Every finding on record at Vaiden Community Living Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was free from accident hazards during a transfer using a mechanical lift which resulted in a fall with major injury for one (1) of three (3) residents reviewed for falls. Resident #2Findings Include: Review of the facility policy Transfer of Resident with Mechanical Lift Procedure revealed that the purpose is To provide resident safety with transfers .Procedure: 1. Two people should assist in transfer involved in resident being lifted via Hoyer Lift . On 08/17/26 at 10:00 AM an interview conducted with the Administrator (ADM) revealed that on 08/15/26, nursing staff observed swelling and bruising to Resident #2's right leg, foot, and ankle and sent her to the hospital for further evaluation. ADM reported that X-rays were ordered and completed, which revealed fractures. She stated that Resident #2 was determined not to be a surgical candidate and returned to the facility. ADM reported that, during the facility's investigation, staff interviews revealed that on the morning of 08/13/26, Certified Nursing Assistant (CNA) #1 attempted to transfer Resident #2 using a total body lift without assistance, during which Resident #2 fell. The ADM reported that CNA #1 initially stated on 08/15/26 that she had lifted Resident #2 from the bed and the lift began swaying, at which point she lowered the resident to the floor. ADM stated that CNA #1 later reported that while transferring Resident #2 with the total body lift, the lift began swaying, causing the resident's body to strike the side of the chair, the lift then tilted and Resident #2 fell to the floor with CNA there trying to protect her from injury. ADM stated that it was not acceptable practice for one CNA to perform a transfer using a total body lift without assistance and reported that CNA #1 was suspended. She further stated that she was not aware of the full circumstances surrounding the incident until after conducting interviews with other staff members, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), Registered Nurse (RN) Supervisor, and RN #2. ADM agreed that CNA #1 used poor judgment and stated that had Resident #2 been transferred appropriately using the total body lift with the required assistance, the fall could have been prevented, and Resident #2 would not have experienced the resulting injury.An interview on 08/17/26 at 10:20 AM with CNA #1 revealed that on 08/13/26, she used a total body lift without assistance to transfer Resident #2 from the bed to her chair. CNA #1 stated that she made the decision to proceed with the transfer without help. CNA #1 reported that she lifted Resident #2 from the bed and, when she turned to position the resident in the chair, the sling began swaying and the lift tilted, causing Resident #2's body to strike the chair. CNA #1 stated that she then grabbed Resident #2 and lowered her to the floor while attempting to protect the resident's head. CNA #1 reported that RN #2 entered the room shortly after the fall and called for assistance. CNA #1 acknowledged that she knew a resident should not be transferred using a lift without assistance and stated that her failure to follow facility protocol resulted in Resident #2's fall. CNA #1 confirmed that two staff members should always be present when transferring a resident using a lift and acknowledged that she should have waited for assistance before transferring Resident #2.An observation on 08/17/26 at 10:40 AM revealed Resident #2 lying in bed with her right leg and foot rotated inward, with her great toe touching the bed sheet. Light purple bruising was observed to the resident's right foot and ankle, as well as bruising to the plantar surfaces of both feet.An interview on 08/17/26 at 1:00 PM with RN #2 revealed that she was working on the medication cart on 08/13/26. RN #2 stated that at approximately 8:30 AM, she entered Resident #2's room and observed the resident lying on the floor on her right side with CNA #1 present. RN #2 reported that CNA #1 was bent over Resident #2, holding the resident's head off the floor, and CNA #1 stated, She fell. RN #2 revealed that she recognized there was a concern when she observed only one staff member present, a Hoyer lift in the room, and Resident #2 on the floor. RN #2 reported that she immediately went into the hallway and called for assistance. She revealed that the DON, ADON, and RN Supervisor entered the room promptly to assist, and RN #2 returned to the medication cart. RN #2 confirmed that two staff members should always assist with a transfer when a lift is required. She stated that failure to have the required assistance contributed to Resident #2's fall and resulting injury. RN #2 reported that Resident #2 was not immediately sent to the hospital following the incident. She stated that on 08/15/26, after bruising and swelling were identified, Resident #2 was sent to the hospital, where X-rays revealed fractures. RN #2 expressed concern for Resident #2 and stated, This never should have happened.On 08/17/26 at 2:35 PM an interview with the DON revealed that on 08/13/26, she was called to Resident #2's room by RN #2. The DON stated that upon entering the room, she observed Resident #2 lying on the floor on her right side with CNA #1 present. The DON reported that CNA #1 stated that Resident #2 had been on the lift when it began to sway and that she lowered the resident to the floor. DON reported that the ADON and RN Supervisor were also present and assessed Resident #2 with no injuries identified at that time. DON stated that Resident #2 was assisted from the floor into her Geri chair and continued to be monitored. The DON confirmed that she did not initially consider the incident to be a fall. She stated that CNA #1 had transferred Resident #2 using a total lift without a second staff member present. DON revealed that on Saturday, 08/15/26, RN #3 notified her after observing bruising and swelling to Resident #2's right leg, foot, and ankle and Resident #2 was sent to the hospital, where X-rays were completed and fractures were identified. DON confirmed that two staff members should always be present when transferring a resident using a lift and acknowledged that the absence of a second staff member contributed to the fall and that the resulting injury could have been prevented. The DON expressed concern regarding Resident #2's condition and confirmed that the resident experienced pain following the injury and was no longer able to get out of bed and sit in her chair due to the fracture.A telephone interview conducted on 08/18/26 at 11:40 AM with RN #3 revealed that on 08/15/26, while CNAs were providing Resident #2's morning care, they called RN #3 to the room. RN #3 reported observing swelling to Resident #2's right thigh, with the right leg rotated inward toward the opposite foot and the toes nearly touching the mattress. RN #3 stated that when she touched the resident's thigh, Resident #2 grimaced and moaned. RN #3 stated, It was evident that it was broken. RN #3 revealed that she also observed significant bruising to Resident #2's right foot and ankle. She reported the findings to the nurse practitioner and received an order to send Resident #2 to the hospital for further evaluation. RN #3 stated that she knew Resident #2 had not been out of bed that morning and recognized that there was an obvious injury. An interview conducted on 08/18/26 at 1:10 PM with Resident #4, who is the roommate of Resident #2, revealed that she witnessed Resident #2's fall. Resident #4 reported that a CNA entered the room and attempted to transfer Resident #2 into her chair using a total body lift. Resident #4 stated that the CNA lifted Resident #2 into the air but not high enough to clear the chair. She reported that the CNA then used her hands underneath Resident #2's body in an attempt to swing and position the resident into the chair, during which Resident #2's body struck the chair. Resident #4 reported that the lift began rocking back and forth, tilted over and the CNA went to the floor with Resident #2. Resident #4 expressed concern regarding the incident and stated that it was sad and should not have happened.Record review of Resident #2's Progress Notes, with an effective date of 08/15/26 at 10:17 AM, revealed the following: Edema and bruising to right leg reported to RN supervisor by CNA during personal care this am. Patient noted lying supine in bed with edema to upper right thigh and hip. Adduction and bruising noted to right foot and ankle. Pt unable to move extremity and displays nonverbal signs of pain such as grimacing and moaning when leg is touched Received orders to transport patient to hospital via ambulance for further evaluation and treatment Record review of Resident #2's Emergency Department (ED) Provider Notes dated 08/15/26 revealed the final X-ray results documented: 1. Acute subtrochanteric fracture with varus angulation of the distal segment. 2. Suspected fracture of the right superior pubic ramus without clear companion fracture.Record review of Resident #2's admission Record revealed an original admission date of 09/03/25 and diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, and Dysphagia. Record review of Resident #2's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/26, revealed a Brief Interview for Mental Status (BIMS) score of 04 under Section C, indicating severe cognitive impairment.Record review of Resident #2's Task List Report revealed the following transfer requirement: Bed-to Chair Transfer: Transfer x 2 (times two) staff using total body lift r/t (related to) Right Hemiparesis.Record review of Resident #2's Mechanical Lift Evaluation dated 01/05/26 revealed that Resident #2 required use of a total body lift for transfers, with the number of staff required to perform the transfer documented as two.

Based on staff and resident representative (RR) interviews, observations, record review, and facility policy review the facility failed to ensure the resident representative was immediately notified of an accident involving a resident that resulted in a major injury for one (1) of three (3) residents reviewed. Resident #2.Findings Include:Review of the facility policy Residents Rights and Quality of Life Policy and Procedure revealed .A resident has the right to be fully informed of his or her health status and medical condition .An interview conducted on 08/17/26 at 10:00 AM with the Administrator (ADM) revealed that on 08/15/26, nursing staff observed swelling and bruising to Resident #2's right leg, foot, and ankle and sent her to the hospital for further evaluation. ADM reported that X-rays were ordered and completed, which revealed fractures. ADM reported that, during the facility's investigation, staff interviews revealed that on the morning of 08/13/26, Certified Nursing Assistant (CNA) #1 attempted to transfer Resident #2 using a total body lift without assistance, during which Resident #2 fell. ADM stated that CNA #1 stated that while transferring Resident #2 with the total body lift, the lift began swaying, causing the resident's body to strike the side of the chair, the lift tilted and Resident #2 fell to the floor with CNA there trying to protect her from injury. ADM stated that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were immediately notified and when the resident was found on the floor with a total body lift involved and only one staff member present that Resident #2's Resident Representative (RR) should have been notified of the fall. An observation and interview on 08/17/26 at 10:30 AM revealed Resident #2 lying in bed with her right leg and foot rotated inward, with her great toe touching the bed sheet. Light purple bruising was observed to the resident's right foot and ankle, as well as the bottoms of both feet. Resident #2's RR and another daughter were present at the bedside. During the interview, RR reported that she had visited Resident #2 on Thursday, 08/13/26, and noticed that the resident's color appeared abnormal and that she was not feeling well. The RR stated that at approximately 11:00 AM, a nurse checked Resident #2's blood pressure, which was low. They assisted Resident #2 in bed with her feet elevated, and RR reported that the resident's blood pressure improved. RR reported that on Friday afternoon, 08/14/26, she arrived at the facility to assist with feeding Resident #2. RR revealed that while assisting a Certified Nursing Assistant (CNA) with changing the resident, Resident #2 yelled out. She stated that Resident #2 had been nonverbal since experiencing a stroke and was unable to communicate what was causing her distress. RR reported that on Saturday morning, 08/15/26, she received a telephone call from the facility informing her that Resident #2 was being sent to the hospital for X-rays due to swelling and bruising of her right leg. RR stated that the X-rays revealed a fractured hip. Following further evaluation and discussion with the physicians at the hospital, RR reported that Resident #2 was determined not to be a surgical candidate due to her baseline bedbound status and she returned to the facility. RR revealed that the DON also contacted her by telephone on Saturday, 08/15/26, she was apologizing but did not provide an explanation regarding how the injury occurred. RR stated, We never were told anything. During the interview, RR also reported that she spoke with Resident #2's roommate who stated she witnessed the incident that involved a CNA and a mechanical lift. RR stated, I realize freak accidents can happen and expressed that not knowing what happened is frustrating. An interview on 08/17/26 at 2:35 PM with DON revealed that on 08/13/26, she was called to Resident #2's room by RN #2. The DON stated that upon entering the room, she observed Resident #2 lying on the floor on her right side with CNA #1 present. DON reported that CNA #1 stated that Resident #2 had been on the lift when it began to sway and that she lowered the resident to the floor. DON reported that ADON and Registered Nurse (RN) Supervisor were present and assessed Resident #2 with no injuries identified at that time. DON stated that Resident #2 was assisted from the floor into her Geri chair and continued to be monitored. DON also confirmed that she had not reported the fall incident to Resident #2's RR and stated that she should have notified them after the fall. DON also revealed that Resident #2 was sent out to the hospital on Saturday, 08/15/26, had x-rays done and was found to have a hip/pelvic fracture.Record review of Resident #2's Progress Note with effective date of 08/13/26 completed by DON was documented, LATE ENTRY: RN entered room and found resident lying in the floor on her right side with lift sling under her. ROM (Range of Motion) provided to R (right) ankle and foot. No S&S (Signes and Symptoms) of discomfort, no skin alterations, no bruising or edema noted. Resident assisted up to chair. VS (Vital Signs) obtained. This note was electronically signed by DON and there was no mention in Progress Note that Resident #2's RR was notified of the fall. Record review of Resident #2's Emergency Department (ED) Provider Notes dated 08/15/26 revealed the final X-ray results documented: 1. Acute subtrochanteric fracture with varus angulation of the distal segment. 2. Suspected fracture of the right superior pubic ramus without clear companion fracture.Record review of Resident #2's admission Record revealed an original admission date of 09/03/25 and diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, and Dysphagia. Record review of Resident #2's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/26, revealed a Brief Interview for Mental Status (BIMS) score of 04 under Section C, indicating severe cognitive impairment.

Based on observation and staff interview, the facility failed to store and serve food in accordance with professional standards for food service safety related to food items improperly stored, a dry bin left uncovered and food prepared and served in unsanitary conditions for two (2) of (2) kitchen observations.Findings Include:On 06/28/2026 at 12:12 PM, an initial tour with [NAME] #1, revealed [NAME] #2 placing a tray of sandwiches in a refrigerator. One of the sandwiches fell from the tray and landed on the floor. [NAME] #2 picked up the sandwich and placed it back on the tray of sandwiches. An observation of the food prep station revealed a pan of raw chicken sitting on the table with the lid to a jar of seasoning sitting top side down, on top of the chicken. [NAME] #2 picked up the lid and proceeded to season the chicken. An observation of the dry bins revealed the lid to the sugar was not completely on the bin, leaving the sugar exposed. An observation of the pantry revealed five (5) loaves of rye bread, boxed and sitting on a shelf, with green bio growth covering the bread. A review of the manufactures box revealed the instructions Best if used by 04/22/2027 and Keep Frozen and six containers of Ham Base with manufacturer's instructions to Keep Refrigerated for Best Quality. An interview with [NAME] #1 revealed she knows the lid to the sugar should have been securely placed on the bin to prevent something from falling into the sugar or a bug from getting in the sugar. [NAME] #1 stated the bread was bought for a one-time meal, and they did not know it was supposed to be frozen. [NAME] #1 stated the kitchen staff have always kept the Ham Base on the pantry shelf because the instructions Refrigerate for Best Quality was viewed as a suggestion. [NAME] #1 affirmed that food in the kitchen is supposed to be covered and unspoiled to prevent the residents from eating contaminated food. An interview with [NAME] #2 revealed she recalled dropping the sandwich and placing it back on the tray with the other sandwiches. [NAME] #2 further stated that she recalled leaving the lid to the seasoning sitting on top of raw chicken. [NAME] #2 affirmed that she should have thrown the sandwich away after picking it up. [NAME] #2 stated that she should not have placed the seasoning lid on top of the chicken. [NAME] #2 confirmed that in both cases there is a risk of contamination of the food. [NAME] #2 reported that another cook could come along and touch that seasoning lid and will then have residue from the raw chicken on their hands, which would have been carried to other parts of the kitchen.On 06/29/2026 at 10:34 AM, during a second visit to the kitchen, an observation of [NAME] #3 setting up food on the hot bar revealed a fly landing on the spaghetti with meat sauce. [NAME] #3 took a serving spoon, gauged where she thought the fly landed and scooped some of the sauce from the pan. [NAME] #3 proceeded to serve the spaghetti with meat sauce. An interview with [NAME] #3 revealed she continued serving the spaghetti with meat sauce because she did not have anything else to serve. [NAME] #3 stated she should have placed a lid on dish prior to walking away. [NAME] #3 noted that the hazard of having a fly in the food is that it could spread illness and could have laid eggs in the food.On 06/29/2026 at 2:15 PM, an interview with the Administrator revealed she was made aware of the poorly stored food bread and Ham Base, exposed sugar, the seasoning lid on the raw chicken, the sandwich picked up from the floor and place back with the other sandwiches and the fly in the Spaghetti with meat sauce. The Administrator stated the hazards of these deficiencies can cause people to become sick. The Administrator noted the cook should have covered the food immediately when she placed it on the holding table. The Administrator affirmed that she should have thrown the food out once the fly was in the spaghetti with meat sauce. The Administrator noted she expects the staff to double-check dry bins when using them to make sure they are closed securely. The Administrator stated she expects the staff to pay attention and read the storage instructions on food packages.

Based on observation, interview, record review, and facility policy review, the facility failed to provide reasonable accommodation for a visually impaired resident by failing to consistently ensure access to a call system that accommodated the resident's disability after identifying the need and receiving complaints from both the resident and the Resident Representative (RR) for one (1) of (15) sampled residents. Resident #43.Findings Include: A record review of the facility policy Resident Rights revised and implemented on November 28,2016, revealed, .The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. On 06/28/2026 at 1:05 PM, during an observation and interview with Resident#43 and the his wife, revealed that the staff hides his call light, often placing it out of his reach. His wife states she made a complaint last week to the facility, but nothing has improved with the call light placement. She noted Resident #43 is blind and has a hard time calling out. At this time Resident # 43's call light was observed to be tied at his right side on the bedrail. On 06/29/2026 at 11:42 AM, the Physical Therapist (PT) was observed in the resident's room adjusting Resident # 43's call light. The PT noted that the call light was wrapped around his bed rail to his right and Resident #43 asked where it was because he couldn't reach it or feel where it was in his bed. The PT then moved the call light to Resident 43's chest and attached it with a clip to his sheet and told him to make sure to tell the aids to place it there, because sometimes she is not sure that he feels it where it is at his side. An interview with the PT at 12:05 PM on 6/29/26, revealed the resident was admitted on [DATE] and first evaluated by therapy on 6/20/26. She noted that the call light in this instance is recommended by therapy to be clipped to Resident # 43's chest because he can use the call light, but he has a hard time finding it when the Certified Nursing Assistants (CNA's) or other staff leave it wrapped on the bed rail, but that is how they are trained to leave it in each room. She noted that the resident has a strong voice and can yell out to get staff and she can hear him from the nearby PT room as she's observed since he's been here but agreed that the resident shouldn't have to do that to get staff in his room. She noted that the facility can get easy type call systems, but the problem with those is they have a likelihood of being pushed by accident resulting in erroneous calls to the nursing station. The PT stated that Occupational Therapy (OT) handles the referrals for call systems like that and did not recommend one on the first assessment. An interview with the Certified Occupational Therapy Assistant (COTA) on 6/29/26 at 12:20 PM, revealed the resident was deemed to be able to manipulate a call light with his right hand, but noted the resident is blind and does have deficits in his left hand making it difficult for him to locate it when it is tied and left on the right bedside rail as has been noted to be done by CNA's. He stated that the facility can order easy type call systems but has not tried one to see if it makes calling out easier for the resident. He also shared that the call light is preferred to be left clipped to the resident's gown or sheet on his chest so he can located it, but noted that staff would be more likely to leave an easy call system on his chest because it doesn't have to be clipped and can simply rest on his chest and he could set it off easier because it only has to be bumped to notify staff. An interview with Licensed Practical Nurse (LPN) #1 on 6/29/26 at 1:28 PM, she stated that most of the time when she comes into the resident' s room the call light is on his chest but at times it is lying next to him. She stated he can reach it if it's on his right side, but not if it's on the left but she stated at times it gets hidden in his bed linens and he gets frustrated and yells out Nurse, Nurse and she comes back to check on him and adjusts the call light to place on his chest again with a clip. She noted that he is blind and in a new environment and likely cannot always feel where the light is and that he would likely benefit from an easy call system that could be laid on his chest and not lost so easily. She further stated that she was unsure why it hadn't been tried yet but had noted that the process to get it started would be that she could ask the charge nurse or Minimum Data Set (MDS) nurse to get it for the resident. An interview with the Director of Nursing (DON) at 2:31 PM, on 6/29/26 revealed the resident had been discussed recently in interdisciplinary meetings with PT and OT and they decided against it due to the fact that they thought he could use the light when he had the light in his hand and easily accessible and an easy call light system could fall off of his chest and ring the nurse's station. She noted that residents shouldn't have to yell out if the call light is working and she stated that complications of not having an adequate call system that meets resident needs based on disability could be delays in receiving care. A record review of the admission Record revealed Resident #43 was admitted on [DATE] with diagnoses that included pneumonitis. A record review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/25/26 revealed a Brief Interview for Mental Status (BIMS) score of (7) which indicated the resident had severe cognitive impairment. A record review of the .Smoking and Safety assessment section dated 6/19/2026 revealed the resident had poor vision or blindness.

Based on interview, record review and facility policy review the facility failed to ensure residents were afforded consistent monthly Resident Council meetings for one (1) of six (6) months reviewed. May 2026.Findings include:A review of the facility's policy, Resident Council, Reviewed 07/24/2023, revealed, .The facility supports residents' rights to organize and participate in the resident council. Policy Interpretation and Implementation.5. Council meetings are scheduled monthly.A review of the Resident Council Minutes for the previous six (6) months revealed the minutes dated 5/12/26 indicated Nursing Home Week No Meeting written across the form. On 06/29/2026 at 1:00 PM, during a Resident Council meeting Residents #26, who is the Resident Council President and Resident #49 reported the meeting for May 2026 was cancelled by the Activities Director (AD). The residents affirmed that the Resident Council members did not initiate the cancelation of the May 2026 meeting, but they were told by the AD that the meeting was cancelled due to it being Nursing Home Week. The residents stated they were not offered a rescheduled meeting for that month.On 06/29/2026 at 2:05 PM, an interview with the AD revealed the May 2026 meeting was canceled because it was Nursing Home Week. The AD stated that she asked the residents if they wanted to cancel the meeting because it was Nursing Home Week. The Activities Director affirmed that she is the one who initiated canceling the meeting. The AD noted that she made no offer to reschedule the meeting within the month of May. The AD stated that she understood that her choice of words may have led the residents to believe she was simply canceling the meeting, and they had no real choice in the matter. The Activities Director confirmed that she should have just had the meeting when it was scheduled. On 06/30/2026 at 9:10 AM, an interview with the Administrator revealed that the Resident Council Meeting belongs to the residents and it should not be canceled to accommodate another event. The Administrator stated that the Activities Director had the option of rescheduling the meeting. The Administrator confirmed that she expects the Resident Council Meeting to occur as scheduled or rescheduled with the authority of the Resident Council members.Resident #26A record review of the facility's admission Record revealed the facility admitted resident #26 on 06/10/2025 with diagnoses including Parkinson's disease with dyskinesia, with fluctuations.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/2025 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of (15) indicating the resident was cognitively intact.Resident #49 A record review of the facility's admission Record revealed the facility admitted Resident #49 on 09/09/2025 with diagnoses including heart failure.A record review of the Quarterly MDS with an ARD of 06/10/2026 revealed the resident had a BIMS score of (15) indicating cognitively intact.

Based on interview, record review and facility policy review, the facility failed to ensure that appropriate medical evaluations were conducted in accordance with the physician orders, specifically failing to perform the necessary Hemoglobin (HbA1c) test for one (1) of (15) sampled Residents. Resident #3.Findings include: A record review of the facility policy Physicians Orders, dated 4/13/21, revealed, Policy Statement: It is the policy of this facility that resident's medication and treatments are ordered by a licensed physician or other licensed health care professional as permitted by state law Physicians' orders are carried out . During an interview with the Director of Nursing on 6/30/26 at 9:05 AM, she emphasized that getting blood work done on time is crucial for keeping residents safe from chemical imbalances and dangerous drug reactions. She admitted she was aware that Resident #3 missed a scheduled HbA1c blood sugar test in April. She explained that regular tracking is vital to make sure the resident's kidneys are functioning properly, warning that skipping these routine tests can lead to serious health complications.A record review of the facility's admission Record revealed the facility admitted the resident on 07/19/2023 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia.A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2026 revealed the Resident #3 had a Brief Interview Mental Score (BIMS) of (15) indicating the resident is cognitively intact.A record review of the Order Summary Report revealed an order dated 2/11/25 .Hemoglobin (HGA1C) every three months (Q3) January, April, July, and October.A record review of the clinical record revealed there was no documentation that the physician ordered Hemoglobin A1c scheduled for April 2026 was obtained.

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices by failing to perform hand hygiene between glove changes during wound care for one (1) of (1) resident observed for wound care. Resident #47.Findings include:A review of the facility policy Hand Hygiene Policy and Procedure dated 12/2025 revealed, Policy: Hand Hygiene will be performed by all staff consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination.At 11:27 AM on 6/30/26, Resident #47 was observed for wound care provided by Registered Nurse (RN) #1. RN#1 removed the resident's shoe and sock while wearing gloves and revealed a right foot wound with no dressing in place. She then removed her gloves, applied new ones and cleansed the wound bed without performing hand hygiene. She then removed her gloves again and applied new ones without performing hand hygiene and applied a clean dry dressing.An interview with RN # 1 at 11:54 AM on 6/30/26, she confirmed that she did not perform hand hygiene between glove changes during care. She stated the reason why was she was not sure if she could leave the room to get hand sanitizer after she had applied her gown due to cross-contamination concerns. She stated that changing gloves does not negate the need to perform hand hygiene to remove contaminants from the hands and prevent infection spreading to other residents or cross contamination.An interview with the Director of Nursing (DON) at 11:56 AM on 6/30/26, revealed her expectation of staff is that they will perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) infection prevention guidelines to prevent infection spreading among residents from staff members. She noted that in this instance the nurse should have cleansed her hands each time gloves were removed during care and once it was completed. She noted that complications of not cleansing hands according to CDC guidelines can result in wound infection including sepsis for the residents.A record review of resident # 47's Order Listing Report revealed an order dated 6/19/26, Wound care: clean right plantar foot with wound cleanser, pat dry, apply collagen to wound bed, cover with border gauze dailyA record review of the admission Record revealed Resident #47 was admitted on [DATE] with diagnoses that included chronic diastolic congestive heart failure.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/26 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of (13) which indicated the resident was cognitively intact.

Based on record review, interview, and facility policy review the facility failed to provide written notice of an involuntary discharge including appeal rights prior to refusing readmission from the hospital for one (1) of three (3) resident reviewed. (Resident #1). Findings Included:Record review of the facility policy titled, Transfer Form, revealed Policy Statement, It is the policy of this facility to provide a completed and accurate transfer form to residents transferred or discharged from this facility .Record review of the facility policy titled, Appealing a Transfer or Discharge Notice revealed Policy Statement, Residenta have the right to appeal transfer or discharge notices.2. Upon notice of transfer or discharge, the resident will be provided with a statement of his or her right to appeal the transfer or discharge.Record review of Progress Notes dated 12/31/25, revealed Resident #1 left the facility at 2:30 PM by facility van to be admitted to [Proper name for psychiatric hospital] for evaluation.Record review of Progress Notes for Resident #1, dated 1/6/26, revealed resident had been discharged from the facility due to aggressive behavior. Further review revealed per conversation with [Proper name for psychiatric hospital], the Administrator and Social Services Director would assist in finding placement for the resident as well as home health if needed. Documentation further indicated that due to threats made, the facility stated it was unable to meet the resident's needs.Record review of Progress Notes for Resident #1, dated 1/6/26, revealed the facility communicated with the resident's family regarding not allowing the resident to return to the facility.Record review of Progress Notes for Resident #1, dated 1/6/26, and interview with the Administrator on 03/24/26 at 10:00 AM, revealed she spoke with the Geri-psych facility on 01/06/26, and they agreed to assist with finding the resident alternative placement. The Administrator revealed she spoke with the resident's family and informed them the resident would not be able to return to the facility. The Administrator verified that the resident and family were not provided a formal involuntary discharge notice and were not provided rights to appeal. The Administrator further verified she could not locate a physician order for discharge. The Administrator stated the formal notice and right to appeal should have been provided and the facility should have obtained a physician order prior to discharge.Record review of the admission Record revealed that the facility admitted Resident #1 on 12/14/21 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the safety of one (1) of four (4) residents reviewed for safe transport (Resident #1), when staff failed to secure the resident's wheelchair with the appropriate safety belts while being transported in the facility van. This failure resulted in the resident sustaining a sternal fracture and a head laceration with bleeding after her unsecured wheelchair tipped over during transport, causing her to fall to the floor of the van. Resident #1 Due to corrective actions implemented prior to State Agency (SA) entrance on 6/18/25, this was determined to be Past Non-Compliance as of 4/30/25. Findings Include: Review of the facility policy titled How to Properly Secure a Wheelchair for Transportation signed and dated by Certified Nurse Assistant (CNA) #1 on 01/03/2025 read . Wheelchair securement systems allow the wheelchair user to drive or ride in a vehicle as safely as anyone else. Securement systems lock the wheelchair in place either with tie-down straps or a mechanical docking device. Securement systems are primarily used in wheelchair accessible vans to safely secure the user in his power chair or wheelchair while the vehicle is in motion. The policy contains a picture diagram of the lap and cross body safety belts and the floor anchorages and pictured the proper way to fasten the residents in the van.´ The policy included diagrammed instructions for securing residents in the van. Review of the facility policy titled Fleet Safety Policy signed by CNA #1 and dated 01/03/2025 revealed, The purpose of this policy is to ensure the safety of those individuals who drive company vehicles. Vehicle accidents are costly to our company, but more importantly they may result in injury to you or others. It is the driver's responsibility to operate the vehicle in a safe manner and to drive defensively to prevent injuries and property damage . An interview on 6/18/25 at 10:15 AM, the Administrator (ADM) confirmed Resident #1 was being transported to a medical appointment on 4/28/25 when the wheelchair flipped in the van, throwing the resident to the floor. The van driver pulled to the side of the road and called 911. The van driver (CNA #1) did not notify the facility. The facility was alerted by the emergency room (ER) when Resident #1 arrived with injuries. Resident #1 sustained multiple head lacerations requiring staples and a nondisplaced sternal fracture, per the ER report dated 4/28/25. The facility ADM and the Director of Nursing (DON) attempted to call the van driver on her cell phone on numerous occasions in the afternoon of 4/28/25 and received no contact with the van/bus driver. At approximately 4:00 PM on 4/28/25 the van/bus driver returned to the facility in the van/bus. CNA #1 then gave a written statement to the ADM and DON and confirmed that she had not properly fastened the wheelchair to the van/bus safety belts and had not positioned the wheelchair properly inside the van/bus. CNA #1 was terminated from employment for not following the facility policy for van/bus safety that caused the fall with injuries to Resident #1. Record review of the typed statement of the facility Administrator (ADM) dated 4/28/25 revealed: Administrator (name of ADM) interviewed employee (name of CNA #1) van driver regarding incident that occurred in the van. (CNA #1) stated I buckled her at the bottom, but I didn't put the seatbelt on. An attempted phone interview on 6/18/25 at 12:30 PM with CNA #1 resulted in no answer and no voice mail. Record review of the handwritten statement of CNA #1 dated 4/28/25 revealed: I (name of CNA #1) was transporting a pt. (patient) to an appt. (appointment) at 1:15 PM on hwy (Highway)82. I heard her yell I pulled over once I found a safe place. Pt. wheelchair had flipped over. I called 911, put a diaper under her head to stop the bleeding. Police and EMT's (Emergency Medical Technicians) arrived I waited I followed them to the hospital. Signed by (name of CNA #1). Record review of the ER report dated 4/28/25 at 2:12 PM documented a 3 (three) cm (centimeter) occipital scalp laceration (closed with four staples), a second 2 (two) cm laceration (closed with two staples), and a confirmed sternal fracture. Resident #1 was hospitalized for additional medical conditions and passed away on 5/03/25 due to acute renal failure, per the death certificate. Record review of the death certificate of Resident #1 dated 5/3/25 and signed by the corner on 5/6/25 listed cause of death in the hospital as Renal Failure. An interview and observation on 6/18/25 at 11:00 AM with CNA #2 loading Resident's #2, #3 and #4 into the van for transportation to dialysis confirmed that CNA #2 properly affixed lap and floor belts on three dialysis residents and demonstrated knowledge of policy-compliant securement procedures. Interviews with Residents #2, #3, and #4 confirmed consistent and safe practices during van transportation. An interview on 6/18/25 at 11:30 AM with the Maintenance Director stated that he inspected the van after the incident and found that the floor stabilizers had not been affixed and the lap belt had not been used. He confirmed that CNA #1 had been previously trained and provided his weekly safety check documentation. Record review of the Quality Assurance Committee (QA) meeting's sign-in sheet dated 4/29/25 revealed that all members were present at the QA meeting on 4/29/25 to review the incident that occurred on 4/28/25. Record review of the admission Record of Resident #1 revealed that the facility admitted the resident on 3/18/25 with medical diagnoses that included Heart Failure, Chronic Obstructive Pulmonary Disease (COPD) and Chronic Kidney Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/25 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. The State Agency (SA) validated through interview and record review on 6/18/25 that the facility began with immediate action of van safety in-service for all authorized drivers, van and seat belt safety inspection, conducted a full investigation and terminated CNA #1. Monitoring to be performed by the ADM and DON to ensure Wheelchair Securement System in proper working order 2 times a week for 2 weeks, then 1 time per week for 2 weeks, then monthly for 3 months. This deficiency was cited as Past Noncompliance at actual harm level, corrected prior to the survey entrance.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure food items in the kitchen refrigerator, freezer, and dry storage room were dated and labeled for one (1) of two (2) kitchen tours completed. Findings Include: Review of the facility policy titled, Food Storage dated [DATE], revealed .8. All foods stored in refrigerators and freezers that have been opened, will be covered and labeled with the date and name of food if appropriate, and will be discarded within the appropriate time frame. 9. All leftover foods are to be stored in covered containers, dated, & labeled . On [DATE] at 9:45 AM, an observation during the initial kitchen tour with the Dietary Manager (DM), revealed multiple unlabeled and undated food items in the refrigerator and freezer. The unlabeled and undated foods included one-half of a five pound bag of frozen chicken strips, one-fourth of a two pound bag of frozen French fries, and one-half of a five pound bag of chicken fried steak. There was also a large bag of frozen ground beef in the freezer that had been opened and was undated and unlabeled. On [DATE] at 9:50 AM, an interview with DM revealed that she had worked there since [DATE], and the Dietary Department had been a mess. She revealed that it was everyone's responsibility to ensure opened food items were labeled and dated to make sure they didn't go over past the dates to be used. She revealed that the person who opened the food item was responsible for dating, labeling, and proper storage of the item. DM revealed that if they didn't date and label the food items when opened, they would not know how long it had been in the refrigerator or freezer and could become freezer burned or expired. DM revealed that they were supposed to use or dispose of leftover food items in the refrigerator three days after it was opened and that opened food items in the freezer were supposed to be used within six months. On [DATE] at 9:55 AM, during the initial tour of the dry storage room revealed a bag of opened vanilla wafers that were unlabeled and undated. There were approximately 30 vanilla wafers left in the bag, and it was folded down and was not sealed. There was a twenty-five pound (lb.) bag of white corn meal with the sack torn near the top and it was open to air and setting on top of an empty dry storage container. There was also an undated and opened and unsealed 5 lb. bag of yellow cake mix with approximately one and one-half cups left in the bag. On [DATE] at 9:58 AM, an interview with Dietary [NAME] revealed that the bag of corn meal was supposed to be closed and inside an air proof container. She also confirmed that the bag of corn meal, cake mix, and vanilla wafers were exposed, open to air, and were not dated or labeled. Dietary [NAME] revealed that they were supposed to make sure that any opened food items such as the cake mix, vanilla wafers, and corn meal were wrapped up in plastic and covered to help prevent contamination and prevent bugs and pests from getting inside the packages. Dietary [NAME] also confirmed that all opened food items were supposed to be dated and labeled.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to create a clean and safe environment, as evidenced by a dirty wheelchair (Resident #27) and an overbed table and bed headboard in disrepair (Resident #34) for two (2) of the 20 residents sampled. Findings Include: A review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment with a revised date of August 2009 revealed that resident-care equipment, including reusable items and durable medical equipment, will be cleaned . Resident #27 On 10/15/24 at 9:20 AM, an observation revealed Resident #27 was sitting on his bed and his overbed table and headboard were noted to be in disrepair. Resident #27 was not interviewable. His overbed table had the plastic strip edging missing from all four sides and had rough jagged edges exposed. Resident #27's headboard on his bed was unsteady and the upper part of the headboard leaned inward at an eighty-degree angle over his mattress and pillow and revealed that the bed frame and bed was unsteady. On 10/16/24 at 10:39 AM, during an interview with Assistant Director of Nursing (ADON), she confirmed that the headboard on Resident #27's bed and his over bed table were in disrepair and needed attention. She confirmed the rough, jagged edges on his over bed table and revealed that this could cause lots of issues including wood splinters in the skin and skin tears. ADON also confirmed that Resident #27's headboard was unsteady, that it leaned inward over the mattress and needed to be fixed. She revealed that she was not aware of these issues, that no one had reported them to her, and that she would notify maintenance. She revealed that they had a maintenance logbook at the nurses desk and any issues they had, they documented in the book and also reported them verbally to the Maintenance Director. ADON confirmed that Resident #27's headboard nor the bedside table had been recorded in the maintenance logbook prior to her observation. On 10/16/24 at 10:46 AM, an observation and interview with the Maintenance Director in Resident #27's room revealed that he had worked there since August 2024, and that the staff usually reported to him verbally and logged any concerns or needed repairs on a Maintenance Work Order form in the maintenance logbook which he checked every morning. He confirmed that Resident #27's headboard was unsteady and was leaning inward over the mattress and needed to be fixed or replaced. He revealed that no one had reported this concern to him, and that if he didn't know about it, he couldn't fix it. Record review of the Maintenance Work Order form revealed that Resident #27's broken headboard was recorded in the maintenance logbook after the concern was identified on 10/16/24. Record review of Resident #27's Admission Record revealed an admitted [DATE]. Record review of Resident #27's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/03/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated that he had severe cognitive deficits. 46013 Resident #34 An observation on 10/15/24 at 10:40 AM and again at 3:00 PM revealed Resident #34 sitting in her wheelchair. A thick gray substance was noted on the frame of the wheelchair and on the spokes of the wheels. An observation and interview on 10/16/24 at 9:25 AM, revealed Resident #34 sitting in her wheelchair, which remained dirty and unchanged from the previous day. Resident #34 revealed she wasn't sure when they cleaned the wheelchairs, but it was dirty and needed to be cleaned. In an interview on 10/16/24 at 11:45 AM, Certified Nursing Assistant (CNA) #1 revealed that the night shift CNAs are responsible for cleaning the wheelchairs, but if any of us notice that they are dirty, we can also clean them off. During an observation and interview on 10/16/24 at 11:55 AM, the Director of Nurses (DON) revealed that the CNAs on the night shift and/or Sundays are responsible for cleaning the wheelchairs. She revealed, I don't have a check-off list, but the staff are responsible for cleaning them on certain days. I guess I need a check-off list to ensure they are being cleaned. She confirmed that the wheelchair had a gray substance on the frame and wheels and needed to be cleaned. During an observation and interview on 10/16/24 at 12:05 PM, the Administrator revealed that the wheelchairs are supposed to be cleaned on the night shift. They can take the equipment outside when it's warm or in the shower room when it's cold, but all equipment is to be cleaned. She confirmed Resident #34's wheelchair was not cleaned and stated, This wheelchair is not clean, and it needs to be cleaned. A record review of Resident #34's Admission Record revealed the resident was admitted to the facility on [DATE] . Record review of the MDS with an ARD of 07/18/24, revealed Resident #34 had a BIMS score of 12, which indicated the resident is moderately cognitively impaired.

Based on staff interviews, facility policy review, and record review, the facility failed to implement an Activities of Daily Living (ADL) care plan for one (1) of the 22 care plans reviewed. Resident #6. Findings include: A review of the facility policy, titled Care Plan-Comprehensive, revealed, It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Record review revealed a current care plan for Resident #6 with a focus on ADL self-care performance deficit. Intervention in place revealed that the resident prefers a bed bath and requires extensive to total assistance of one (1) staff member. During observations on 10/15/24 at 11:55 AM and again at 3:30 PM revealed Resident #6 lying in bed with hair oily and disheveled, and a thick white, flaky substance was noted on her scalp. Resident #6 had facial hair approximately one (1) inch long to her chin and sporadic areas around her mouth. Her bilateral fingernails were approximately one (1) inch long with a brown substance noted under them. On 10/16/24 at 10:05 AM, during an observation and interview Certified Nursing Assistant (CNA) #2 stated that the resident's Hair looks wet and greasy, she has a lot of dandruff, her facial hair hasn't been shaved in quite some time, and her fingernails are long and dirty. It looks like it's been more than a week or so since she's been really cleaned up. CNA #2 revealed the CNA's are responsible for bathing her, which included washing her hair, trimming her facial hair, and doing her nail care since she is not diabetic. An interview on 10/16/24 at 10:45 AM, the Minimum Data Set (MDS) Coordinator revealed she is responsible for developing the care plans and revealed the purpose of the care plan is to guide and direct all staff to the individualized care needed for each resident. She confirmed according to Resident #6's care plan, she needs extensive to total assistance with her hygiene needs, and if she was not clean, her plan of care was not being followed. She confirmed that there was no documentation of refusal of care under the ADL care plan. Record review of Resident #6's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Peripheral vascular disease, Lack of coordination, and Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side. Record review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident is severely cognitively impaired.

Based on observation, staff interviews, and facility policy review, the facility failed to provide personal hygiene, as evidenced by long facial hair, unkempt hair, and long nails with a brown substance under them for one (1) of 20 residents sampled. Resident #6 Findings include: Review of the facility policy titled A.M. Care (Day Tour of Duty) dated August 25, 2014, revealed under Purpose: 1. To refresh the resident. 2. To provide cleanliness, comfort, and neatness . An observation on 10/15/24 at 11:55 AM and again at 3:30 PM revealed Resident #6 lying in bed. Her hair appeared oily and disheveled, and a thick white, flaky substance was noted on her scalp. Resident #6 had facial hair approximately one (1) inch long to her chin and sporadic areas around her mouth. Her bilateral fingernails were approximately one (1) inch long with a brown substance noted under them. An observation on 10/16/24 at 8:45 AM, revealed Resident #6 lying in bed, with no change in the observation of appearance from the previous day. During an observation and interview on 10/16/24 at 10:05 AM, Certified Nurse Aide (CNA) #2 stated that Resident #6's hair looks wet and greasy, she has a lot of dandruff, her facial hair hasn't been shaved in quite some time, and her fingernails are long and dirty. CNA #2 revealed, It looks like it's been more than a week or so since she's been really cleaned up. CNA #2 revealed the CNA's are responsible for bathing her, which includes washing her hair, trimming her facial hair, and doing her nail care since she is not diabetic. CNA #2 stated, I was off work yesterday, but she still should have been cleaned up. During an observation and interview on 10/16/24 at 10:35 AM, the Director of Nurses (DON) confirmed that Resident #6's hair was greasy, with thick white dandruff on her scalp. The DON stated that she's a little hairy when referencing the resident's facial hair and confirmed that her fingernails were long and not clean. Record review of Resident #6's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Peripheral vascular disease, Lack of coordination, and Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side. Record review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/02/24, revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident is severely cognitively impaired.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the proper storage of treatment medications and disinfectant wipes on the treatment cart as evidenced by an unlocked treatment cart in the residents' hallway for one (1) of three (3) survey days. Findings include: Record review of facility policy titled, Medications, Individual Medication Storage Cabinets, dated 8/25/14, revealed, Medication administration utilizing individual medication storage cabinets will meet the same criteria for timeliness, infection control, and medication safety as standard medication administration . 4. The medication storage cabinet will remain locked when not in use . During an interview and observation of a treatment with Licensed Practical Nurse (LPN) #1 on 10/16/24 at 10:05 AM, the treatment cart was left in the hallway while the treatment was being done in the resident's room. Upon the exit of the resident's room, the cart was observed unlocked and unattended in the hallway. LPN #1 stated the lock on the cart had been broken for approximately a month so she was unable to secure the items in the cart. She verified that the cart was locked in the office when not being used, but confirmed when treatments were being done, the unlocked cart was in the hall and not within sight since the resident's door was closed during care. She stated this was a safety concern since a resident could gain access to the treatment items/medications/disinfectant wipes on the cart. An observation of the cart revealed drawers that contained topical medications, creams, treatment medication items such as collagen, xeroform dressings and other supplies as well as disinfectant wipes. She confirmed these treatment medications should be secured in a locked cart to ensure no one had access to these items. An observation and interview with the Assistant Director of Nursing (ADON) on 10/16/24 at 10:30 AM, revealed the cart would lock but it was difficult to position the lock handle into the locked position and it had to be jiggled and twisted until it went into the place where the lock could be secured. She demonstrated the process that was necessary to lock the cart, which consisted of several seconds of twisting and adjusting the handle and finally getting it into the appropriate spot to lock. She confirmed that not all of the staff that used this cart were notified of how to securely lock this since it had been damaged and not easily locked. During an interview on 10/16/24 at 10:30 AM, the Administrator confirmed the cart was left unlocked and unattended in the hallway during a treatment and medications used for residents' treatments were on the cart. She confirmed the facility failed to secure medications and disinfectant wipes in a locked room or locked cart to ensure no one had access to those supplies which could affect resident safety.

Based on observation, staff and resident interview, and facility policy review the facility failed to clean a visibly soiled overbed light and window blind and replace a broken window blind for two (2) of 58 residents reviewed. Resident #1 and Resident 21. Findings include: Record review of the facility policy titled, Maintenance Service with a revision date of June 2000 revealed, Policy Statement: It is the policy of this facility that maintenance service be provided to all areas of the building, grounds, and equipment . Procedure .2. The following functions are performed by maintenance, but are not limited to . k. Others that may become necessary as appropriate. Ex.(example) Replace broken blinds. Record review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces with a revision date of August 2009 revealed .Policy Interpretation and Implementation .9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . 11. Walls, blinds, and window curtains in resident areas will be cleaned when the surfaces are visibly contaminated or soiled . Resident #1 An interview and observation on 06/13/23 at 2:20 PM, with Resident #1 in her room revealed that her window blinds were not working properly. She stated that the blinds will not close unless she takes her hand and closes each blind slate individually. She stated that she told Maintenance about it a while back and the Administrator a week or so ago, but it's still not fixed. An interview and observation on 6/14/23 at 8:05 AM with Resident #1 in her room revealed that the lower part of her window blinds was closed, and the upper part was open. This observation revealed there was no wand or string attached to the blinds to close or open them. Resident #1 stated that the blinds had been that way since she moved in this room in March of 2023 and that she closes them by hand. An interview on 6/14/23 at 8:10 AM, with Registered Nurse (RN) #1 revealed that if staff notices something that is broken then they let maintenance know and put it in his logbook that is kept at the nurse's station. She revealed the staff usually text or call him. She stated that if she notices something that needs to be cleaned then she will let housekeeping know or just clean it herself. She revealed the rooms get deep cleaned per housekeeping schedule and when they do that everything is taken out of the room and the walls are cleaned in addition to everything else. An interview and observation on 6/14/23 at 8:40 AM, with the Administrator confirmed that resident rooms do get deep cleaned as the Housekeeping Supervisor had revealed. She confirmed that Resident #1 had told her about her blinds being messed up about a week and a half ago and she notified maintenance but has not followed up on the issue. She revealed she did not put it in the maintenance logbook but should have so that would have been followed up on and fixed. Record review of the maintenance logbook at the nurse's station revealed there was no request for the broken blinds in Resident #1's room. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Fracture of Shaft of Humerus, Left Arm, Initial Encounter for Closed Fracture. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #21 On 06/13/23 at 2:45 PM, an observation and interview with Resident #21 in his room revealed numerous raised spots of a brown substance along with a white substance that was the size of a tennis ball stuck to the light cover that was directly over his bed. An interview and observation on 6/14/23 at 8:20 AM, with the Housekeeping Supervisor revealed that a different room each day gets deep cleaned. She revealed that when a room gets deep cleaned then the residents are moved out, the floors get stripped and waxed and the walls and everything gets wiped down and dusted. An observation of Resident #21's room with the Housekeeping Supervisor confirmed that there was a brown substance splattered all over half of the residents overbed light and on half of his window blinds. She revealed that this resident's room had been deep cleaned a couple of weeks ago. She stated that they had tried to get the brown substance off the blinds, but they could not, so maintenance had ordered more blinds. An interview on 6/14/23 at 9:00 AM, with the Maintenance Director and the Administrator revealed that no one had mentioned the substance on the light cover in Resident #21's room to the Maintenance Director. The Administrator stated that she thinks the staff get tunnel vision and don't look up so that is why they never noticed Resident #21's light. Record review of Resident #21's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Obstructive and Reflux Uropathy, Unspecified. Record review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 11, which indicated that the resident had moderate cognitive impairment.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to implement a fluid restriction care plan for one (1) of 17 care plans reviewed. Resident #9 Findings include: A review of the facility policy titled, Care plans, Comprehensive Person Centered, revealed, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial needs is developed and implemented for each resident .Policy Interpretation and Implementation .7. The comprehensive, person-centered care plan .: b.) describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . An observation and interview with Resident #9 on 6/13/23 at 11:00 AM, revealed she was on dialysis, and is doing well, and is on fluid restrictions. The State Agent (SA) also observed a plastic measured water pitcher on the bedside table with 600 ml (milliliters) of water in the pitcher. A review of the care plan revealed Focus: I need dialysis (hemo) hemodialysis related to (r/t) renal failure. I receive hemodialysis Monday, Wednesday, Friday (Mon, Wed, Fri) at (Proper name) of kidney care clinic in (proper name), revision on 3/31/21 .Interventions/Tasks: 1000 ml fluid restriction as ordered. FLUID RESTRICTION: 1000 ml (milliliters)/24 HR (hour). Nursing to provide 280 ML/day: 7a-7p (AM-PM) 140 ML, 7p-7a (PM-AM) 140 ML. Dietary to provide 720 ml/day: B-(Breakfast)240 ml, L-(Lunch) 240 ml, D- (Dinner) 240 ml . A record review of the medical record for Resident #9 and interview with the Director of Nursing (DON) on 6/13/23 at 3:20 PM, revealed Resident #9 was on a 1000 ml fluid restriction. She revealed the fluid restriction was care planned and on the Care Guide for the Certified Nurse's Assistant's (CNA's) but confirmed the care guide does not reflect the fact that the CNAs are not to give resident any fluids. She also confirmed staff are not following the fluid restriction care plan. Record review of the Care Guide for the CNAs revealed, FLUID RESTRICTION: 1000 ML/24 HR. Nursing to provide 280 ML/day: 7a-7p 140 ML, 7p-7a 140 ML. Dietary to provide 720 ml/day: B-240 ml, L-240ml, D-240 ml. An interview with the Minimum Data Set (MDS) Nurse on 6/14/23 at 10:04 AM, revealed the purpose of the comprehensive care plan was to map out the individualized care needed by each resident and confirmed that staff were not following Resident #9's fluid restriction plan of care. Record review of the Admission Record revealed that the facility admitted Resident #9 to the facility on [DATE] with diagnoses of Chronic Kidney Disease and Right sided heart failure, unspecified. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 4/14/23, revealed that Resident # 9 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy the facility failed to follow a resident's physician prescribed fluid restriction for one (1) of three (3) residents on fluid restriction. Resident #9 Findings include: Record review of the facility policy titled, Fluids, Encouraging, and Restricting, with a revised date of August 25, 2014, revealed, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging and restricting fluids . General guidelines: 1. Follow specific instructions concerning fluid restrictions . 7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. If the resident refuses, notify the supervisor and in turn, the physician . Documentation .The following information should be recorded in the resident's medical record . 8. If the resident refuses treatment, the reason why and the intervention taken . An observation and interview with Resident #9 on 6/13/23 at 11:00 AM, revealed she was on dialysis, and she was to be following fluid restrictions. The staff provided the number of fluids she needs each day. The State Agent (SA) observed a plastic measured water pitcher on the bedside table with 600 ml (milliliters) of water in the pitcher. Resident #9 revealed one of the Certified Nurse Assistant's (CNA's) came in earlier and filled it up with water and ice. Resident #9 confirmed staff are good about making sure she has fresh water. An observation and interview with Licensed Practical Nurse (LPN) #1 on 6/13/23 at 3:15 PM, confirmed there was a pitcher with water in Resident #9's room and there should not be, because the resident was on a 1000 ml fluid restriction daily. LPN #1 stated that staff should never leave water or any fluids in Resident #9's room and should notify the nurse if the resident is drinking something she should not. LPN #1 confirmed staff were not following Resident #9's fluid restriction orders and that could lead to fluid overload and distress. A record review of the Order Summary Report dated June 13, 2023 revealed a physician order with an order date of 12/08/22 for Resident #9 Fluid Restriction: 1000 ml/24 hr (hours).Nursing to provide 280 ml/day: 7a-7p 140 ml, 7p-7a 140 ml. Dietary to provide 720 ml/day, B-(Breakfast) 240 ml, L- (lunch) 240 ml, D-(Dinner) 240 ml . An interview with the Director of Nursing (DON) on 6/13/23 at 3:20 PM, revealed that Resident #9 had a physician's order for 1000 ml fluid restriction daily and confirmed Resident #9 should not have a water pitcher in her room. The DON stated that a resident on dialysis receiving more than the prescribed fluids ordered is fluid overload and confirmed staff are not following physician prescribed fluid restriction orders. An interview with CNA #1 on 6/13/23 at 3:30 PM, she revealed that she provides care for Resident #9 often and she fills the water pitcher for Resident #9 twice a shift. CNA #1 confirmed she was unaware Resident #9 was on a fluid restriction and that she was not supposed to provide her with water. An interview with CNA #2 on 6/14/23 at 9:39 AM revealed she provides care for Resident #9 at least two days a week and is aware that the resident is on fluid restriction. She stated that she does not give the resident any fluids other than those that come with her meals. She stated she fills up Resident #9's water pitcher twice per shift and that she never asks for any extra fluids. If she did, she would remind her of her fluid restriction and inform the nurse. Record review of the Admission Record for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses of Chronic kidney disease and Right sided heart failure, unspecified. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 4/14/23, revealed that Resident # 9 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated that she was cognitively intact. Review of Section O revealed that the resident was receiving dialysis.

Based on observation, staff interview, record review, and facility policy review the facility failed to maintain strict aseptic technique to prevent the spread of infection during an observation of medication administration via percutaneous endoscopic gastrostomy (PEG) tube for one (1) of four (4) medication administration observations. Resident #20 Findings Include: A review of the facility's policy titled, Cleaning/Disinfection of Resident Care Items and Equipment, dated June 15, 2010, revealed, Policy Statement: Resident care equipment, including reusable items .will be cleaned and disinfected according to the CDC (Centers for Disease Control) for disinfection and OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard .Reusable Items . 1. Single resident use items are to be cleaned/disinfected between uses by a single resident and disposed of afterward .Single use items will be discarded after a single use . A review of the facility's policy titled, Enteral Tube Medication Administration, dated May 10, 2013, revealed .Procedures .U. Clean feeding syringe and store . A review of the facility's policy titled, Enteral Feedings-Safety Precautions. dated May 10, 2013, revealed, Purpose: To ensure the safe administration of enteral nutrition Preventing contamination: 1. Maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas . A review of the manufacturer guidelines for the Enteral Feeding Tube clog remover revealed Once the clog is clear dispose of the wand .Single use only . An observation of medication administration via PEG tube for Resident #20 with Licensed Practical Nurse (LPN) #2 on 6/14/23 at 7:50 AM revealed, LPN #2 placed the continuous feeding pump on hold, disconnected the tubing from Resident #20's PEG tube and placed it on the resident's bed. After placement check, LPN #2 revealed she could not get the diluted medication to go in the PEG tube confirming it must be clogged. LPN #2 removed the PEG tube adapter and syringe and placed it on the over bed table with no barrier. She then removed an Enteral feeding Tube Clog Remover wand from Resident #20's bedside table drawer that was not bagged and lying open on top of the resident's personal items and inserted the clog remover wand into the PEG tube. She then removed the wand and placed it on the bedside table with no barrier. LPN #2 then picked up the PEG tube adapter that was lying on the bedside table with no barrier and inserted it in the resident's PEG tube. The State Agent (SA) observed LPN #2 repeat this process three times, each time placing the items on the bedside table with no barrier. LPN #2 stated, I cannot get the PEG tube unclogged. I am calling the charge nurse. While waiting for the charge nurse the SA observed the formula tubing that was placed on Resident #20's bed by LPN #2 earlier hanging off the side of the bed and touching the floor. When Registered Nurse (RN) #1 entered Resident #20's room, LPN #2 handed RN #1 the peg tube syringe and clog remover wand from the bedside table with no barrier and RN #1 inserted them into Resident #20's PEG tube to unclog the tube. LPN #2 then picked up the PEG tube adapter from the bedside table and reinserted it into Resident #20's PEG tube and administered all the medications. After completion of administering the medications, LPN #2 flushed the tube placed the PEG syringe in the storage bag on the bedside table without rinsing and drying the syringe, picked up the formula feeding tube that was hanging off the bed and touching the floor and connected it to Resident #20. LPN #2 then rinsed the clog remover wand and placed it back in Resident #20's bedside table drawer with no storage bag. An interview with LPN #2 on 6/14/23 at 8:15 AM, confirmed she placed the PEG tube syringe, adapter, and tube clog remover on the bedside table with no barrier and confirmed she should have put the supplies on a clean barrier. LPN #2 then revealed both the PEG tube syringe and clog remover should have been rinsed, dried .and stored in a clean storage bag but confirmed that she did not do that. LPN #2 went on to confirm she had placed the formula feeding tube on Resident #20's bed and saw it hanging off but did not realize it was on the floor. She then confirmed the formula tubing should have been placed in a clean area and not on the bed. LPN #2 stated the tubing would be considered dirty after touching the floor and should not have been reconnected to Resident #20's PEG tube. When the SA asked LPN #2 of possible concerns with using equipment considered dirty, LPN #2 replied possible transfer of bacteria, causing a bacterial or gastrointestinal infection could have occurred. An interview with the Director of Nurses (DON) on 6/14/23 at 8:30 AM, reviewed the findings of the infection control concerns that were observed during medication administration for Resident #20. The DON confirmed the PEG syringe, clog remover, and the formula tubing was considered dirty after not being placed on a clean barrier by LPN #2. An interview with the RN #1 on 6/14/23 at 1:00 PM, she revealed she believed the equipment that LPN #2 handed her to unclog Resident #20's PEG tube to be clean, and confirmed that the PEG syringe would have been considered dirty if it was placed on the bedside table with no barrier and also confirmed the clog remover wand is single use item only and should have been disposed of. An interview with the Infection Control nurse on 6/14/23 at 1:20 PM, she revealed any item placed on a dirty surface must be cleaned after use. If items are not cleaned or discarded, then the resident is at risk for transfer of numerous types of infections. A record review of LPN# 2's Continuing Education Earned form revealed, Infection Prevention in Long-Term Care Setting with a completion date of 5/17/23 and Basics of Enteral Nutrition with a completion date of 5/18/23. Record review of the Admission Record revealed the facility admitted Resident #20 to the facility on [DATE].Diagnosis Information included diagnoses that included Encounter for attention to gastrostomy and Dysphagia. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 4/12/23, revealed Resident #20 had a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. Section K indicated Resident #20 had a feeding tube while a resident.

Based on interview and record review the facility failed to notify the resident representative in writing of a transfer to the hospital for one (1) of 22 residents reviewed for transfer. Resident #46. Findings include: Record review of a Health Status Note dated 10/22/21 revealed Resident #46 was transferred to the local hospital by emergency services and review of a Health Status Note dated 1/28/22 revealed she was transferred to the local emergency room . An interview, on 02/08/22 at 5:20 PM, with the Social Service Director revealed that she was not aware of transfer forms needing to be sent to the families. She stated that she sends the bed holds and she calls the responsible parties. An interview, on 02/10/22 at 5:25 PM, with the Administrator revealed that she stated that she dropped the ball. She stated that she accepts responsibility because she should have told her new social worker about the forms.

Based on staff interviews and record review the facility failed to accurately complete a Preadmission Screening and Resident Review (PASRR) Level 2 change in status form for one (1) of three (3) residents reviewed for PASRR. Resident #44. Findings include: Record review of a typed statement and signed by the Administrator on 2/9/22 revealed, Currently (Proper Name of Facility) does not have a specific policy related to doing a Level 2. An interview with the Social Worker on 2/9/22 at 10:30 AM, revealed that at the facility, she is responsible to complete the request for a PASRR Level 2. She stated she was unaware of the requirement that a PASRR Level 2 was needed when the resident had a change of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed that requests for PASRR Level 2 were not done by the facility for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed this was needed to ensure safe placement for the residents. An interview with the Administrator on 2/9/22 at 10:45 AM, revealed she was not aware that Resident #44 needed a request for PASRR Level 2 and the request had not been done. She confirmed the facility failed to submit the PASRR Level II Change in Status Request for this resident. She confirmed this is needed for the safe care of the resident and to ensure appropriate placement. She confirmed the facility does not have a policy for PASRR submission. Record review of the Admission Record revealed the resident was admitted to the facility on [DATE]. Resident #44 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow care plans to prevent, and identify the development of new pressure ulcers for three (3) of seven (7) residents reviewed for pressure ulcers, Residents #1, #2, and #12. The facility's failure to follow the care plan for risk of skin impairment resulted in harm and development of new wound areas. Findings include: Review of the facility's Care Plan Committee/Team policy, not dated, revealed it is the policy of this facility that Care Planning Committee/Team develop a comprehensive person-centered care plan for each resident within seven (7) days of completing the resident assessment (MDS/Minimum Data Set). Care Plan to be completed no later than 21 days after admission. Care Plans will be modified as needed to reflect resident's status, and needs. Review of the facility's Using the Care Plan policy, not dated, revealed it is the policy of this facility that the care plan be used in developing the resident's daily care routines. Care plans will be available in the resident's Point of Care (Kiosk) program. The nurse aide is responsible for reporting to the nurse or charge nurse any changes in the resident's condition. Review of the facility's Skin Care Process policy, dated November 11, 2016, revealed it is the facility's process included: Developing and implementing an individualized plan of care. The plan of care should be based on the results of the risk evaluations, consideration of medical conditions, and the goals and wishes of the resident. The effectiveness of the plan of care is demonstrated through ongoing evaluations of skin integrity and progress of wounds or pressure wounds. Resident #2 Review of Resident #2's Care Plan initiated on 10/24/16 revealed the facility failed to prevent the potential for further impairment to skin integrity due to the wound care was not provided at ordered after the dressing was soiled during an incontinent episode, and the CNA failed to notify the Treatment nurse. The facility failed to prevent new skin impairment as addressed on the Care Plan initiated on 12/3/16 due to the development of a Stage three (3) pressure ulcer to the left elbow on 12/5/16. An observation during the initial tour of the facility on 01/11/17 at 10:50 AM, with LPN #2, revealed the resident was admitted to the facility with a Stage 4 (four) pressure ulcer to the sacrum, and developed a Stage 3 (three) pressure ulcer to the left elbow after admission to the facility. Resident #2 was lying in the bed on an air mattress. Observation and interview on 01/12/17 at 5:00 PM, revealed incontinent care was provided for Resident #2 by CNA #5, and CNA #6. When the resident was turned to his left side there was not a wound dressing in place, and the wound to the sacral area was opened to the air. There was a foul odor noted, and a large amount of a pink with a red tinged bloody drainage covering the blue pad the resident was lying on, and both of the resident's buttocks. The bloody drainage also covered the skin around the wound area. CNA #6 stated CNA #4 had taken care of him today, and she had already gone for the day. An interview on 01/12/17 at 5:10 PM, revealed LPN #2 stated, Nobody told me his dressing was off. He had a dressing on when he came from wound care center late yesterday afternoon. Observation at this time revealed LPN #2, assisted by RN #1, provided wound care to Resident #2's sacral area as ordered. Interview with CNA #4 on 01/12/17 at 6:05 PM, revealed she was the CNA for Resident #2 today (1/12/17). CNA #4 confirmed she did not notify LPN #2 the dressing was off of the wound, and she had been educated to inform the nurse when a resident's dressing comes off during incontinent care. CNA #4 stated she provided incontinent care of a bowel movement around 9:30 AM this morning, and the dressing to the sacral area was off due to a bowel movement covering the buttocks area. LPN #2 provided Resident #2's wound care on 01/12/17 at 5:45 PM, to the left elbow. The area was about dime sized, or approimately two (2) cm covered with yellow slough with a moderate amount of drainage on the old dressing. LPN #2 stated, We thought it was [MEDICAL CONDITION], and the Nurse Practitioner (NP) looked at it, and she thought it may be that too, but then it developed a break in the skin, we began a treatment on it. LPN #2 reported it was swollen and puffy, and had a blister. The wound care was provided as ordered by the physician, and the wound matched the most recent Wound Assessment Evaluation dated 1/5/17 for a Stage three (3) pressure ulcer to the left elbow. On 01/17/17 at 3:45 PM, an interview with the Director of Nurses (DON) revealed the Stage 3 (three) to Resident #2's left elbow was discovered on a Weekly Body Audit on 12/05/16. Interview on 01/18/17 at 3:05 PM, with RN #2/MDS Nurse revealed the care plans were not followed to prevent new pressure ulcers, and the CNAs should have reported changes with the wound. RN #2/MDS Nurse confirmed she developed the resident's care plans, and the resident was at high risk for skin breakdown. Review of Resident #2's Admission MDS with an ARD of 10/31/16 revealed he was admitted by the facility on 10/24/16 with [DIAGNOSES REDACTED]. Resident #2's Cognitive Skills for Daily Decision Making was coded a three (3), which indicated severe impairment, indicating the resident rarely or never made decisions. Further review of the MDS revealed Resident #2 was at risk for developing pressure ulcers, and had one (1) Stage 4 (four) pressure ulcer. Resident #1 Review of Resident #1's Care Plan initiated on 10/26/15 revealed the facility did not follow the care plan for the potential for skin integrity impairment as evidenced by failure to report abnormalities to the Medical Doctor (MD), observe for redness, open areas, scratches, cuts, bruises, and report any changes to the Nurse. Review of the Care Plan initiated on 12/17/15 revealed the CNAs failed to report abnormalities to the nurse regarding the Daily Skin Inspections. During the initial tour of the facility on 01/11/17 at 10:30 AM, with Licensed Practical Nurse (LPN) #2/Treatment Nurse revealed LPN #2 stated the resident had a stage 2 (two) or 3 (three) pressure ulcer to her left heel that was acquired in the facility, and a bruise to her right heel. Observation revealed after LPN #2 completed the wound care on 01/11/17 at 2:15 PM, the SA surveyor asked him to lift the resident's right foot up to further observe the resident's skin Observation of the foot and heel revealed a reddened area approximately five tenths centimeter (0.5 cm) in diameter to the outer edge of the right foot around the bony prominences below the fifth toe. The center of the this red discolored area was a deep purple color. There was also a deep red discolored area to the outer edge of the fifth digit approximately five tenths (0.5) cm in diameter. LPN #2 confirmed the presence of these areas. LPN #2 stated he did not have knowledge the two areas were present. An interview on 1/12/17 at 7:50 PM, revealed CNA #7 stated she has taken care of Resident #1 on the night shift for the last three (3) months. CNA #7 confirmed her documentation on the Skin Observation sheet was correct. CNA #7 stated she provided Resident #1's care each night, which included removing the heel cradle to provide a bath, and turning her in the bed. CNA #7 stated she had not observed any problems with the resident's skin, and would report it to the nurse if she did. Interview on 02/13/17 at 3:30 PM, with CNA #6 confirmed she provided incontinent care for Resident #1 on the 7 AM until 7 PM shift. CNA #6 stated she had not observed any skin concerns on her heels, but that the resident had heel cradles on, and stated, So unless they (heel cradles) came off I would not have noticed that area to her heel. CNA #6 stated the resident received a bath on the night shift, and the CNA's are in-serviced to report skin concerns to the nurse. An interview on 2/13/17 at 3:45 PM, with CNA #5 revealed the CNAs document any skin concerns on the computer's Kiosk, and the CNAs know what care the residents require by looking it up in the Kiosk, or they can go to the chart and look at the care plan. CNA #5 stated the nurses would notify the CNAs if there were any changes in the resident's care. Record review of the Certified Nursing Assistant (CNA) documentation of daily Skin Observation completed daily from 12/30/16, to 01/12/17 indicated there were no Scratched, Red Area, Discoloration, Skin Tear, or Open Areas to the resident's skin. Interview on 01/18/17 at 3:05 PM, with RN #2/ Minimum Data Set (MDS) Nurse confirmed she developed the residents care plans, and the resident was at high risk for skin breakdown. RN #2/MDS Nurse stated the care plans were not followed to prevent new pressure ulcers. RN #2 stated the CNAs should have reported the first sign of redness, skin tears, open areas, and scratches to a nurse, and they failed to do that. RN#2 stated, When I develop a care plan, I add it to the CNA's Task List and it will show on the kiosk for the CNA's to provide the care. Review of the Admission Record revealed Resident #1 was admitted by the facility on 09/10/15 with [DIAGNOSES REDACTED]. Review of the most recent MDS with an Assessment Reference Date (ARD) of 12/28/16 revealed a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was rarely, or never understood. Further review of the MDS revealed Resident #1 was totally dependent, and required two person physical assist with ADL care. Resident #1 was assessed at high risk for development of pressure ulcers. Resident #12 Review of Resident #12's Care Plan initiated on 12/2/15 revealed the facility did not prevent further skin integrity impairment as evidenced by no observation, or documentation of two (2) new pressure ulcers, a Stage three (3) to the right great toe, and a Stage two (2) to the coccyx. An observation on 1/13/17 at 2:50 PM, revealed LPN #2 provided Resident #12's wound care to her right great toe. LPN #2 removed the dressing to reveal the wound was free of odor, and appeared to be almost healed. The wound area was approximately one half inch (1/2) in diameter at the corner of the toenail, and pink coloration with no skin break. LPN #2 provided the wound care as ordered. Resident #12's most recent Weekly Wound Assessment Evaluation dated 1/9/17 documented a Stage three (3) Pressure Ulcer to the right great toe. An observation on 1/13/17 at 3:25 PM, revealed LPN #2/Treatment Nurse provided Resident #12's wound care to the Stage 2 (two) pressure ulcer to the coccyx area. LPN #2 removed the dressing. The wound had no drainage. The wound bed was red with an excoriated appearance. The wound edges were pink. The wound was approximately one to one and a half (1-1 1/2) cm in diameter. The wound care was provided as ordered. Resident #12's most recent Wound Assessment Evaluation dated 1/9/17 identified the Stage two (2) pressure ulcer to the coccyx. Review of Resident #12's Skin Observation sheet documented by the CNAs each shift, and dated 12/22/16 to 1/13/17 revealed None of the Above, or Not Applicable was checked, indicating no scratches, red areas, discoloration, skin tears, or open areas were observed. Interview on 01/12/17 at 7:50 PM, with CNA #7 revealed she stated, I never seen any problems with her skin that I would need to report. CNA #7 confirmed the resident had no skin problems on the Skin Observation Sheet. Interview on 01/18/17 at 3:05 PM, with Registered Nurse (RN) #2/MDS Nurse revealed care plans are updated on a daily basis. RN #2 stated when orders are written, the nurses are responsible for updating the care plan. RN #2 further revealed she checks behind the nurses after changes have been made to the care plan. Review of the Admission Record revealed the facility admitted Resident #12 on 10/28/09, with [DIAGNOSES REDACTED]. A review of the significant change MDS assessment with an ARD of 12/30/16, revealed Resident #12 scored three (3) on the Brief Interview for Mental Status (BIMS) assessment, which indicated severely impaired cognition. Further review of the MDS revealed Resident #12 now required total assistance with one to two person physical assist with ADLs. Resident #12 now had impaired ROM to both upper and lower extremities, and continued to always be incontinent of bowel and bladder.

Based on observations, record review, staff interview, and facility policy review, the facility failed to prevent the development of pressure ulcers, and to identify pressure ulcers for residents who were assessed at risk for skin breakdown for three (3) of seven (7) residents reviewed with facility acquired pressure ulcers, Resident # 1, #2, and #12. The failure to assess, identify, treat, and obtain orders to treat pressure ulcers resulted in harm, and the development of new pressure ulcers. Findings include: Review of the facility's policy titled, Skin Care Process, dated November 11, 2016, revealed it is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur. The Process included: Developing and implementing an individualized plan of care. Evaluating the effectiveness of the plan of care and revising approaches as needed. The Process Guidelines included: Developing and implementing a plan of care: The plan of care should be based on the results of the risk evaluations, consideration of medical conditions, and the goals and wishes of the resident. The effectiveness of the plan of care is demonstrated through ongoing evaluations of skin integrity and progress of wounds or pressure wounds. Staff roles for the Registered Nurse includes overseeing the Licensed Practical Nurse and Nursing Assistant in the implementation of the plan of care. The staff role for the Licensed Practical Nurse includes overseeing the Nursing Assistant in the implementation of the plan of care. The staff role for the Nursing Assistant includes: Providing turning, supportive/positioning devices, and skin care according to the plan of care. Observes the skin during bathing and personal care. Notifies the nurse in charge of areas of concern noted. Pressure Wounds: The goal of this facility in regard to pressure wounds is to promote the prevention of and healing of pressure wounds that are present, and to minimize the potential for development of new pressure wounds using the Skin Care Process. Documentation should be comprehensive, concise, consistent, chronological, and complete. Resident #2 During the initial tour of the facility with LPN #2 on 1/11/17 at 10:30 AM, an observation revealed Resident #2 was lying in the bed on an air mattress. LPN #2 stated the resident was admitted to the facility with a Stage 4 (four) pressure ulcer to the sacrum, and had developed a Stage 3 (three) pressure ulcer to the left elbow since admission. An observation on 01/12/17 at 5:00 PM, revealed Resident #2's incontinent care was provided by Certified Nursing Assistants (CNAs) #5, and #6. When the resident was turned to his left side the sacral area wound dressing was not in place, and the wound was opened to the air. There was a large amount of a wet pink bloody drainage with a red tinge covering the blue pad the resident was lying on. The bloody drainage covered both sides of the resident's buttocks, and the skin around the open wound. There was a foul odor present. CNA #6 reported CNA #4 had taken care of Resident #2 today, and she had already left for the day. An interview with CNA #4 on 01/12/17 at 6:05 PM, revealed she was the assigned CNA for Resident #2 today (1/12/17), and she provided incontinent care for a bowel movement around 9:30 AM this morning. CNA #4 stated the dressing was off the wound at that time due to the bowel movement covered the buttocks area. CNA #4 stated she did not notify LPN #2 the dressing was off of the wound, and she had been educated to inform the nurse when a resident's dressing comes off during incontinent care. On 1/12/17 at 5:10 PM, an observation and interview revealed Licensed Practical Nurse (LPN) #2 stated he was not informed the resident's dressing was off. LPN #2 provided Resident #2's wound care to the coccyx area Stage 4 (four) pressure ulcer. The wound bed was pink with minimal slough, with a large amount of bloody pink drainage on the blue pad. There was a foul odor present. LPN #2 provided the wound care as ordered. The wound matched the most recent Wound Assessment Evaluation for a Stage four (4) pressure ulcer to the coccyx dated 1/5/17. An observation on 01/12/17 at 5:45 PM, revealed Resident #2's wound care to the left elbow was provided by LPN #2. The area was about two (2) cm diameter, covered with yellow slough with a moderate amount of drainage on the old dressing. LPN #2 stated the left elbow was initially, swollen and puffy, and had a blister. LPN #2 stated, We thought it was [MEDICAL CONDITION], and the Nurse Practitioner (NP) looked at it, and she thought it may be that too, but then it developed a break in the skin, we began a treatment on it. The wound care was provided as ordered by the physician, and the wound matched the most recent Wound Assessment Evaluation dated 1/5/17 for a Stage three (3) pressure ulcer to the left elbow. An interview on 01/17/17 at 3:45 PM, with the Director of Nurses (DON) revealed she confirmed the Stage 3 (three) to Resident #2's left elbow was discovered on a Weekly Body Audit on 12/05/16. The DON stated the facility does not discuss residents in the PAR meetings, unless they have open areas. The State Agency (SA) surveyor asked the DON when they had noticed the facility was finding the wounds already at a Stage 3 (three), did the facility see that they had a concern with preventive measures. The DON stated, No. Interview with CNA #5 on 02/13/17 at 3:45 PM, confirmed she cared for Resident #2 around December 2016, and she had not noticed any open areas or swelling to the resident's elbows. CNA #5 stated if she did then she would have reported it. A review of the facility's PAR notes revealed on 12/09/16, Left elbow Stage 3 (three) measurements of 5.0 (five) cm length, 4 (four) cm width, and 0.1 (one tenth) cm depth. The PAR note stated to provide the treatment as ordered, and monitor weekly for changes. Review of Resident #2's Weekly Body Audit dated 12/05/16 revealed: Left elbow Stage 3 pressure injury. Review of Resident #2's Weekly Wound Evaluation dated 12/05/16, revealed the following measurements for the left elbow Stage 3 (three) pressure ulcer: Five (5.0) cm length x four and eight tenths (4.8) cm width x zero (0) cm depth. Review of Resident #2's Admit/Readmit Screener revealed the facility admitted her on 10/24/16 with a Stage 4 (four) pressure ulcer to the sacrum measuring seven and four tenths centimeters (7.4 cm) length x seven and five tenths (7.5) cm width x two and eight tenths (2.8) cm depth. No other pressure ulcers were identified. Record review revealed Resident #2's Braden Scale completed on 12/21/16 revealed a score of 12, indicating the resident was a High Risk for pressure sores. Interview on 1/13,/17 at 1:30 PM, with Medical Doctor (MD) #2 revealed he stated the NP takes care of the wounds. I did not know he had a facility acquired Stage 3. MD #2 stated, You are telling me one of my patients has a Stage 3 that when they first saw it that it was a Stage 3? I am not happy with that at all. I would have chewed them out if they called me with a Stage 3 they had found. MD #2 stated he does attend the Quality Assurance (QA) meeting every other month, but doesn't recall the facility talking about facility acquired pressure sores. MD #2 reported they do discuss how many pressure sores are in the building. On 01/13/17 at 11:45 AM, an interview with the Nurse Practitioner (NP) revealed she stated, When I looked at that wound on his elbow it was already open. I remember that. I don't remember [MEDICAL CONDITION] (swelling) being in that arm. The NP stated she was not called much about wounds, and if she was in the building, they would come get her to look at a wound. The NP stated it became difficult around September 2016 to get information, the wound nurse had left, there was inconsistency with the wound care, different people were doing the wound care, and then LPN #2 took over. It was difficult to track down staff to get what I needed. The NP stated she did not have computer access, and had to get the nurses to pull information up for her. The NP confirmed in an interview on 02/13/17 at 2:15 PM that the facility uses a communication book for updates that she would need to address while she is in the building and stated, I only see acute residents. They usually have something going on when I see them once a week on my visit. I have never given any orders on wounds, they would call MD #1 or MD #2, they don't call me. A review of the NP's Progress Notes dated 11/28/16, 12/5/16, 12/12/16, 12/19/16, and 12/27/16 revealed documentation the left elbow was boggy with surrounding redness. Review of Resident #2's Physicians Orders revealed orders dated 1/11/17 to apply Therahoney Gel to the left elbow daily for a Stage 3 pressure injury. Cleanse the wound with wound cleanser, pat dry, apply the Therahoney to the wound bed with calcium alginate cover with [MEDICATION NAME] border dressing daily and as needed. Review of the physician's orders [REDACTED]. Cleanse the wound with wound cleanser, pat dry, apply Therahoney to wound bed with calcium alginate with [MEDICATION NAME] Border daily and as needed. Review of Resident #2's Admission MDS with an ARD of 10/31/16 revealed he was admitted by the facility on 10/24/16 with [DIAGNOSES REDACTED].The Brief Interview for Mental Status (BIMS) was not scored due to the resident was not able to complete the interview. Resident #2's Cognitive Skills for Daily Decision Making was coded a three (3), which indicated severe impairment, indicating the resident rarely or never made decisions. Further review of the MDS revealed Resident #2 was at risk for developing pressure ulcers, and had one (1) Stage 4 (four) pressure ulcer. The Skin and Ulcer Treatments included: Pressure reduction devices, pressure ulcer care, nutrition and hydration interventions, and ointments/medications. Further review of the MDS revealed Resident #2 required extensive to total assistance with two to three person physical assistance with all ADLs. Resident #2 was assessed to have impaired Range of Motion (ROM) to his bilateral upper and lower extremities. Resident #1 During the initial tour of the facility on 01/11/17 at 10:30 AM, with Licensed Practical Nurse (LPN) #2/Treatment Nurse, an observation was made of Resident #1 lying in the bed, an air mattress was in place on the bed, and the head of the bed was elevated at forty-five degrees. LPN #2 stated the resident had a Stage 2 or 3 (two or three) pressure ulcer to her left heel that was acquired in the facility, and a bruise to her right heel. An interview on 1/11/17 at 10:30 AM, revealed LPN #2 stated he has provided wound care in the facility for the last five months, and the previous treatment nurse quit. LPN #2 reported a Registered Nurse (RN) goes with him to take wound measurements every week, the Director of Nurses (DON), or the RN Supervisor, LPN #2 stated, Just whoever I can get, LPN #2 stated, A lady comes about once every two to three weeks and looks at wounds with me. After further discussion, LPN #2 confirmed he was with (Name of Medical Technology Company), and is a certified wound care nurse. LPN #2 confirmed he had received training related to wound care, and stated, She (Name of Medical Technology Company's Consultant) gave me a book to look at, and I can call her anytime I have questions. If the Nurse Practitioner (NP) is here, I'll get her to look at the wounds. An observation of wound care on 01/11/17 at 2:15 PM, revealed LPN #2 provided the wound care to the resident's left and right heel as ordered, and the wounds were observed to match the most recent Wound Assessment evaluations dated 1/12/17. LPN #2 described the wounds to the right and left heel. LPN #2 stated the left heel wound had no slough, the bed was pink with white edges which were macerated. LPN #2 stated the right heel wound was a dark purple color with black specks, the skin was intact with some areas of peeling. After LPN #2 completed the wound care, the SA surveyor asked him to lift the resident's right foot up to further observe the resident's skin, which revealed the outer edges of the foot and heel. Further observation revealed a reddened area approximately the size of the end of a pencil eraser (which measured five tenths centimeter/0.5cm) in diameter on the bony prominence below the fifth toe with a deep purple color in the center. A second reddened area approximately five tenths (0.5) cm in diameter was on the outer side of the fifth toe. LPN #2 confirmed the presence of these areas, and he did not have knowledge the two areas were present. LPN #2 stated, I'll take care of it. On 01/12/17 at 10:30 AM, a record review and interview revealed the SA surveyor was unable to locate the physician's orders [REDACTED].#1's right lateral foot that were observed during the wound care on 01/11/17 at 2:15 PM. LPN #2 stated at this time he had failed to notify the physician of the new wound areas to the right lateral foot. LPN #2 stated, I just forgot about it. I'll go call him (physician) right now and get new orders. Observation and interview on 01/12/17 at 11:45 AM, with the Director of Nurses (DON), and LPN #2 regarding the Stage 3 (three) pressure ulcer to Resident #1's left heel, revealed the DON confirmed when the wound was first seen it was already a Stage 3 (three). The DON stated, Nothing had been reported to us. When I first saw this wound, it was an open area with no depth. The outer edges were dark, black edges, so I staged it a 3 (three). An observation at this time of the measurements of the left heel was 2 (two) cm length and 1.5 (one and five tenths) cm width with 0 (zero) cm depth. Review of the Certified Nursing Assistants (CNAs) documentation of Resident #1's daily Skin Observations completed from 12/30/16 to 01/12/17, revealed the daily checks were for None of the above observed, indicating there were no, Scratched, red area, discoloration, skin tear or open areas to the resident's skin during that time. Interview on 01/12/17 at 7:50 PM, with CNA #7 revealed Resident #1 received a bath every night on the 7 PM until 7 AM shift, and she has cared for the resident for about three months. CNA #7 reviewed the Skin Observation check sheet at this time, and stated she marked None of the above observed, confirming the resident had no skin problems. CNA #7 stated, I never seen any problems with her skin that I would need to report. An interview on 02/13/17 at 3:30 PM, with CNA #6 revealed she provided incontinent care for Resident #1 on the 7 AM until 7 PM shift. CNA #6 confirmed the resident received a bath on the night shift, and the CNA's were in-serviced to report skin concerns to the nurse. CNA #6 stated she had not observed any skin concerns on her heels. CNA #6 revealed the resident had heel cradles on, and stated, So unless they (heel cradles) came off I would not have noticed that area to her heel. Interview with the DON on 02/13/17 at 2:45 PM, confirmed the facility would identify on admission if the residents needed preventative measures, and the facility would complete the Braden Scale and Malnutrition Assessment on admission and quarterly. Record review revealed that Resident #1's Braden Scale completed on, 12/08/16, revealed a score of 11, indicating the resident was a High Risk for pressure sore. An interview on 01/17/17 at 3:45 PM, with the Director of Nurses (DON) revealed the facility does not discuss residents in the Patient At Risk (PAR) meetings, unless they have open areas. The DON stated in response to the State Agency (SA) surveyor's question when they had noticed the facility was finding the wounds already at a Stage 3 (three), did the facility see that they had a concern with preventive measures. The DON stated, No. Review of the Patient At Risk (PAR) notes on 12/08/16 revealed no documentation to address/discuss the (Suspected Deep Tissue Injury) SDTI on Resident #1's right heel identified on 12/08/16. The PAR note on 12/21/16 revealed the SDTI to the right inner heel that was identified on 12/08/16 was discussed for the first time. PAR notes on 01/06/17 revealed the SDTI to the right heel, and Stage 3 (three) pressure ulcer to the left heel was documented. PAR notes on 01/13/17, after the discovery of the two reddened areas observed during the wound care on 1/11/17 revealed, Multiple wounds noted: Stage 3 (three) left heel, SDTI right heel, and Stage 1 (one) in two areas to right outer foot. Review of the Weekly Wound Evaluations dated 1/12/17 revealed (1) Stage one (1) pressure ulcer to the outer right foot one and two tenths (1.2) cm length, nine tenths (0.9) width, and zero (0) cm depth. (2) Stage one (1) pressure ulcer to the outer right foot fifth toe five tenths (0.5) cm length, nine tenths (0.9) cm width, and zero (0) cm depth. Review of the Weekly Wound Evaluation dated, 01/04/17, revealed the left heel was identified on, 01/04/17, as a Stage 3 (three) pressure ulcer, 2 (two) cm in length, and 1.5 (one and five tenths) cm in width, with 0 (zero) cm depth. The Weekly Wound Evaluation dated, 1/12/17, revealed the left heel was a Stage three (3) pressure ulcer, and the measurements were unchanged. Record review of Resident #1's Weekly Wound Evaluation revealed the right heel area was identified on, 12/08/16, as a dark purplish area to the inner right heel, 2.5 (two and five tenths) centimeters (cm) in length and 2.5 (two and five tenths) cm in width. The Weekly Wound Evaluation dated, 1/12/17, revealed the right heel Suspected Deep Tissue Injury (SDTI), and the width had decreased to one and five tenths (1.5) cm. Review Resident #1's physician's orders [REDACTED]. Apply to left heel topically one time a day for wound care. Clean area to left heel with wound cleanser. Pat dry. Apply Santyl ointment, cover with calcium alginate. Wrap with kerlix and secure with tape daily. Review of the physician's orders [REDACTED]. Apply skin prep to Stage 1 pressure injury to right outer foot one time a day, and apply skin prep to Stage 1 pressure injury to right outer foot fifth toe daily. Review of the physician's orders [REDACTED]. Interview on 01/18/17 at 1:50 PM, with the Medical Director/Medical Doctor (MD) #1 revealed he stated we have a Nurse Practitioner (NP) that comes once a week, I am in there about one time a month. When they identify the wound, they call me and let me know. They have a treatment plan they go by, and if I want something different, I will let them know. The NP looks at the wounds when she is there. If a wound is not healing then I send them out to wound care. MD #1 confirmed Resident #1 was his patient, and stated, They probably called me about her (Resident #1's wounds) I just don't remember it. Interview on 01/13/17 at 11:45 AM, with the Nurse Practitioner (NP) revealed she began work there in May 2016, and she comes to the facility on ce a week on Monday. The NP stated, I am not called much about wounds. If I am in the building, they will come get me to look at a wound. The NP stated, It was very difficult around September 2016, it was hard to get information, the wound care nurse left, there was inconsistency with wound care, different people were doing the wound care, and then (LPN #2) took over. It was very difficult to track down staff to get what I needed. I don't have computer access so I can't see what's on the computer unless a nurse pulls it up for me. The NP confirmed in an interview on 02/13/17 at 2:15 PM, the facility uses a communication book for updates that she would need to address while she is in the building, and stated, I only see acute residents. They usually have something going on when I see them once a week on my visit. I have never given any orders on wounds, they would call MD #1 or MD #2, they don't call me. Interview on 01/12/17 at 11:00 AM, with the Nurse Consultant confirmed LPN #2 began providing wound care in the facility in or around August 2016, and she provided a one on one in-service to LPN #2 on 11/29/16 of wound care, and documentation of wounds. Review at this time of an In-Service Record 1:1 dated 11/29/16 with the Topic: Wound care and documentation. Review (Name of Medical Technology Company) manual. Gave copy to treatment nurse. Section reviewed and given to treatment nurse. Skills check completed. The Topic was presented by the Nurse Consultant. The record was signed at the bottom by LPN #2. The Nurse Consultant stated she did not have the contents of the in-service with her at the facility. Interview on 01/13/17 at 2:15 PM, with (Name of Medical Technology Company) Certified Wound Nurse confirmed she comes to the facility about once a month, and she doesn't look at all the wounds because she can only evaluate the residents who are not receiving skilled care. She stated they have a NP that they get to look at the wounds every week. I will go with the treatment nurse to look at a wound if he has questions, and I will give him suggestions. We also provide an (Name of Medical Technology Company) wound care manual that indicates the stages of wounds, and gives recommended wound care for wounds, and they use that. Review of the Admission Record revealed Resident #1 was admitted by the facility on 09/10/15, with [DIAGNOSES REDACTED]. Review of the most recent MDS with an Assessment Reference Date (ARD) of 12/28/16 revealed a Brief Interview for Mental Status (BIMS) score of zero (0) which indicated the resident was rarely, or never understood. Further review of the MDS revealed Resident #1 was totally dependent, and required two person physical assist with ADL care. Resident #1 was assessed at risk for development of pressure ulcers, and had one (1) unstageable-deep tissue area. The Skin and Ulcer Treatments included: Pressure reducing device for the bed. Nutrition or hydration intervention to mange skin problems. Pressure ulcer care. Applications of ointments/medications. Resident #12 On 1/13/17 at 2:05 PM, an observation revealed LPN #2 provided wound care to Resident #12's medial aspect of the left foot. LPN #2 removed the dressing The wound bed was red, with a reddish-purpled coloration to the skin around the wound. There was a moderate amount of serosanguinous drainage. There was a slight foul odor. The wound was approximately five (5) cm in diameter. LPN #2 reported this was a Stage four (4) pressure ulcer. LPN #2 proceeded to the left lateral foot area, which was a reddened area, approximately one (1) cm in diameter. There was no drainage. LPN #2 provided the wound care as ordered. Resident Resident #12's Weekly Wound Evaluation dated 1/9/17 identified the Stage four (4) pressure to the left medial foot area. The reddened area to the left lateral foot was identified on 1/12/17 as a Stage one (1) per the Weekly Evaluation at 1:05 PM. An observation on 1/13/17 at 2:50 PM, revealed Resident #12's wound care to her right great toe was provided by LPN #2/Treatment Nurse. Resident #12's lower extremities were drawn up due to contractures of her bilateral lower extremities, and she was wearing heel protectors at this time. LPN #2 removed the dressing to reveal the wound was free of odor, and appeared to be almost healed. The wound area was approximately one half inch (1/2) in diameter at the corner of the toenail, and pink coloration with no skin break. LPN #2 provided the wound care as ordered. Resident #12's most recent Weekly Wound Assessment Evaluation dated 1/9/17 documented a Stage three (3) Pressure Ulcer to the right great toe. An observation on 1/13/17 at 3:25 PM, revealed LPN #2/Treatment Nurse provided Resident #12's wound care to the Stage 2 (two) pressure ulcer to the coccyx area. LPN #2 removed the dressing. The wound had no drainage. The wound bed was red with an excoriated appearance. The wound edges were pink. The wound was approximately one to one and a half (1-1 1/2) cm in diameter. The wound care was provided as ordered. Resident #12's most recent Wound Assessment Evaluation dated 1/9/17 identified the Stage two (2) pressure ulcer to the coccyx. An interview on 01/13/17 at 4:00 PM, with the Director of Nurses (DON) revealed the Stage 3 (three) pressure ulcer on Resident #12's right great toe was identified at the wound care clinic. The DON reported they were not aware of the new pressure areas until the report from the wound care center was received on 1/2/17. The Body Audit on 12/25/16 only documented the wound to the left foot. An interview with RN #3 on 2/17/17 at 12:05 PM, revealed she no longer was employed at the facility. She had left a few days before the state survey. RN #3 stated she did recall Resident #12, and she had identified an area on the ball of her left foot. RN #3 stated she could not remember what she wrote, it had been two months ago. RN #3 stated she did notify the physician, and that you would just have to go by what I wrote. Review of Resident #12's Weekly Body Audits revealed on 12/25/16 a Stage 2 (two) pressure area was identified on the left outer foot by Registered Nurse (RN) #3. This was the only pressure ulcer documented, and identified at this time. Review of the Nurses' Notes dated 12/25/16, revealed a pressure ulcer was noted to the left outer foot per body audit. Medical Doctor (MD) #1 was notified, and new orders received. There was no documentation regarding a pressure ulcer to the right great toe. The note was documented by Registered Nurse (RN) #3. Review of the physician's orders [REDACTED].#12 to the wound care center. The appointment was made for 1/2/17 at 9:30 AM. Review of the physician progress notes [REDACTED].#12 was seen and evaluated by Medical Director/Medical Doctor (MD) #1, and was currently being treated for [REDACTED]. There was no documentation noted to address a wound to the right great toe, or coccyx. Review of the (Name of Wound Care Center) report dated 01/02/17, revealed Resident #12 had a Stage 4 (four) pressure ulcer to the left medial foot, with an onset date of 12/25/16. The facility assessed this wound a Stage two (2) on 12/25/16. The measurements documented for the left medial foot pressure ulcer at the wound care center indicated the wound size had increased, and there was now some depth. A Stage 3 (three) pressure ulcer to her right great toe, with an onset date of 12/25/16. (The Stage three (3) to the right great toe was not identified on the facility's Body Audit, or Wound Evaluation dated 12/25/16, it was not identified until 1/2/17 at the wound care center). A Stage 2 (two) pressure ulcer to the coccyx, with an onset date of 1/2/17. The resident's Body Audit, and Wound assessment dated [DATE], did not identify a wound to the right great toe, or the coccyx. Review of Resident #12's Weekly Wound Assessments revealed: On 12/25/16 the first observation of a Stage 2 (two) pressure ulcer to the outer left foot measuring three tenths (0.3) cm x three tenths (3.0) cm x zero (0) cm. On 1/2/17 at 4:23 PM the first observation on 12/25/16 of a Stage 4 (four) pressure ulcer was identified to the resident's left medial foot measuring four (4) cm x three and nine tenths (3.9) cm x one tenth (0.1) cm. On 1/2/17 at 4:37 PM, after the resident's wound care center appointment earlier that morning at 9:30 AM, a Stage 3 (three) pressure ulcer was identified on the resident's right great toe, measuring three tenths (0.3) cm x four tenths (0.4) cm x one tenth (0.1) cm. The Date First Observed box was blank. On 1/2/17 at 4:41 PM, after the resident's wound care center appointment earlier that morning, a Stage 2 (two) pressure ulcer was identified to the resident's coccyx area measuring two x two x one-one hundredth (2 x 2 x 0.01) cm. The Date First Observed box was blank On 1/12/17 at 1:05 PM a Stage 1 (one) non blanchable area was identified to the resident's left lateral foot measuring one and four tenths (1.4) cm x one and five tenths (1.5) cm. Review of Resident #12's Skin Observation sheet dated 12/22/16 to 1/13/17 revealed the Certified Nursing Assistants (CNAs) checked either None of the Above, or Not Applicable, indicating no scratches, red areas, discoloration, skin tears, or open areas were observed. Interview on 01/12/17 at 7:50 PM, with CNA #7 revealed she stated, I never seen any problems with her skin that I would need to report. CNA #7 confirmed her documentation on the Skin Observation Sheet was correct, and she had no skin problems. Interview on 2/13/17 at 2:40 PM, revealed CNA #4 stated the CNAs report skin problems to the nurses. CNAs have been provided in-services about reporting skin issues to the nurses, and CNAs also document skin observations in the computer, which goes directly to the nurses. Review of Resident #12's Treatment Administration Record (TAR) for January 2017, revealed the following physician's orders [REDACTED]. Start Date 1/2/17. (2) Clean Stage 4 pressure ulcer medical aspect of left foot with normal saline, pat dry, apply calcium alginate with silver, cover with ABD pad, wrap with kerlix, secure with tape 3x weekly and PRN. Start Date 1/11/17. (3) Clean Stage 2 pressure ulcer on the coccyx with normal saline, pat dry, apply collagen cover with border gauze 3x weekly and as needed. (3) Apply Sure Prep to left lateral foot daily. Start Date 1/13/17. Review of Resident #12's Admission MDS with ARD of 11/3/16, revealed the resident was assessed to be at risk for developing pressure ulcers. There were no pressure ulcers coded on this assessment. The Skin and Ulcer Treatments was checked for applications of ointments and medications. Interview on 1/18/17 at 1:50 PM, with the Medical Director/Medical Doctor (MD) #1 revealed the facility notifies him the day of or the day after when they identify a wound. MD #1 further revealed he is updated about wounds during monthly rounds. MD #1 stated the facility has no formal sit down meeting to discuss wounds. The staff has a protocol that they go by to treat wounds. MD #1 stated he tries to look at the residents' wounds when he makes rounds. MD #1 revealed that he couldn't remember if he was told about the Stage 3 pressure wound to the right great toe of Resident #12. MD #1 stated, I'm pretty sure I looked at it when I rounded on the 28th (December). A review of the Nurse Practitioner (NP) notes dated 11/21/16 to 12/27/16 revealed Resident #12 had no reports of skin rashes or w

Based on staff interview, record review, and facility policy review, the facility failed to identify and implement preventative measures to reduce the amount of facility acquired pressure sores through a quarterly Quality Assurance Performance Improvement (QAPI) program for one of four (1 of 4) quarters reviewed. Findings include: Review of the facility's policy titled, QAPI Program stated each department along with the QAPI committee would identify critical items within that department's area of responsibility that must be monitored and reported. These items are those things most important to the successful functioning of the department, the quality of services provided to the resident, or areas that are inherently high risk. The QAPI committee will maintain written minutes of its activity. This is accomplished by the use of the Quality Assessment and Performance Improvement Committee Minutes form. Open improvement plans will be discussed and either resolved, revised, or continued. Minutes and documentation of the committee's activity will be maintained in a binder and should be kept by the Administrator. Review of the 672 Resident Census and Conditions dated 02/14/17 indicated the facility had a total of eleven pressure ulcers excluding stage one, and that only four residents had pressure ulcers on admission. The facility had seven facility acquired pressure ulcers that were identified on the State Agency (SA) annual survey's initial tour of the building on 01/11/17. Review of the QA meeting minutes dated 12/15/16 indicated the committee only noted there were seven Ulcers/Skin concerns from the previous November meeting, but did not indicate that these were Facility Acquired. The QA Committee Minutes indicated the Open items/action plans were [MEDICATION NAME] skin test compliance and medical records audits. The Director of Nurses (DON) stated the facility does not discuss residents in the Patients at Risk (PAR) meetings, unless they have open areas. The State Agency (SA) surveyor asked the DON when they had noticed the facility was finding the wounds already at a Stage 3 (three), did the facility see they had a concern with preventive measures and this may be an area that they should have implemented in the QAPI or QA program, and the DON stated, No. The DON confirmed she usually was responsible for the QA book, and maintains the meeting minutes. The DON confirmed in a later interview on 02/14/17 at 2:45 PM, usually all the department heads are in the meeting, and each area brings in any concerns. The DON stated, We discuss pressure sores but not in detail. We discussed the amount of wounds for November, but confirmed they did not talk about if the wounds were facility acquired. The DON confirmed the QA committee was not aware there was a problem with facility acquired pressure ulcers until the State Agency (SA) pointed it out to the facility. The DON confirmed her last day as the DON was 02/03/17, and she did not know who was in charge of QA at this time. Interview with the Minimum Data Set Registered Nurse ( MDS/RN) #2 on 02/14/17 at 9:45 AM, confirmed they have a QA meeting every other month with the medical director, but she was not aware they discussed pressure sores that were acquired in the facility, nor have they had that noted as a concern area to monitor. Interview on 01/13/17 at 1:30 PM, with the Medical Director (MD) #2 confirmed that he does not know what a PAR meeting was, and that he does not attend the care plan meetings, but he does attend the Quality Assurance (QA) meeting every other month. MD #2 stated he doesn't recall the facility talking about facility acquired pressure sores, but they do discuss how many pressure sores are in the building. MD #2 confirmed he was not aware his residents had acquired pressure ulcers in the facility. Interview with the Administrator on 02/14/17 at 1:55 PM, confirmed he had began his employment at the facility as the Administrator on 08/08/16, and that he had been to one QA meeting in October of 2016. The Administrator confirmed he was just told today that he would be maintaining the QA binder from this point on, and stated, I wasn't aware of it until today that I was over QA, but they told me today. The Administrator confirmed the DON stepped down from the position on 02/13/17, and no specific person has been in charge of QA until today.