Every finding on record at Vancrest-Upper Valley

Based on record review, staff interview, observation, and policy review, the facility failed to properly assess and obtain consultation for existing pressure ulcers in a timely manner to prevent the worsening of a pressure ulcer. This resulted in Actual Harm on 06/26/26 when Resident #112 was admitted to the facility with a stage II pressure ulcer which was not assessed by the facility or the wound physician and deteriorated to a stage three pressure ulcer with slough to the wound bed. The facility also failed to administer pressure ulcer treatment per the physician's order. This affected one (Resident #112) of two residents reviewed for pressure ulcers. The facility census was 114 residents.Findings include:Record review revealed Resident #112 was admitted on [DATE] with diagnoses including Alzheimer's disease, left humerus fracture, sacrum fracture and hypertension. Review of the care plan for Resident #112 revealed the resident was at risk for the development of skin breakdown related to decreased mobility and incontinence. Interventions included the following: weekly skin assessments per nurse, assess and record changes in skin status, report changes in skin to the physician, complete skin risk assessment quarterly, minimize pressure over bony prominences, provide/monitor effectiveness of pressure relieving or reduction device. Review of the pressure ulcer risk assessment (Braden scale) for Resident #112 dated 06/25/26 revealed the resident scored a 15 on a scale of zero to 23 which indicated the resident was at mild risk for the development of pressure ulcers. Review of the progress note dated 06/26/26, written by Licensed Practical Nurse (LPN) #406 documented Resident #112 returned from a hospital stay with a fluid filled blister to right buttock measuring two centimeters (cm) in length by one cm in width with orders to apply skin prep to the area once daily and refer the resident to be evaluated by a wound specialist at Wound Company (WC) #1. Review of the physician's orders for Resident #112 revealed an order dated 06/25/26 for skin prep to right buttock/sacral area every shift for wound care with a start date of 06/25/26 and a stop date of 07/09/26. Review of the Minimum Data Set (MDS) assessment for Resident #112 dated 06/29/26 revealed the resident was cognitively impaired, required staff assistance with activities of daily living (ADL), and did not have pressure ulcers. Review of the Treatment Administration Records (TARs) for Resident #112 dated June and July 2026 revealed the treatment order to the right buttock was signed off as completed. Review of the medical record for Resident #112 dated 06/26/26 to 07/08/25 revealed there were no documented assessments or measurements of the wound to the resident's right buttock. Review of the progress note dated 07/09/26 and written by LPN #406 revealed the wound to the resident's right buttock was open and measured 1.6 cm in length by 1.4 cm in width by 0.2 cm in depth with yellow slough and a small amount of serosanguineous drainage noted to the wound bed. The nurse obtained a physician's order for a low air-loss and a referral to WC#1. Review of the weekly skin assessment for Resident #112 dated 07/09/26 per LPN #406 revealed the wound to the resident's right buttock was classified as a stage III pressure ulcer (a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible). Review of the physician's orders for Resident #112 revealed an order dated 07/10/26 to cleanse the pressure ulcer to the right buttock with saline, gently pack with calcium alginate, and cover with bordered foam daily and as needed. Review of the wound assessment note for Resident #112 dated 07/13/26 per Certified Nurse Practitioner (CNP) #300 with WC #1 revealed the resident had a stage III pressure injury to the right buttock which measured 2 cm in length by 1.5 cm in width by 0.2 cm in depth with a small amount of serosanguinous drainage noted. Part of the wound bed contained pink granulation but there was a large amount of adherent slough. CNP #300 mechanically debrided (a procedure in which a healthcare provider uses a scalpel, scissors, or curette to precisely cut away dead, damaged, or infected tissue from a wound) the wound bed. Resident #112 tolerated the procedure well with a pain level of two on a scale of zero to 10 with 10 being the worst pain and had a moderate amount of bleeding following the debridement which was controlled with pressure. Following the debridement the wound measured 2 cm in length by 1.5 cm in width by 0.3 cm in depth. Review of the care plan for Resident #112 dated 07/13/26 revealed the resident had an actual pressure ulcer related to decreased mobility, fragile skin, impaired nutritional status and incontinence. Interventions included the following: measure and document condition of skin weekly, provide resident with incontinence are after each incontinence episode, provide and monitor effectiveness of pressure relieving device. Review of the physician's orders for Resident #112 revealed an order dated 07/14/26 to cleanse the wound to the right buttock with saline, apply Medihoney and cover with bordered foam every dayshift and as needed. During an interview on 07/15/26 at 2:35 P.M., LPN #406 stated she assessed Resident #112's skin upon the resident's readmission from a hospital stay on 06/26/26 and noted the resident had developed a blister to the right buttock which she acknowledged was a stage two pressure ulcer. LPN #406 verified she obtained an order for skin prep the pressure ulcer and for the resident to be referred to WC #1 for evaluation of the wound. LPN #406 confirmed the facility did not assess Resident #112's wound again until 07/09/26 and at that time the wound had deteriorated to a stage III pressure ulcer with slough tissue present in the wound bed. LPN #406 stated the order for Resident #112 to be evaluated by a wound specialist with WC #1 was not implemented timely and the resident was not seen by CNP #300 until 07/13/26 at which time the wound required incisional debridement. LPN #406 further confirmed pressure ulcers should be assessed and measured at least once weekly. Observation on 07/16/26 at 9:13 A.M. of wound care for Resident #112 per LPN #406 revealed the nurse removed a white bordered dressing dated 07/15/26 with minimal drainage. The area under the dressing was raised and bright red with a dime-sized reddened open area. LPN #406 completed the treatment and applied foam bordered gauze per the physician's order. During an interview on 07/16/26 at 9:23 A.M., LPN #406 verified Resident #112's wound care physician's order was for foam bordered gauze and not a white bordered dressing which staff had applied to the wound on 07/15/26. LPN #406 stated it appeared Resident #112 had experienced an adverse reaction to having the wrong dressing applied on 07/15/26. Review of the facility policy titled Pressure Ulcer Risk and Management dated 01/20/25 revealed measurements and treatment evaluations of pressure areas would be completed weekly during skin rounds.

Based on staff interview and policy review the facility failed to offer and administer the Coronavirus (COVID-19) vaccines to employees. This had the potential to affect all residents in the facility. The facility census was 114 residents. Findings include:Interview on 07/15/26 at 3:32 P.M. with Business Office/Human Resource Manager (BO/HRM)#402 confirmed there are no employee vaccinations in the employee files. BO/HRM #402 stated Infection Control Nurse (ICN) #408 would have any employee vaccine forms.Interview on 07/15/26 at 3:40 P.M. with ICN #408 verified there was no documentation of any employee being offered or given the COVID vaccines per the COVID policies. Review of the facility policy titled Coronavirus Disease (COVID-19) dated May 2023 revealed all staff would be educated and offered the COVID-19 vaccine. Staff would record the date of administration of the COVID-19 vaccine and keep it in the employee file.

Based on observation, staff interview, manufacturer instruction, and policy review, the facility failed to maintain the ice machine and distribute food in a sanitary manner. This had the potential to affect all of the residents in the facility with the exception of four facility-identified (Residents #10, #32, #37 #55) who did not receive food from the facility kitchen. The facility census was 114 residents.Findings include: 1. Review of the monthly ice machine cleaning log revealed the kitchen ice machine was cleaned on 06/05/26. Observation 07/14/26 at 10:02 A.M. with the Dietary Manager (DM) revealed the ice machine had a thin black layer along the lip of the ice chute. The DM wiped the lip of the ice chute with a damp cloth and a black substance came off the chute onto the cloth. Interview on 07/14/26 at 10:03 A.M. with the DM confirmed the ice chute was dirty and the maintenance department was responsible to clean the ice machine on a monthly basis. Review of the manufacturer's instruction for the ice machine undated revealed the ice machine should be cleaned and sanitized every six months and when dirty. 2. Observation on 7/14/26 at 11:02 A.M. of the food line revealed [NAME] #403 with gloved hands moved the dish holder cart to her right, retrieved a package of buns, took the package of buns to the tray line, reached into the bag of buns with her gloved hand, removed a bun and prepared a sandwich. While wearing the same gloves [NAME] #403 continued to serve the lunch trays, using a gloved hand to remove tacos from the tray. The DM then walked around the tray line, obtained a set of tongs and laid them on the serving line in front of the tacos. Interview on 07/14/26 at 11:08 A.M. with the DM confirmed [NAME] #403 had stepped from the tray line touched unclean items and had then returned to the serving line and touched food items without changing gloves. Record review of the facility policy titled Food Preparation and Service dated October 2022 revealed cross contamination can occur when disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, utensils, etcetera that are not adequately cleaned.

Based on medical record review, observation, staff interview, and policy review, the failed to ensure medications were not left unattended with a resident. This affected one (Resident #21) of three residents observed for medication administration. The facility also failed to ensure the medication cart was locked while left unattended in the hallway. This had the potential to affect the 15 facility-identified independently mobile residents on Center Hall (Residents #7, #16, #20, #22, #40, #49, #63, #64, #69, #89, #90, #93, #105, #118, and #119.) The facility census was 114 residents. Findings include: 1.Review of the medical record for Resident #21 revealed an admission date of 04/26/18 with diagnoses including diabetes mellitus, schizoaffective disorder, Alzheimer's disease, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 04/25/26 revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living (ADLs.) Observation on 07/13/26 at 11:42 A.M. revealed Resident #21 sitting in a chair in the common area on the memory care unit with a medication cup with several medications in her hand. Licensed Practical Nurse (LPN) #324 was across the room assisting another resident with medication administration. Interview on 07/13/26 at 11:44 A.M. with LPN #324 confirmed she had given Resident #21 her medications and went across the room to assist another resident with medication administration. LPN #324 verified she had not stayed with Resident #21 to observe the resident consuming her medications. Review of the facility policy titled Administering Medications revised April 2019 revealed during administration of medications, the personnel administering the medication will stay in residents' presence until all medications have been given. 2. Observation on 07/14/26 at 7:30 A.M. revealed LPN #337 left the medication cart unlocked and unattended while she administered medications to Resident #118. The medication cart was in the hallway across from Resident #118's room. Resident #7 was near the medication cart at the time it was left unattended and unlocked. Interview on 07/14/26 at 7:40 A.M. with LPN #337 confirmed she had left the medication cart unlocked and unattended while she administered medications to Resident #118. Review of the facility policy titled Medication Labeling and Storage revised February 2023 revealed the facility ensures all medications are locked when unattended. Review of the facility policy titled Administering Medications revised April 2019 revealed the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on medical record review, staff interview and policy review the facility failed to offer influenza and pneumococcal vaccinations to residents. This affected four (Residents #22, #34, #59, and #111) of five residents reviewed for vaccinations. The facility census was 114 residents. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 11/02/24 with diagnoses including congestive heart failure, dysphagia, and ulcer of the esophagus. Review of the medical record for Resident #22 revealed there was no documentation of the influenza or pneumococcal vaccine being offered or administered to the resident. 2.Review of the medical record for Resident #34 revealed an admission date of 09/06/24 with diagnoses including venous insufficiency, type two diabetes mellitus, and rheumatoid arthritis. Review of the medical record for Resident #34 revealed there was no documentation of the influenza or pneumococcal vaccine being offered or administered to the resident. 3.Review of the medical record for Resident #59 revealed an admission date of 06/24/25 with diagnoses including rheumatoid arthritis, dementia, and chronic kidney disease. Review of the immunization consent form for Resident #59 dated 06/25/25 revealed the resident's family representative gave consent for the resident to have the influenza vaccine and the pneumococcal vaccine. Further review of the medical record revealed Resident #59 was not administered the pneumococcal vaccine. 4.Review of the medical record for Resident #111 revealed an admission date of 06/09/25 with diagnoses including type two diabetes mellitus, nontraumatic subdural hemorrhage, and chronic obstructive pulmonary diseaseReview of the immunization consent form for Resident #11 dated 06/10/25 revealed there was no consent for the influenza vaccine or the pneumococcal vaccine. Review of the immunization report for Resident #111 dated 07/15/26 revealed the resident received the influenza vaccine on 01/19/26. Interview on 07/15/26 at 3:04 P.M. with Licensed Practical Nurse (LPN) Unit Manager #408 confirmed there wa no documentation of Residents #22 and #34 being offered or administered the influenza or pneumococcal vaccines. LPN #408 verified Resident #59 had not received the pneumococcal vaccine despite consent for the vaccine obtained on 06/25/25. LPN #408 stated there was no follow up on Resident #111 regarding if the pneumococcal vaccine was to be administered or not. Review of the facility policy titled Influenza Vaccine dated March 2022 revealed all residents will be offered the influenza vaccine annually. If a resident received or refuses the vaccine it will be documented in the medical record.Review of the facility policy titled Pneumococcal Vaccine October 2023 revealed all residents will be offered the pneumococcal vaccine. If a resident received or refuses the vaccine it will be documented in the medical record.

Based on medical record review, review of resident fund accounts, staff interview, and policy review, the facility failed to ensure residents' personal funds were deposited in an interest-bearing account. This affected four (Residents #11, #22, #40, and #77) of six residents reviewed for resident fund accounts. The facility census was 114 residents. Findings include: 1.Review of the medical record for Resident #11 revealed an admission date of 01/27/25 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension (HTN), and Alzheimer's disease. Review of the resident funds authorization form for Resident #11 dated 12/03/25 revealed the resident authorized the facility to manage the resident's funds. Review of the quarterly statement for Resident #11 dated 06/20/26 revealed an account balance of $374.15. The statement did not include documentation of disbursement of interest to the resident's account. 2. Review of the medical record for Resident #22 revealed an admission date of 11/02/24 with diagnoses including congestive heart failure (CHF), HTN, and dysphagia. Review of the resident funds authorization form for Resident #22 dated 08/05/25 revealed the resident authorized the facility to manage the resident's funds. Review of the quarterly statement for Resident #22 dated 06/20/26 revealed an account balance of $650.00. The statement did not include documentation of disbursement of interest to the resident's account. 3. Review of the medical record for Resident #40 revealed an admission date of 05/07/22 with medical diagnoses including COPD, HTN, and cerebral infarction. Review of the resident funds authorization form for Resident #40 dated 05/07/22 revealed the resident authorized the facility to manage the resident's funds. Review of the quarterly statement for Resident #40 dated 06/20/26 revealed an account balance of $237.60. The statement did not include documentation of disbursement of interest to the resident's account. 4. Review of the medical record for Resident #277revealed an admission date of 07/27/22 with medication diagnoses of HTN, heart failure, and anxiety. Review of the resident funds authorization form for Resident #77 dated 03/08/23 revealed the resident authorized the facility to manage the resident's funds. Review of the quarterly statement for Resident #77 dated 06/20/26 revealed an account balance of $1995.62. The statement did not include documentation of disbursement of interest to the resident's account. Interview on 07/15/26 at 3:39 P.M. with Accounts Receivable (AR) #255 confirmed the accounts for Resident #11, #22, #40 and #77 had not been placed in interest bearing accounts. AR #225 stated none of the residents who had RFA have received interest in the money in their accounts. Review of the facility policy titled Management of Residents' Personal Funds revised March 2021 revealed the resident may have the facility hold, safeguard, and manage his or her personal funds. The policy stated should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident.

Based on medical record review, observation, staff interview, and policy review, the facility failed to notify the physician of resident refusal of treatment. This affected one (Resident #94) of five residents reviewed for positioning. The facility also failed to notify the physician of weight changes as per the physician's order. This affected one (Resident #22) of five residents reviewed for nutrition The facility census was 114 residents. Findings include: 1. Review of the medical record for Resident #94 revealed an admission date of 07/22/14 with diagnoses including diabetes mellitus, paraplegia, and chronic obstructive pulmonary disease. Review of the care plan for Resident #94 revealed it did not include use of the left hand splint nor did it include refusal of the splint. Review of the physician's orders for Resident #94 revealed an order dated 10/23/25 for a left hand splint as tolerated during first shift and to monitor for signs of redness or discomfort. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 05/14/26 revealed the resident had moderate cognitive impairment and limited range of motion to both upper and lower extremities. Review of the splint documentation for Resident #94 for April, May, and June 2026 revealed the resident refused to wear the splint to his left hand daily. Observation on 07/13/26 at 2:31 P.M. revealed Resident #94 had contractures to bilateral hands and was not wearing a hand splint on the left hand. Observation on 07/14/26 at 2:21 P.M. revealed Resident #94 was lying in bed with no hand splint noted to left hand. Interviews on 07/15/26 at 7:57 A.M. with Certified Nursing Assistants (CNAs) #309 and #289 verified Resident #94 had refused to wear the left-hand splint for several months. Interview on 07/16/26 at 8:22 A.M. with Licensed Practical Nurse (LPN) #406 verified she was the Unit Manager for Resident #94's hall and was not aware the resident had refused the left-hand splint for several months. LPN #406 confirmed Resident #94's physician had not been notified of his refusal to wear the left-hand splint as ordered. Review of the facility policy titled Change in Resident's Condition or Status undated revealed the facility should the attending physician of changes in the resident's medical/mental condition and/or status. The nurse should notify the resident's attending physician or physician on call when there has been a refusal of treatment or medications two (2) or more consecutive times. 2. Review of the medical record for Resident #22 revealed an admission date of 11/02/24 with diagnoses including congestive heart failure, dysphagia, and ulcer of the esophagus.Review of the Minimum Data Set (MDS) assessment for Resident #22 dated 06/06/26 revealed the resident and required staff assistance with activities of daily living (ADLs.)Review of the physician's orders for Resident #22 revealed an order dated 06/26/25 to be weigh the resident daily and to notify the physician if resident had a weight gain greater than two pounds in one day or five pounds in one week.Review of the weight record for Resident #22 revealed that on 06/28/26 the resident weighed 168.8 pounds and on 06/29/26 the resident weighed 172.0 pounds. There was no documentation of physician notification of the weight gain on 06/29/26.Review of the weight record for Resident #22 revealed that on 07/11/26 the resident weighed 174.0 pounds and on 07/12/26 the resident weighed 178.0 pounds. There was no documentation of physician notification of the weight gain on 07/12/26.Interview on 07/16/26 at 9:06 A.M with Licensed Practical Nurse (LPN) Unit Manager #406 confirmed Resident #22 had a 3.2 pound weight gain on 06/29/26 and the physician was not notified on 06/29/26 per the physician order dated 06/26/25. Interview also confirmed Resident #22 had a 4.2 pound weight gain on 07/12/26 and the physician was not notified on 07/12/26 per the physician order dated 06/26/25. Further interview confirmed the physician was notified on 07/14/26 of the 07/12/26 weight gain of 4.2 pounds at which time the physician ordered Lasix 40 milligrams (mg) daily.

Based on medical record review, staff interview, review of the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to submit completed Minimum Data Set (MDS) assessments timely. This affected two (Residents #2 and #3) residents of three residents reviewed for discharges. The facility census was 114 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 02/24/26 with diagnoses including anemia, hypertension, and atherosclerotic heart disease and a discharge date of 03/06/26. Review of the medical record for Resident #2 revealed it did not include a discharge Minimum Data Set (MDS) assessment. 2.Review of the medical record for Resident #3 revealed an admission date of 02/26/26 with diagnoses including diabetes mellitus, cirrhosis of liver, and hypertension and a discharge date of 03/21/26. Review of the medical record for Resident #3 revealed it did not include a discharge MDS assessment. Interview on 07/15/26 at 8:59 A.M. with the Director of Nursing (DON) confirmed the facility had not submitted discharge assessments for Resident #2 and #3 to the Centers for Medicare and Medicaid Services (CMS). Review of the facility policy titled, MDS Completion and Submission Timeframes revised October 2021 revealed the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy stated timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual (RAI). Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated October 2025 revealed on page 2-38 through 2-39 that discharge assessments must be completed within 14 days of the resident's discharge from the facility and submitted within 14 days of the MDS completion date.

Based on medical record review, observations, staff interview, and policy review, the facility failed to develop comprehensive person-centered care plans. This affected two (Residents #40 and #94) of five residents reviewed for activities of daily living (ADLs). The facility census was 114 residents. Findings include: 1.Review of the medical record for Resident #40 revealed an admission date of 05/07/22 with diagnoses including chronic obstructive pulmonary disease (COPD), cerebral infarctions, hypertension, and chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 04/17/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #40 revealed an order dated 06/27/26 for an indwelling foley catheter and an order dated 06/29/26 to cleanse left forearm skin tear with saline, apply double layer xeroform and cover with bordered gauze, to change every other day and as needed. Review of the care plan for Resident #40 revealed the care plan did reflect the use of an indwelling catheter nor did it reflect the presence of the resident's skin tear to the left forearm. Interview on 07/15/26 at 11:33 A.M. with the Director of Nursing (DON) confirmed the facility had not developed a comprehensive person-centered care plan to address Resident #40's indwelling catheter or skin tear. 2.Review of the medical record for Resident #94 revealed an admission date of 07/22/14 with diagnoses including diabetes mellitus, paraplegia, and chronic obstructive pulmonary disease. Review of the care plan for Resident #94 revealed it did not include use of the left hand splint nor did it include refusal of the splint. Review of the physician's orders for Resident #94 revealed an order dated 10/23/25 for a left hand splint as tolerated during first shift and to monitor for signs of redness or discomfort. Review of the MDS assessment for Resident #94 dated 05/14/26 revealed the resident had moderate cognitive impairment and limited range of motion to both upper and lower extremities. Review of the splint documentation for Resident #94 for April, May, and June 2026 revealed the resident refused to wear the splint to his left hand daily. Observation on 07/13/26 at 2:31 P.M. revealed Resident #94 had contractures to bilateral hands and was not wearing a hand splint on the left hand. Observation on 07/14/26 at 2:21 P.M. revealed Resident #94 was lying in bed with no hand splint noted to left hand. Interviews on 07/15/26 at 7:57 A.M. with Certified Nursing Assistants (CNAs) #309 and #289 verified Resident #94 had refused to wear the left-hand splint for several months. Interview on 07/16/26 at 8:00 A.M. with MDS Nurse #409 confirmed Resident #94's care plans did not have documentation to support Resident #94 had a left-hand splint for contracture and that the resident refused to wear left-hand splint. Review of the facility policy titled Care Plans Comprehensive Person-Centered undated revealed the facility would develop comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs for each resident.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents received showers and assistance with grooming. This affected one (Resident #94) of five residents reviewed for activities of daily living (ADLs). The facility census was 114 residents. Findings include: Review of the medical record for Resident #94 revealed an admission date of 07/22/14 with diagnoses including encephalopathy, diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 05/14/26 revealed the resident had moderate cognitive impairment and required substantial/maximum staff assistance with eating and personal hygiene and was dependent upon staff for bathing, bed mobility, and toilet hygiene. Review of the shower/bathing documentation for Resident #94 revealed the resident had received a shower/bath every Monday and Thursday from 06/15/26 to 07/13/26 as scheduled. Observation on 07/13/26 at 2:47 P.M. revealed Resident #94 lying in bed sleeping an had an overgrowth of facial hair. Observation on 07/14/26 at 2:21 P.M. of Resident #94 revealed facial hair growth and that resident had not been shaved. Observation on 07/15/26 at 7:55 A.M. revealed Resident #94 was lying in bed watching television and had an overgrowth of facial hair. Interview on 07/15/26 at 7:56 AM. with Resident #94 verified the facility staff had not shaved his face in a while. Interviews on 07/15/26 at 7:57 A.M. with Certified Nursing Assistants (CNAs #309 and #289 confirmed Resident #94 had not been shaved in several days. CNA #309 stated Resident #94 did not refuse care and staff were to shave the resident on shower days Review of the facility policy titled Activities of Daily Living dated September 2023 revealed the facility staff would provide grooming assistance for residents who were unable to carry out ADLs independently. This deficiency represents noncompliance investigated under Complaint Number 2960631.

Based on medical record review, staff interview, and policy review, the facility failed to ensure interventions for contracture management were implemented as needed. This affected one (Resident #94) of two residents reviewed for positioning. The facility census was 114 residents. Findings include: Review of the medical record for Resident #94 revealed an admission date of 07/22/14 with diagnoses including diabetes mellitus, paraplegia, and chronic obstructive pulmonary disease. Review of the care plan for Resident #94 revealed it did not include use of the left hand splint nor did it include refusal of the splint. Review of the physician's orders for Resident #94 revealed an order dated 10/23/25 for a left hand splint as tolerated during first shift and to monitor for signs of redness or discomfort. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 05/14/26 revealed the resident had moderate cognitive impairment and limited range of motion to both upper and lower extremities. Review of the splint documentation for Resident #94 for April, May, and June 2026 revealed the resident refused to wear the splint to his left hand daily. Observation on 07/13/26 at 2:31 P.M. revealed Resident #94 had contractures to bilateral hands and was not wearing a hand splint on the left hand. Observation on 07/14/26 at 2:21 P.M. revealed Resident #94 was lying in bed with no hand splint noted to left hand. Interviews on 07/15/26 at 7:57 A.M. with Certified Nursing Assistants (CNAs) #309 and #289 verified Resident #94 had refused to wear the left-hand splint for several months. Interview on 07/16/26 at 8:22 A.M. with Licensed Practical Nurse (LPN) #406 verified she was the Unit Manager for Resident #94's hall and was not aware the resident had refused the left-hand splint for several months. LPN #406 confirmed Resident #94's physician had not been notified of his refusal to wear the left-hand splint as ordered. LPN #406 confirmed the facility had not implemented any interventions to treat the resident's contracture. Review of the facility policy titled Change in Resident's Condition or Status undated revealed the facility should the attending physician of changes in the resident's medical/mental condition and/or status. The nurse should notify the resident's attending physician or physician on call when there has been a refusal of treatment or medications two (2) or more consecutive times.

Based on medical record review, staff interview, and policy review, the facility failed to provide ongoing dialysis assessments and communications for a dialysis resident. This affected one resident (Resident #8) of one resident who received dialysis. The facility census was 114 residents.Findings include: Review of medical record for Resident #8 revealed admission date of 5/30/25 with diagnoses including end stage renal disease, chronic osteomyelitis, and dependence on renal dialysis.Review of the care plan for Resident #8 initiated 01/10/24 revealed the resident received dialysis. Interventions included the facility staff would coordinate the resident's care with the dialysis center. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 4/11/26 revealed the resident had intact cognition, required set up assistance with activities of daily living (ADLs), and received dialysis. Review of the care plan for Resident #8 initiated 01/10/24 revealed the resident received dialysis. Interventions included the facility staff would coordinate the resident's care with the dialysis center. Interview on 07/15/26 at 11:11 A.M. with Licensed Practical Nurse (LPN) #326 verified there was no routine paperwork documenting communication to or from the dialysis center on Resident #8's scheduled dialysis days. LPN #326 shared the only times she recalled an exchange of communication were if there was a diet change, a lab order or pertinent lab results. Interview on 07/15/26 at 2:09 P.M. with the Director of Nursing (DON) confirmed in the past the facility had used a flowsheet that was used for communication between the facility and the dialysis center. The DON verified the flowsheet had not been used since January 2026 and she was unsure why it had been discontinued. Review of the facility policy titled Dialysis revealed there should be ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments and ongoing communication and collaboration with dialysis facility regarding dialysis and services as outlined in agreement between the facility and the dialysis facility.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure blood pressure medication was administered as ordered. This affected one resident (Resident #118) of three residents reviewed for medication administration. The facility census was 114 residents. Findings include: Review of the medical record for Resident #118 revealed an admission date of 04/02/26 with diagnoses including chronic obstructive pulmonary disease (COPD), nonrheumatic aortic stenosis, and Raynaud's Syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #118 dated 04/08/26 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #118 revealed an order dated 04/17/26 for amlodipine besylate (blood pressure medication) 5 milligram (mg) one tablet daily and to hold the medication for systolic blood pressure less than 100. Review of the blood pressure record for Resident #118 dated 07/12/26, 07/13/26, and 07/14/26 revealed there were no blood pressures recorded. Review of the Medication Administration Record (MAR) for Resident #118 revealed the facility staff administered amlodipine besylate to the resident on 07/12/26, 07/13/26, and 07/14/26. Observation on 07/14/26 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #337 administered amlodipine besylate tablet to Resident #118 but did not obtain a blood pressure prior to administration. Interview on 07/14/26 at 7:40 A.M. with LPN #337 confirmed she had not taken Resident #118's blood pressure prior to administering amlodipine. Interview on 07/14/26 at 11:08 A.M. the Director of Nursing (DON) confirmed Resident #118's medical record did not have documentation to support the facility staff obtained Resident #118's blood pressure prior to amlodipine besylate administration on 07/12/26, 07/13/26, and 07/14/26. Review of the facility policy titled Administering Medications revised April 2019 medications are administered in a safe and timely manner, and as prescribed. The policy stated medications are to be administered in accordance with prescriber orders, including any required timeframe.

Based on medical record review, staff interview and policy review the facility failed to communicate and collaborate with hospice services. This affected one (Resident #9) of two residents reviewed for hospice and end of life care. The facility census was 114 residents. Findings include: Review of the medical record for Resident #9 revealed an admission date of 06/16/23 with diagnoses including senile degeneration of brain, chronic kidney disease, metabolic encephalopathy, and type two diabetes mellitus. Review of the physician's orders for Resident #9 revealed an order dated 04/16/26 for the resident to admit to hospice services for a diagnosis of senile degeneration of the brain.Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 04/27/26 revealed the resident was cognitively intact, required assistance with activities of daily living (ADLs), and received hospice care.Review of the care plan for Resident #9 dated 04/17/26 revealed resident was admitted to hospice services for senile degeneration of the brain. Interventions included the following: call hospice services with any changes, assist with ADLS, provide comfort measures as needed, hospice aide to visit weekly and as needed hospice nurse to visit weekly and as needed.Review of the medical record for Resident #9 revealed it did not include a signed hospice contract between the facility and the hospice provider nor did it include documentation of hospice nurse and aide visits.Interview on 07/15/26 at 1:11 P.M. with Licensed Practical Nurse (LPN) Unit Manager #407 confirmed Resident #9 continued on hospice services. LPN #407 stated there was not a signed contract with hospice services for Resident #9 and there was no communication or documentation present in the facility of hospice visits or any documentation of communication between the facility and the hospice provider.Review of the facility policy titled Hospice Services dated July 2017 revealed the facility would obtain from hospice the plan of care for the hospice resident, the hospice election form, the physician certification and recertification of the terminal illness specific for the resident and hospice physician and attending physician orders specific to each resident.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (Resident #118) of three residents observed for medication administration. The facility also failed to follow transmission-based precautions. This affected one (Resident #129) of five residents reviewed for transmission-based precautions. The facility census was 114 residents. Findings include: Review of the medical record for Resident #118 revealed an admission date of 04/02/26 with diagnoses including chronic obstructive pulmonary disease (COPD), non-rheumatic aortic stenosis, and Raynaud's Syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #118 dated 04/08/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #118 revealed orders dated 04/02/26 for Wellbutrin 150 milligram (mg) one tablet by mouth daily, Buspar 10 mg one tablet by mouth two times per day, docusate sodium 100 mg one tablet by mouth two times per day, and famotidine 40 mg one tablet daily and an order dated 04/20/26 for ferrous sulfate 325mg one tablet by mouth two times per day. Observation on 07/14/26 at 7:30 A.M. of Licensed Practical Nurse (LPN) #337 preparing medications for Resident #118 revealed one of the resident's medications packets had been opened and Wellbutrin, Buspar, docusate, ferrous sulfate, and famotidine tablets were laying on the bottom of the medication cart drawer. LPN #337 used a gloved hand to pick the medications off the bottom of the medication cart, verified the medications against the description on the medication packet, placed the medications into a medication cup, and administered the medications to the resident. LPN #337 put cup of medications to the resident's mouth and poured all the medications into her mouth at one time. One pill missed Resident #118's mouth and LPN #337 used her bare hand to pick the pill off of Resident #118's chest and placed it into the resident's mouth. Interview on 07/14/26 at 7:40 A.M. with LPN #337 confirmed Resident #118's medication packet had been opened prior to administration, and the medications had fallen out and were on the bottom of the medication cart drawer. LPN #337 verified she picked up the Wellbutrin, Buspar, docusate, ferrous sulfate, and famotidine tablets from the bottom of the medication cart drawer and placed them into a medication cup and administered the medications to Resident #118. LPN #337 stated she used her bare hand to take the pill from Resident #118's chest and placed the pill into Resident #118's mouth. Interview on 07/14/26 at 9:35 A.M. with the Director of Nursing (DON) #400 staff were not to administer medications from an opened medication packet nor were staff to administer medications that were found loose on the bottom of the medication drawer. 2. Review of the physician's orders for Resident #129 revealed an order dated 07/13/26 for contact precautions for methicillin-resistant staphylococcus aureus (MRSA) in surgical wound/ Observation on 07/14/26 at 8:07 A.M. revealed there was a sign posted to the right of the door frame of resident #129's which indicated the resident was on contact precautions everyone must clean their hands before entering and leaving the room. Providers and staff must also put on gloves before room entry and discard gloves before room exit, put on gown before room entry and discard gown before room exit and do not wear the same gown and gloves for the care of more than one person. Certified Nursing Assistant (CNA)#288 assisted Resident #129 onto the side of the bed. CNA #288 readjusted Resident #129's gown, physically assisted him to the standing position and held onto Resident #129's gown as he walked with him onto the bathroom and was no longer able to be observed from the hall. CNA #288 then exited the bathroom and walked straight into the hallway. Interview on 07/14/26 at 8:17 A.M. with CNA #288 verified Resident #129 was in contact isolation and he did not wash his hands after removing his gloves and exiting the resident's room. Review of the facility policy titled Isolation, Categories of Transmission-Based Precautions dated September 2022 revealed staff and visitors should wear gloves when entering the room. Gloves are to be removed and hand hygiene performed before leaving the room.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to make prompt efforts to resolve a resident's grievance related to missing property. This affected one (#83) of three residents reviewed for missing property. The facility census was 99. Findings include: Review of the medical record for Resident #83 revealed an admitted [DATE]. Diagnoses included diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure. Resident #83 was admitted to the hospital on 05/29/24 and returned to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was cognitively intact. Interview on 07/22/24 at 9:26 A.M. with Resident #83 stated she was hospitalized in early June 2024 and while she was at the hospital, her roommate at the facility had discharged . Resident #83 stated her roommate's family packed all the roommate's belongings and took the items home. Resident #83 stated when she returned to the facility, she noticed three of her blankets were missing and she notified Social Service of the missing items. Resident #83 stated she had not heard any updates related to her missing blankets. Interview on 07/24/24 at 10:06 A.M. with Social Service (SS) #329 confirmed Resident #83 informed her that she was missing three blankets upon her return to the facility in early June 2024. SS #329 stated Resident #83's roommate discharged at the time Resident #83 was in the hospital and she believed the roommate's family took Resident #83's blankets home. SS #329 stated she called Resident #83's roommate's family to determine if they accidentally took Resident #83's blankets home but did not get an answer and left a message. SS #329 stated she had not followed up on the missing blankets since the initial call to Resident #83's roommate's family. SS #329 confirmed Resident #83's concern related to missing blankets was not documented on the grievance log or in Resident #83's medical record. Review of the facility policy titled Lost and Found revealed the facility shall assist all personnel and residents in safeguarding their personal property. The policy stated the resident or family complaints of missing items must be reported to the DON and reports of misappropriation or treatment of resident property are immediately investigated.

Based on medical record review, resident representative interview, and staff interview, the facility failed to notify resident representative of new order for antibiotic and reason for the use of the medication. This affected one (#1) resident out of two residents reviewed for antibiotic use. The facility census was 99. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included quadriplegia, chronic respiratory failure, anoxic brain damage, persistent vegetative state, and tracheostomy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/30/24, revealed Resident #1 was in a persistent vegetative state. Review of the physician order dated 07/18/24 revealed an order for amoxicillin-pot Clavulanate (Augmentin) 875-125 (antibiotic) milligram (mg) one tablet via gastrostomy (g-tube) every 12 hours for bacterial infection. Review of the physician note, dated 07/18/24, revealed Resident #1 was seen due to redness and swelling of the right jaw. Resident #1's examination was positive for swollen glands and was ordered Augmentin 875-125 mg via g-tube every 12 hours for seven days. Review of the nurse progress note, dated 07/24/24 at 11:21 A.M., revealed Resident #1 continued on Augmentin for swollen lymph node to the right neck. The medical record for Resident #1 revealed no documentation to support the facility notified Resident #1's representative of the order for antibiotic to treat a bacterial infection. Interview on 07/22/24 at 11:11 A.M. with Resident #1's representative stated she was notified Resident #1 was on an antibiotic a few days after the antibiotic started and was told the antibiotic was for a throat infection. Resident #1's representative stated she was not aware of the name of the antibiotic or for how long Resident #01 was to receive the medication. Interview on 07/24/24 at 11:21 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #1 did not contain documentation to support Resident #1's representative was notified of the order for the antibiotic or the reason for the use of the medication. The DON stated the facility did not have a policy for notifying the resident and/or resident representative of order changes.

Based on observation, policy review, record review, and staff interview, the facility failed to follow proper mechanical lift protocols during a resident's transfer from the bed to a wheelchair. This affected one resident (#47) of three residents reviewed for transfers with lifts. The facility census was 99. Findings include: Record review for Resident #47 revealed the resident was originally admitted to the facility on [DATE]. Diagnoses for Resident #47 included cerebral infarction, diabetes mellitus type two, obesity, and heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition and was dependent on staff for transfers. Review of Resident #47's care plans dated 05/01/17 revealed a focus for falls and injuries relating to mobility. Resident #47 utilized a lift for transfers. Interventions included using a Hoyer lift for all transfers with two staff members. Continuous observation on 07/23/24 from 9:16 A.M. to 9:30 A.M. revealed State tested Nurse Aide (STNA) #271 was observed pulling a mechanical lift into Resident #47's room where Resident #47 was observed laying in bed. At 9:30 A.M., STNA #271 was observed opening the door and pulling the lift out of the resident's room. Resident #47 was observed sitting in her wheelchair at 9:30 A.M. During the continuous observation from 9:16 A.M. to 9:30 A.M., there was no other staff observed entering or exiting or standing in Resident #47's room. Interview on 07/23/24 at 9:32 A.M. with STNA #271 verified she was the only staff to use the mechanical lift to transfer Resident #47 at the time of the observation. STNA #271 verified it was in the resident's care plan she was to be transferred using two staff members in the lift. Review of the undated facility policy titled 'Mechanical Lift Policy' revealed two trained staff are to be present at all times while using the mechanical lift.

Based on medical record review and staff interview, the facility failed to ensure a resident had a care plan in place for his behavior with wandering and residing on a secure unit. This affected one (Resident #20) of 27 residents reviewed for care plans. The facility census was 99. Findings include: Review of the medical record of Resident #20 revealed an admitted d of 05/13/24. Diagnoses included dementia with behavioral disturbance and Alzheimer's disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was at a risk for wandering. Review of the form Wandering Risk assessment dated [DATE] revealed Resident #20 was at a high risk for wandering. Review of Resident #20's care plan revealed there was no focus area of wandering or residing on a secure unit. Interview on 07/24/24 at 3:27 P.M. with Licensed Practical Nurse (LPN) #327 verified Resident #20's care plan contained no focus or interventions for wandering or residing in a secure unit.

Based on medical record review, staff interview, policy review, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed timely after a resident experienced a significant change of condition. This affected one (#83) of seven residents reviewed for significant change in condition. The facility census was 99. Findings include: Review of the medical record for Resident #83 revealed an admitted [DATE]. Diagnoses included nondisplaced intertrochanteric fracture of right femur and right clavicle, diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure. Resident #83 was admitted to the hospital on 05/29/24 and returned to the facility on [DATE]. Review of the Medicare five-day MDS assessment, dated 04/14/24, revealed Resident #83 was cognitively intact and required supervision or touching assistance with toilet hygiene, transfers, and toilet transfers, partial/moderate staff assistance with showers and was independent with bed mobility. Resident #83 did not ambulate, did not have a pressure ulcer, and did not have weight loss. The quarterly MDS assessment, dated 05/13/24, revealed Resident #83 was cognitively intact and was dependent upon staff for toilet hygiene, bed mobility, and transfers, required substantial/maximum staff assistance for bathing, and did not ambulate. Resident #83 had no weight loss and did not have a pressure ulcer. Review of the Skin/Wound note dated 05/20/24 revealed Resident #83 had a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to the sacrum. Review of the nutrition/dietary note, dated 06/25/24, revealed Resident #83 had a significant weight loss within the last 30 days. The note stated Resident #83's weight loss was nine pounds or 5.4% weight loss in 30 days. The note stated Resident #83's weight was 156.2 pounds. The nutrition/dietary note, dated 07/09/24, revealed Resident #83 was noted to have 16.6-pound unplanned significant weight loss or 10% in 180 days and weighed 148.6 pounds. Review of Resident #83's MDS assessments from 05/13/24 to 07/23/24 revealed the facility had not completed a significant change MDS assessment for Resident #83. Interview on 07/24/24 at 4:17 P.M. with Quality Assurance (QA) nurse #328 confirmed the facility had not completed a significant change MDS assessment after Resident #83 had a significant weight loss, development of a Stage III pressure ulcer, and decline in two or more Activities of Daily Living (ADLs). QA Nurse #328 stated the facility utilized the RAI 3.0 manual for guidelines on when to complete a significant change MDS assessment. Review of the facility policy titled, Change in Resident's Condition or Status, stated a significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by the staff or implementing standard disease-related clinical interventions and impacts more than one area of the resident's health status. The policy also stated if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition would be conducted as outlined in the MDS RAI manual. Review of the RAI manual 3.0 October 2023 pages two through 24 stated a significant change is a major decline in a resident's status that would not normally resolve without intervention by staff or by implementing standard disease-related clinical interventions, impacts ore than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The RAI manual stated a significant change MDS is appropriate when the resident's condition was not expected to return to baseline within two weeks. The RAI manual also stated a resident must have a decline in two or more areas that included any decline in ADL physical functioning area, emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days), and the emergence of a new pressure ulcer at Stage II or higher.

Based on medical record review, observations, resident and staff interview, policy review and review of medication information from Medscape, the facility failed to administer insulin as physician ordered resulting in a significant medication error. This resulted in actual harm when staff failed to add Resident #10's insulin order to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#10) out of four residents reviewed for insulin administration. Facility census was 100. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE], transferred to the hospital on 06/13/21 and returned to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set, (MDS), assessment dated [DATE] revealed the resident had slightly impaired cognition, was receiving tube feeding and insulin. Review of Resident #10's care plans dated 06/14/21 revealed a focus for risks for hypo/[CONDITION(S)] relating to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's hospital discharge paperwork dated 06/10/21 revealed the resident was receiving insulin [MEDICATION(S)] 100 unit/milliliter (ml) subcutaneously (SQ) three times per day with meals per a sliding scale. The sliding scale instructed the following: if blood sugar is 140 to 189-give two units SQ; if blood sugar is 190 to 239-give four units SQ; if blood sugar 240 to 289-give seven units SQ; if blood sugar 290 to 339-give 10 units SQ; if blood sugar 340 to 389-give 13 units SQ; and if blood sugar is greater than 389 call the physician. Review of Resident #10's progress notes dated from 06/11/21 to 06/24/21 revealed on 06/11/21 Resident #10 was admitted from the hospital with wounds, a feeding tube, a catheter and a wound vac. Per the note dated 06/12/21 at 6:35 A.M. Resident #10 was transported to [CONDITION(S)] per order. Resident #10 arrived back to the facility on [DATE] at 10:40 A.M. and was assessed by the nurse with no issues. Per the note dated 06/13/21 at 1:45 A.M. the resident was assessed by the nurse for the night shift and there were no issues notes, vital signs were within normal limits. Per the note dated 06/13/21 at 10:54 A.M. the resident was observed having convulsions and was sent to the hospital for a change in condition. The nurse documented in the note the resident's blood sugar read as high. The resident's husband and physician were notified of the transfer to the hospital. Review of the note dated 06/24/21 at 2:01 P.M. the resident returned to the facility. Review of Resident #10's hospital paperwork dated 06/13/21 revealed the resident had been admitted to the hospital with altered mental status and convulsions. Per the physician documentation the resident's blood sugar was 758, (high), upon admission and the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was treated, monitored, and was discharged back to the facility on [DATE]. Review of Resident #10's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Further medical record review revealed no orders for insulin were in Resident #10's medical chart from 06/11/21 to 06/14/21. Observation and interview on 07/06/21 at 11:25 A.M. revealed Licensed Practical Nurse, (LPN) #200 administered insulin [MEDICATION(S)] six units subcutaneously per physician order. Resident #10 stated she had no issues receiving her medications at the facility. Resident #10 stated she remembered going to the hospital last month because she was feeling bad, the resident could not recall any details about the event. Interview on 07/06/21 at 1:00 P.M. with the Director of Nursing (DON) verified when Resident #10 was admitted on [DATE], the insulin orders were left out of the medical record and medication plan for the resident by accident. The DON verified Resident #10 had not been administered any insulin during the first two days of her admission to the facility. Per the DON the mistake was a communication error between the day and night shift nurses. DON verified the resident did not receive any insulin from 06/11/21 to 06/13/21 when she was transferred to the hospital for a change in condition. The DON stated, Resident #10 had been admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy titled Drug Regimen Review Policy, dated 09/27/18, revealed per the policy upon admission the nurse is to complete a drug regimen review and prevent clinically significant medication errors. The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medication information from Medscape revealed [MEDICATION(S)] is a rapid-acting insulin used to treat diabetes mellitus type one and two. [MEDICATION(S)] should be administered as physician ordered. Other names for [MEDICATION(S)] include [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] Kwikpen, [MEDICATION(S)] [NAME] KwikPen, [MEDICATION(S)] [MEDICATION(S)], insulin [MEDICATION(S)]-aabc and [MEDICATION(S)]. This deficiency substantiates Complaint Number OH 512.

Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure staff provided ongoing monitoring of a resident's left heel pressure ulcer and failed to notify the physician when the wound deteriorated/began draining. This resulted in Actual Harm to one resident (#75) when facility staff did not provide ongoing monitoring of Resident #75's left heel pressure ulcer including measuring/staging the wound, did not notify the physician when the wound began to drain and Resident #75's left heel ulcer subsequently deteriorated into an unstageable pressure ulcer (the area could not be staged due to presence of slough and/or eschar). Additionally, the facility failed to ensure preventative measures were in place and treatments were completed as ordered by the physician for a second resident's (#112) pressure ulcer, which placed the resident at risk for potential harm. This affected two (#75 and #112) of six residents reviewed for pressure ulcers. The facility identified 10 residents with pressure ulcers. The facility census was 120. Findings include: 1. Review of medical record of Resident #75 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed), muscle weakness, depression, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/12/19, revealed the resident had intact cognition and had unhealed pressure ulcers. Review of the care plan, dated 06/10/19, revealed a focus for skin breakdown related to pressure ulcers. Interventions for the focus included to monitor the skin, treatments per order, notify physician of changes in skin and to complete weekly skin assessments. Review of the physician orders, dated 06/20/19, revealed an order to wash the left heel with normal saline, pat dry, apply [MEDICATION NAME] and calcium alginate. Cover with heel protector then wrap with Kerlix every evening shift for wound care and every 24 hours as needed for wound care. Review of the skin assessment to the resident's left heel, dated 06/26/19, revealed the left heel wound was measured at five centimeters (cm) in length by five cm in width and noted as a pressure wound. This was the first measurement of the resident's wound to her left heel since admission. There was no other description of the wound and no staging of the pressure ulcer. Review of the physician's progress notes, dated 07/16/19, revealed when Resident #75 was admitted to the facility, the resident had bilateral heel wounds, large sacral decubitus ulcer, and myositis of the left gluteal maximus with osteo[DIAGNOSES REDACTED] to the left iliac bone and sacrum. Foot wounds were noted to be healing after skin grafts applied. Further review of Resident #75's weekly skin assessments revealed there was no documentation on the left heel from 06/26/19 until 08/14/19. On 08/14/19, the left heel was documented as the area continued, treatment was in place and there was moderate amount of drainage from the wound. There were no measurements of the wound, description of the wound and what stage the pressure ulcer was. Interview on 08/20/19 at 8:53 A.M. with Resident #75 revealed she had to go to the hospital when she had a wound on her backside. Resident #75 stated she had wounds on her feet which caused her to lay down more which caused the wound on her coccyx. The resident stated she felt the wounds were improving but was unsure of the wound on her left heel. Resident #75 stated she didn't have any pain associated with the left heel wound. Observation on 08/22/19 at 9:37 A.M. of Resident #75's dressing change, with Registered Nurse (RN) #182 and Physician Assistant (PA) #200, revealed the PA was measuring and ordering treatments for the resident's coccyx wound but not the left heel wound. Interview on 08/22/19 at 10:29 A.M. with PA #200 revealed she does care for all the pressure ulcers for all the residents residing in the facility. The PA stated she was not aware Resident #75 had skin breakdown on her left heel and verified she was not currently caring for Resident #75's heel wound and was unaware if it was a pressure ulcer. Observation and interview with Licensed Practical Nurse (LPN) #183 and LPN #186 on 08/22/19 at 11:30 A.M. of Resident #75's left heel wound revealed the wound appeared to be an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar). The heel was covered with a heel protector and Kerlix. Upon removal of the dressing, dated 08/21/19, the wound bed was not visible, there was moderate amount of drainage noted on the dressing, and the tissue covering the wound appeared to be necrotic. LPN #186 measured the wound to be 8.5 cm by 7.5 cm. Interview on 08/22/19 at 11:30 A.M. with LPN #186 and LPN #183 revealed the evening shift nurses do all dressing changes not associated with the wound team and the nurses were to document all findings in the weekly skin assessments. Per LPN #186, all wounds appearing to be pressure related were to be reported to the wound nurse, RN #182. Interview on 08/22/19 at 11:35 A.M. with RN #182 verified Resident #75 had an unstageable pressure wound on her left heel. Per RN #182, the LPNs at the facility do not stage pressure ulcers per facility policy. RN #182 stated as the wound nurse she was to be notified of all skin issues once discovered by nurses and aides to be assessed for treatment by the wound team. RN #182 verified the left heel wound was measured on 06/26/19 to be five cm by five cm. The RN verified LPN #186 measured the wound to be increasing in size. RN #182 stated she had not been notified of the wound and had not assessed the wound herself. 2. Review of Resident #112's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had no impairment in cognition and was always incontinent of urine and bowel. She required extensive assistance of one staff member for bed mobility and dressing. She required extensive assistance with two staff members for transfers. She was at risk for pressure ulcer, with no unhealed pressure ulcers. She had a pressure reducing device for her bed. Review of the resident's care plan, initiated on 07/25/19 and revised on 08/02/19, revealed the resident was at risk for skin breakdown, skin tears, bruising and pressure ulcers due to weakness, fragile skin, decreased mobility and incontinence. Interventions included to apply a protective barrier cream as ordered, assess and record changes in skin status, report pertinent changes to physician, minimize pressure over bony prominence, provide/monitor effectiveness of pressure relieving or reduction device(s) (pressure reduction mattress to bed), treatments per Treatment Administration Record (TAR), and weekly skin assessments by nurse. Review of the resident's admission nursing assessment, dated 07/24/19, revealed the only skin impairment the resident had was a spine abrasion. It measured 5.0 centimeters (cm) in length by 3.0 cm wide. There was no further description of the area. Review of the physician's order, dated 07/25/19, revealed to apply bordered foam daily to mid back spine area until healed for abrasion. This order was discontinued on 08/19/19. Review of the resident's TAR revealed bordered foam daily to mid back spine area was signed off daily as completed. Further review of the physician's orders, dated 08/07/19, revealed to apply skin prep (a liquid that when applied to the skin forms a protective film or barrier) to tips of bilateral great toes due to redness. On 08/09/19, an order was written to apply a foot cradle (a device that attaches to the bed to keep sheets and blankets from touching and rubbing your legs or feet) to the end of the bed. The resident's TAR had multiple blank entries noted for the resident's bed cradle. Continued review of the medical record revealed no further documentation of the resident's skin impairment to the mid back area until 08/06/19. The note indicated redness to area, skin intact. No further description was documented. The next entry for the resident's mid back area was dated 08/19/19 and indicated the physician wanted to discontinue the foam border to the reddened area on her back and a new order was obtained to apply skin prep to reddened area to mid upper back daily. There was no documentation regarding the impairment to the resident's toes. Observation of the resident on 08/19/19 at 10:02 A.M. revealed she had a bed cradle on her bed. The resident's sheet and blanket were under the bed cradle, touching her feet and legs. Observation of care and interview with State tested Nursing Assistant (STNA) #180 on 08/19/19 at 10:05 A.M. verified the bed cradle was not being used properly. Observation during care also revealed a dressing to the resident's mid back dated 08/13/19. Observation and interview on 08/19/19 at 10:56 A.M. with Registered Nurse (RN) #181 revealed the resident's right great toe was red, but blanchable. She verified there was a large bandage on the resident's back dated 08/13/19. Further observations of the resident on 08/21/19 at 8:35 A.M. and 9:02 A.M. revealed she was in bed with her sheet and blankets resting on her feet and legs. The bed cradle was on the bed but not being used properly. Observation of the resident on 08/21/19 at 10:05 A.M. with Licensed Practical Nurse (LPN) #177 revealed the resident had a large foam dressing on her mid back dated 08/19/19. LPN #177 verified the order for a dressing to the resident's back had been discontinued. She stated the order was changed to skin prep on 08/21/19. The reddened area on the resident's mid-back spine area was measured at 7.0 cm by 1.0 cm and was red and not blanchable per LPN #177. She stated the area was a Stage I pressure area. The resident's right great toe was also observed to be red and not blanchable. It measured 1.0 cm by 1.5 cm with skin starting to flake off the middle portion of the reddened area. LPN #177 stated this area was also a Stage I pressure area. Interview with RN Wound Nurse #182 on 08/21/19 at 12:22 P.M. revealed LPNs were not permitted to stage pressure areas at their facility. She stated she assessed the resident and the area to the resident's back was a Stage I, but the right great toe was red and blanchable per her assessment, and therefore, not a Stage I pressure ulcer. She verified there was no documentation indicating the resident's toes were being monitored and there was no additional documentation on the resident's back impairment. Interview with the Director of Nursing on 08/22/19 at 11:06 A.M. verified there were multiple blank entries on the TAR for the resident's bed cradle. She also verified nurses had signed they were placing a dressing on the resident's back from 08/13/19 through 08/19/19 when it had not been changed since 08/13/19. Review of the facility policy titled Pressure Prevention Policy, revised on 01/05/17, revealed the geriatric population is at risk for skin breakdown. The risk becomes greater with co-morbidities, and during times of acute illness. The facility will ensure the nursing staff are providing preventative practices which help decrease the risk of skin breakdown. Procedures included: assessing skin daily during activities of daily living, weekly skin checks by nursing staff, protect skin against friction and shearing force.

Based on medical record review, observation, staff interview, personnel file review, facility policy review and review of Posey Hipsters manufacturer information, the facility failed to ensure all safety injury prevention interventions were in place as physician ordered for residents identified at risk for falls. Actual harm occurred to Resident #26 and #61 when their safety interventions were not in place resulting in hospitalization s and surgical interventions for broken hips. This affected two (#26 and #61) of four residents reviewed for falls. The facility census was 110. Findings include: 1. Medical record review for Resident #26 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/10/18, revealed the resident had severe cognitive impairment and required extensive assistance from two staff members for bed mobility and transfers, and one person physical assistance for ambulation with use of a walker. Review of the plan of care, initiated on 01/27/18, revealed, the resident was at risk for falls/injuries related to history of falls, medications and unaware of own safety needs due to dementia. The interventions included for the resident to wear hipsters (padded protective garment) at all times except during care and this was initiated on 05/04/18. Review of physician orders, dated 04/30/18, revealed an order for [REDACTED]. Review of the fall assessment, completed 06/20/18, identified Resident #26 at a high risk for falling. Review of a nursing progress note, dated 07/10/18 at 1:08 P.M., revealed it described a fall incident that occurred. According to the nurses documentation, the resident was being walked to the restroom by a state tested nursing aide (STNA), lost his balance and was lowered to the floor. The STNA reported the resident did not hit his head. Resident assessment by the nurse revealed some pain noted when moving the left leg/hip. The resident was assisted back to bed with two staff members and use of a gait belt and it was noted the resident had a hard time walking. Further review of the nurse's notes revealed the physician was notified of the fall and complaints of pain. A mobile x-ray of the hip was completed, which indicated a [MEDICAL CONDITION] hip. Resident #26 was transported to the local hospital for evaluation and treatment on 07/10/18. Review of the medical records from the hospital revealed Resident #26 was diagnosed with [REDACTED]. An orthopedic consult was obtained. Resident #26 had a surgical repair of the left hip on 07/11/18. The resident was discharged from the hospital and returned to the facility on [DATE]. Interview with STNA #260 on 07/17/18 at 1:55 P.M. explained the fall event that occurred on 07/10/18 with Resident #26. On that date, she used the gait belt to assist the resident to the bathroom. Resident #260 appropriately used the walker to ambulate. STNA #260 said the resident took a few steps, lost balance and fell backwards. The aide said she caught the resident from behind and tried to lower him more gently to the floor. The resident landed on his lower back/buttocks first and immediately rolled over on the left side in the fetal position. STNA #260 notified other staff for assistance following the fall. The staff member reported she was given a verbal reprimand for ambulating the resident without hipsters in place. Personnel file review for STNA #260 revealed a Corrective Action Record, dated 07/11/18, for a verbal warning signed by the supervisor, employee and the Administrator. It stated the reason for the disciplinary action was because the employee did not ensure the resident (#26) was wearing hipsters when she lowered him to the floor on 07/10/18. The action plan stated the STNA was responsible to safely transfer residents and to ensure all safety equipment was in place at all times. Interview with Licensed Practical Nurse (LPN) #180 on 07/19/18 at 10:32 A.M. revealed the nurse was on duty, but not present when Resident #26 experienced a fall on 07/10/18. The LPN reported they were summoned to the room by STNA #260. Upon arrival, Resident #26 was lying on his back on the floor. During the interview, LPN #180 verified Resident #26 was not wearing hipsters at the time of the fall. 2. Review of Resident #61's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/23/18, revealed the resident was severely cognitively impaired. Resident #61 was assessed as requiring extensive assistance with activities of daily living. Review of a physician order, dated 03/12/18, revealed an order for [REDACTED]. Review of the care plan revealed the resident was at risk for falls/injuries. An intervention, dated 03/12/18, was added for the resident to wear hipsters at all times. Review of a fall risk assessment, dated 05/29/18, revealed Resident #61 was at a high risk for falls. Review of a progress note, dated 07/05/18 at 8:35 P.M., revealed Resident #61 was heard calling out and was found to be laying on the floor in the north east hallway, next to her Geri-chair (geriatric chair). Upon assessment by the nurse, the resident was noted not to be wearing hipsters. A physician order [REDACTED]. Review of hospital records, dated 07/08/18, revealed Resident #61 was admitted on [DATE] with a closed [MEDICAL CONDITION] hip. The resident had surgical repair of the left [MEDICAL CONDITION] on 07/06/18 and was discharged back to the facility on [DATE]. Review of a physician progress notes [REDACTED].#61 was readmitted from a local hospital with [DIAGNOSES REDACTED]. Observation of Resident #61 on 07/18/18 at 1:27 P.M. revealed the resident was lying in bed with her eyes closed. Resident #61's soft touch call light was on her bed and a blue fall mat was on the floor to the left side of her bed. Interview with the Director of Nursing (DON) on 07/18/18 at 2:06 P.M. verified Resident #61 was not wearing hipsters as ordered and per the care plan when she fell from a Geri-chair on 07/05/18. The DON stated Licensed Practical Nurse (LPN) #250 and State tested Nursing Assistant (STNA) #200 were both disciplined for Resident #61 not wearing hipsters as ordered. Review of Posey Hipsters manufacturer information revealed it was a padded garment which featured impact absorbing, soft foam pads over the critical fracture area to help reduce the risk of injuries from a fall, such as [MEDICAL CONDITION]. This deficiency is an example of continued non-compliance from the complaint survey completed on 07/05/18.

Based on observations, record review, staff interview and review of facility policy, the facility failed to provide routine skin cleansing and monitoring of a pressure point under a contracture resulting in harm as evidence by a stage four pressure ulcer with an infection forming at the base of the left thumb for a resident (Resident #7). This affected one of three residents reviewed for pressure ulcers, the facility indicated four residents with pressure ulcers stage 2 or greater. The current census was 124. Findings include. Record review of Resident #7's medical chart revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] revealed the resident was listed as an extensive assist, needing more than one person, for bed mobility, dressing, and personal hygiene. In the area of bathing the resident was listed as needing total dependence. The comprehensive assessment revealed the resident was moderately cognitively impaired. Review of Resident #7's comprehensive care plan dated 10/16/14 did not include a care plan for Resident #7's bilateral hand contractures or interventions to prevent pressure ulcers occurring as a result from the contractures. A revision to the comprehensive care plan dated 12/28/15 revealed no added focuses or interventions regarding the bilateral hand contractures or prevention of pressure ulcers. Review of physician orders dated 10/08/14 revealed the resident was to have a body assessment bi-weekly and skin assessments to be completed weekly and pain assessments to be completed three times a day. Review Resident #7's pain interventions flow sheets for January 2016 and February 2016 listed pain interventions of apply heat, cold pack, cream and lotion, repositioning, activity and exercise, massage, pain medication. There were no pain assessments completed for the resident. Review of Resident #7's Braden scale assessment for predicting pressure ulcers completed on 10/11/15 revealed the resident was a moderate risk due to limited mobility. On 10/10/15 the physician ordered triple antibiotic ointment to be applied to the resident's left hand and to leave open to air. Review of nurses ' notes dated 10/11/15 at 2:15 A.M. and 10/12/15 at 3:15 A.M. revealed the nurses documented triple antibiotic ointment applied to open area on left hand. The order was discontinued on 10/19/15 per the skin assessment completed on the same date which revealed the open area on the palm of the left hand, thumb was resolved. Review of physician's order dated 01/10/16 revealed to apply lamb ' s wool to bilateral hands between fingers and palms, change lamb ' s wool every day and as needed for prevention. Review of Resident #7's treatment administration record, (TAR) for January 2016 revealed the body assessment was charted as abnormal only for the 01/16/16 date, no documentation was noted for what was found on the body assessment. No documentation of any other hand care was noted on the TAR. Review of Resident #7's restorative flow sheets for January 2016 and February 2016 revealed the resident received hand washing twice a day, no other interventions were noted. Review of Resident #7's TAR for February 2016 revealed the body assessment was charted as abnormal from 02/06/16 to 02/24/16, no assessment was completed on 02/27/16. On 02/25/16 the dressing to the left hand was not completed on the third shift and on 02/27/16 the dressing was not completed on second or third shift. On 02/23/16 wound culture was collected. No documentation of hand care was noted on the TAR. Review of Resident #7's acute care plan dated 02/08/16 revealed a problem with the resident's left thumb with a goal for the area to resolve without difficulty. Interventions included notify physician, notify wife, treatment in place, protective measure was to apply Kerlix to the palm. During an interview on 03/09/16 at 9:20 A.M. with Licensed Practical Nurse, (LPN) #105 she stated she was the wound nurse for the facility and she was notified of the wound on 02/10/16. LPN #105 stated she dated the acute care plan wrong and the pressure ulcer was found by the LPN #103 on 02/10/16. On 02/10/16 a nurse's note documented area to anterior left thumb re-opened from pressing index finger with a tight grip. One centimeter, (cm), by one cm area noted triangular in shape, area cleansed with soap and water and calcium alginate applied. A physician's order was received to cleanse the left hand and thumb with soap and water, apply calcium alginate to thumb change every day and as needed until healed. Review of STNA skin reports for January 2016 and February 2016 revealed the reports were completed twice a week. On 02/10/16 the STNA noted a 1 cm by 1 cm triangle on the resident's left hand, no other reports had any documentation regarding the resident's hands. Review of wound nurse's flow sheets revealed on 02/10/16 LPN #105 documented Resident #7 had a pressure site on the left thumb measuring 1.0 cm by 1.0 cm, (no depth charted), LPN #105 listed the wound as unstageable. On 02/11/16 at 10:25 A.M. nurse's note documented calcium alginate changed to left thumb small amount of yellow drainage noted to old dressing no odor noted, due to the way the resident holds that thumb and pain it causes him to move it the nurse was unable to examine the open area at this time,however new calcium alginate was applied. On 02/11/16 at 10:43 A.M. the nurse's note stated the physician was made aware of the area on the left thumb. Review of a skin assessment dated [DATE] revealed LPN #105 documented an area on Resident #7's left hand with yeast smell present. LPN #105 further documented she was unable to view the wound bed, the area was cleansed with soap and water, calcium alginate applied, and rolled wash cloths placed in bilateral palms. The LPN further charted in the wound flow sheet Resident #7 had a pressure ulcer to the left thumb measuring 1.5 cm by 2.0 cm, (no depth charted), unstageable. On 02/18/16 at 1:32 P.M. the nurse documented during the dressing change to the left thumb the area was noted to be getting worse. Unable to measure due to resident being non-compliant and thumb contracted over his index finger. Calcium alginate and treatment nurse called into room to examine thumb. The physician was made aware of the condition of the resident's thumb and suggested the physician come and look at the resident's thumb. Resident's wife made aware of the area to the resident's thumb. On 02/21/16 at 2:01 P.M. the nurse noted dressing change to left thumb the area noted to have increased drainage and a foul odor. On 02/23/16 the physician ordered a wound culture to the left thumb. On 02/24/16 LPN #105 documented in a skin assessment continue same treatment, physician aware of odor to the palm. A wound culture was ordered and the physician was coming to see the resident. Continue with the interventions in place. On 02/24/16 LPN #105 documented on the flow sheet Resident #7 had a pressure ulcer to the left thumb measuring 1.5 cm by 2.0 cm, (no depth charted) as unstageable. On 02/24/16 at 12:00 A.M. the nurse documented a wound culture was collected and given to supervisor. The resident tolerated procedure well. Review of lab result on 02/24/16 of wound culture showed the wound was positive for Proteus Mirabilis and Escherichia Coli. On 02/27/16 the physician ordered the resident to have [MEDICATION NAME] (anti-biotic) 500 milligrams (mg) twice a day for ten days for a positive wound culture. The resident's family member was made aware. On 02/28/16 at 8:30 P.M. the nurse's note revealed the physician was in to see the resident and new orders were received. Physical therapy and Occupational therapy was ordered to evaluate the resident for a splint or foam or a gel to separate the digits from the palm of the right and left hand, if any questions instructed to call the physician. On 03/02/16 LPN #105 charted on the wound flow sheet Resident #7 had a pressure ulcer to the left thumb measuring 1.0 cm by 2.0 cm by 0.2 cm depth as a stage 4. During an interview on 03/09/16 at 9:25 A.M. with LPN #105 it was revealed the nurse charted the pressure ulcer as unstageable in previous assessments because she could not get the resident to open his hand so she could properly visualize the wound and it wasn ' t until the first assessment she completed in February the resident allowed the nurse to examine the wound properly. LPN #105 stated it was during this assessment she was able to fully see the wound and she noted the tendon was visible on the anterior side of the left thumb. On 03/02/16 the physician ordered to discontinue the current treatment to the left hand, cleanse with soap and water, pat dry and apply collagen and silver alginate on top, place rolled Kerlix in the palm of hand, change twice a day until healed. Cleanse right hand with soap and water pat dry, placed rolled Kerlix in palm for protection, change twice a day. Discontinue lamb ' s wool to bilateral hands. On 03/07/16 LPN #105 documented in a skin assessment the wound was a stage 4 pressure ulcer to the left thumb, measured at 1.0 centimeter, (cm), by 2.0 cm by 0.2 cm in depth. The nurse charted in the note section of assessment there was a scant amount of bleeding noted, slight odor noted, collagen with silver alginate, Kerlix rolled in bilateral palms, the tendon showing. Wound staged as a healing stage 4 with surround tissue pink and intact with no signs and symptoms of infections noted. Continue with interventions in place. Observation on 03/08/16 at 4:03 P.M. revealed the resident was lying in bed and he stated he was OK today. Resident #7 denied any pain at the time. His bilateral hands were observed with white material gripped inside his fists. When asked if he could open his hands Resident #7 stated he could not. Observation on 03/09/16 at 10:13 A.M. of the dressing change to Resident #7's hands noted three staff members were present to complete the task, LPN #105, LPN #107, and STNA #104. STNA #104 calmed the resident with distraction and gave one on one attention while the nurse prepared for the dressing change. During the observation it was observed the resident was unable to open his hands when asked by the aide. The resident ' s right hand was clenched in a fist, the thumb of the right hand was over the top of the right index finger and all the fingers on the right hand appeared to be pressing into the palm of the right hand. Resident #7 ' s left hand was noted to be in a clenched fist, the left thumb was over the top of the left index finger and all the fingers on the left hand appeared to be pressing into the palm of the left hand, it was noted Kerlix gauze rolls were in both of the resident ' s palms before the dressing change procedure started. The nurse and the aide placed his hands over the basin and the nurse washed the resident's hands with wash clothes. STNA #104 was able to open the resident's right hand while LPN #107 replaced the Kerlix. Resident #7 became agitated when LPN #107 tried to open his left hand to replace the Kerlix. STNA #104 was able to calm the resident while LPN #105 stood next to the resident holding his right arm and handed supplies to LPN #107. The resident did eventually open his left hand slightly for LPN #107 to replace the dressing on his thumb, at this time the wound was able to be viewed. The wound was located on the left thumb on the palm side of the left hand. The wound was noted to be pink with no bloody drainage visible; the inside of the wound was a white color with slough noted around the edges of the wound. The surveyor was unable to view the tendon of the left thumb due to the angle the resident was holding his hand and the short time before the resident closed his fist. During the dressing change no odor was noted. LPN #107 replaced the calcium alginate to the resident's thumb and placed a new Kerlix to the palm. LPN #105 was able to weave pieces of Kerlix in between the fingers of the resident on the right hand but was unable to complete the finger wrap on the left hand as the resident became agitated and would not open his hand again. During the procedure when the resident's left hand was being cared for the resident continually said, it hurts. Interview on 03/08/16 at 4:03 P.M. with LPN #109 revealed the wound on the resident's left hand was healing. LPN #109 stated the STNAs were supposed to wash the resident's hands. LPN #109 stated no aides had reported to her they were unable to complete hand washing due to the resident resistance to care. The nurse stated the dressing change was completed on day shift and she checked the dressing to make sure it was in place during her shift. LPN #109 stated before the pressure ulcer was discovered lamb ' s wool was to be placed in the resident's bilateral palms daily. LPN #109 stated she would change the lamb ' s wool to the resident ' s hands, however did not actually wash the resident ' s hands herself. Interview on 03/09/16 at 9:18 A.M. with LPN #105 revealed she is the wound nurse for the facility. The LPN stated she was made aware of the pressure ulcer on Resident #7's hand on 02/08/16. LPN #105 stated there was an acute care plan put into action on that date. LPN #105 stated she charted on flow sheets her measurements for the wound. LPN #105 stated the resident did not tolerate the splint on the hand prior to the wound being discovered so lamb ' s wool was to be placed in the bilateral palms. LPN #105 stated no other interventions were in place except hand washing twice a day which the restorative aides were to complete. The nurse denied any reports from other nurses or aides of the resident resisting care and interventions not being completed due to the non-compliance of the resident. Interview on 03/09/16 at 10:56 A.M. with LPN #101 revealed she was the restorative nurse for the facility. The nurse stated Resident #7 did have a request for hand washing. LPN #101 stated the restorative aides washed the resident's hand twice a day. LPN #101 reviewed the restorative aides flow sheets with surveyor. The nurse denied any reports from the aides of the resident resisting care. LPN #101 stated she did not do any of the handwashing herself or care of the dressing to the resident's hands. The nurse stated the hand washing was a nursing intervention and the resident was not on an official restorative program. Interview on 03/09/16 at 11:15 A.M. with STNA #106 revealed she was the restorative aide assigned to Resident #7. STNA #106 stated she was to wash his hands twice a day. STNA stated she has been washing the resident's hand before and after the pressure ulcer was discovered. STNA #106 stated she did not remove the material that was in the resident's palms when she washed his hands. She stated she did not know what lamb ' s wool looked like and could not remember if the resident had the lamb ' s wool in his hands prior to the pressure ulcer being discovered. STNA #106 stated the resident was resistant to care and often did not open his hands for the aide. When asked the aide stated she did not report this to the nurses when the resident was non-compliant with care. Interview on 03/09/16 at 1:39 P.M. with STNA #104 revealed the resident was often resistant to care when it came to his hands. The aide stated she was good at getting the resident to calm down and open his hands for care. STNA #104 stated she often washed his hands during the day, however she did not discover the wound on the resident's left thumb. The aide stated he once had a splint on his left hand, however he did not tolerate it and it was discontinued. STNA #104 revealed she knew the resident was to have lamb ' s wool in his palms for protection but would find the resident without the lamb ' s wool, on those occasions she would report to the nurse and the lamb ' s wool would be placed. The aide stated she could not remember what days the lamb ' s wool was not in place. She stated the resident was unable to remove the lamb ' s wool himself due to the hands being contracted. STNA #104 did stated she did not report to the nurse when the resident was resistant to care and was unable to wash his palms, she stated she would wash the outside of the resident's hands on those days. STNA #104 stated she did not do range of motion with the resident. Interview on 03/09/16 at 3:45 P.M. with LPN #107 denied any reports from aides the resident was not receiving care due to non-compliance. LPN stated she changed the resident's dressing daily after the STNAs washed his hands and she replaced the dressings to the resident ' s hands. She revealed the resident needed two or more staff in the room to do the dressing change due to his resistance to care. LPN #107 stated she did know of any range of motion being completed with the resident. LPN #107 stated nail care is not charted in the medical chart and she had not cut the resident's nails herself. Interview on 03/10/16 at 9:40 A.M. with STNA #110 revealed she was a restorative aide working with Resident #7. STNA #110 stated she has worked with the resident before and after the pressure ulcer was discovered. The aide stated she washed the resident's hands and did not remove the material that was inside the resident's fists. STNA #110 stated the resident was often resistant to care and when he was she would just wash the back of hands and not his palms. STNA #110 stated she did not report to the nurse when the resident was resistant to care. STNA #110 stated the resident did have lamb ' s wool some days in his palms but she could not remember the days when the lamb ' s wool was not in place. Interview on 03/10/16 at 10:15 A.M. with Director of Nursing, (DON) revealed the DON stated she herself had cut the resident's nails in January 2016. DON stated she did not recall on what day she cut the resident's nails and it was not documented in medical chart. DON stated due to the resident's resistance to care it was 'difficult to see the resident's palms'. DON denied any reports from STNAs or nurses the resident was not having palms washed or the skin on the hands assessed. Review of the facility policy titled, 'Protocols for wound care and prevention', dated 12/2000 revealed any resident at risk for, or with a pressure ulcer (whether admitted with or acquired in house) will have evidence of basic nursing practices occurring to aid in prevention and healing of the pressure ulcers, for instance pressure relief, proper turning and positioning, range of motion, and moisture barriers. Listed for pressure relieving resident to have pressure redistribution devices/positioning devices. STNAs are to observe resident's skin condition daily during care and report skin conditions to the licensed nurse.