator stated the resident was on isolation and a sign should have been on posted on the resident's door. On 04/16/19 at 12:25 PM, certified nurse aide (CNA) #1 was observed taking a styrofoam tray into the resident's room. CNA #1 did not put on PPE prior to entering the resident's room. CNA #1 moved the bedside table, placed the resident's tray on the table, and exited the room. CNA #1 did not wash her hands prior to exiting the room. On 04/16/19 at 12:30 PM, CNA #1 was interviewed regarding isolation and PPE. CNA #1 stated PPE was not required if staff walk into the resident's room, place the resident's food tray down, and did not touch anything. The admission assessment, dated 04/17/19, documented the resident was independent for daily decision making. The assessment documented the resident required extensive assistance with one person for toileting. The assessment documented the resident was continent of bowel and bladder. The assessment documented the resident was on isolation. On 04/23/19 at 9:05 AM, a nursing student was observed sitting in the resident's room. The nursing student was not wearing any form of PPE. 0n 04/23/19 at 10:00 AM, LPN #1 stated when a resident was placed on contact isolation the staff were required to apply PPE before entering a isolation room and remove it before leaving.

Based on observation, interview, and record review, it was determined the facility failed to monitor intake and output (I&O) for one (#9) of 24 sampled residents reviewed for I&O. The facility identified nine residents with intake and output monitoring lived in the facility. Findings: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The quarterly assessment, dated 01/14/19, documented the resident was independent for daily decision making and required extensive assistance with the activities of daily living (ADLs). The assessment documented the resident was on a weight gain regimen and received a diuretic. Physician orders [REDACTED]. The care plan, dated 01/24/19, documented the resident was on a 1500 ml fluid restriction and staff were to obtain weights as ordered. The treatment administration record (TAR) for (MONTH) 2019 documented I&O was checked off for monitoring but no intake or output values were documented. The daily I&O sheets in the resident's room were incomplete and were not totaled. On 04/18/19 at 2:40 PM, licensed practical nurse (LPN) #2 stated she totaled the I&Os at the end of the shift to see if the intake was within the fluid restriction range but did not document the amounts in the resident's record. She stated some nurses document the intake and output values in the nurse notes. On 04/18/19 at 2:45 PM, the director of nurses (DON) was interviewed regarding I&O monitoring. The DON stated residents on fluid restrictions, catheters, and tube feedings were to be on I&O and total amounts should be documented.