Every finding on record at Wedgemere Healthcare

Based on records reviewed and interviews for one of three sampled residents (Resident # 1), the Facility failed to ensure they developed and implemented a comprehensive person-centered care plan with interventions, treatment goals, and outcomes that addressed his/her individual recreational activity needs.Findings Include: Review of the Facility's Policy titled, Care Plans, Comprehensive Person-Centered, dated as revised 01/2024, indicated the following:-A comprehensive, person-centered care plan will be developed for each resident; the care plan will include objectives that meet the resident's physical, psychosocial and functional needs is developed for each resident.-The resident comprehensive care plan will identify problem areas, and their causes as warranted and developing interventions that are targeted and meaningful to the resident.-Evaluation of residents is ongoing and care plans are revised as information about the resident and the resident's condition changes.-The Interdisciplinary Team (IDT) reviews and updates the care plan when there has been a significant change in the resident's conditions, when there is a change and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Resident #1 was admitted to the Facility in October 2025 diagnoses included Alzheimer's, major depression, and history of falling.Review of Resident #1's Medical Record from 10/21/25 through 05/11/26 (seven months), indicated there was no documentation to support an Activities Care Plan had been developed and implemented that was person-centered to meet his/her individual recreational activities of choice and interest.Review of Resident #1's Care Plan Meeting Form, dated 04/29/26, indicated that his/her activities of interest included music, games, television, family visits, outdoors, horses, and hot cocoa were reviewed by the Interdisciplinary team (IDT).Review of Resident #1's Comprehensive Care Plan indicated there was no documentation to support that the Facility had developed and implemented a care plan to address Resident #1's recreational activity needs, until 05/12/26 (seven months after his/her admission).During an interview on 05/12/26 at 1:15 P.M., the Activity Director (interim) said the previous Activity Director had left the facility at the end of April 2026. The Activity Director said she reviewed all residents' assessments and care plans and saw that Resident #1 did not have an Activity Care Plan in place. The Director said she created Resident #1's Activity Care Plan today (05/12/26, day of survey).The Director said that the Activity Director is responsible for developing an Activity Care Plan for every resident and that every resident should have one.During a telephone interview on 05/26/26 at 10:29 A.M., the Director of Nursing (DON) said she was not aware that Resident #1 did not have an Activitys' Care Plan in place. The DON said that the Activity Director is responsible for developing Activity Care Plans for all residents. The DON said residents care plans are reviewed at quarterly care plan meetings by IDT. The DON said she was surprised Resident #1 did not have an Activity Care Plan for so long and that it had been missed by the IDT.Review of Resident #1's medical record indicated he/she had a quarterly MDS completed in April 2026, and a care plan for Activities was not in place or added at that time.The DON said that it was her expectation that Comprehensive Care Plans are created by all disciplines, including activities within 21 days of a resident's admission.

Based on interviews and review of the Activity Director's (AD) personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include:Review of the employee file for the Activity Director (AD) indicated the following: - she was offered and accepted the role of AD in January 2026;- she did not possess the completed training and qualifications of an AD;- she signed a job description indicating she was the AD on 1/6/26.Further review of the AD's personnel file on 4/1/26 failed to indicate she was a qualified therapeutic recreation specialist or an activities professional, who had two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program, or was a qualified occupational therapist or occupational therapy assistant. During an interview on 4/1/26 at 7:46 A.M., the AD said she started her current role in January and worked full-time. She said she did not currently hold any certifications or education relevant to the position of AD. She said the vast majority of her career had been in the preschool setting. She also said she had worked in the activities department in a nursing home for five months prior to becoming this facility's AD. The AD said she had not applied for any education or training programs because she was awaiting a response from the facility to see if they would provide financial support for the program. She said she reached out to corporate last week for an answer. The AD said she did not collaborate with or receive oversight from an occupational therapist for her role. She said, prior to last week, she wasn't aware she did not hold the required qualifications for the position.During an interview on 4/1/26 at 8:07 A.M., Rehab Staff #1 said she was the only full time registered occupational therapist at the facility, and she had no involvement in the activity program.During an interview on 4/1/26 at 9:30 A.M., the Regional Nurse said she would expect the AD to be enrolled in an education or training program, have required oversight, or be fully qualified at the time of hire. During an interview on 4/1/26 at 3:30 P.M., the Administrator said, until last week, he was unaware the AD did not have the required qualifications for the role.

Based on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include:Review of the facility's policy titled Resident Council, dated 2/24, indicated but was not limited to the following:-The Resident Council members will meet once each month or as desired.-The facility will provide a designated staff person who is approved by the resident group and facility who is responsible for helping and responding to written request formed at the group meeting.-Department heads must respond to grievances addressed in the minutes in writing before the next meeting.-The resident council may make recommendations for the improvement of resident services, and make recommendations, and serve as an advisory group between the residents and facility. Review of Resident Council Minutes held from October 2025 through March 2026 indicated, but were not limited to, the following: Review of Resident Council Minutes, dated 10/30/25, indicated: Old Business: (review each issue brought up as new business at last meeting. Read the department response that was submitted to show the resolution of the issue and attach the response to the meeting minutes) call bell response time-not resolved; -staff using cellphones, earbuds, and being unfriendly- not resolved. New Business: call light response time, staff often not friendly, staff being on their phones and using earbuds, food arriving cold, and staff speaking another language in common areas. There was no documentation indicating the facility followed-up on the unresolved old business or the new business discussed at the Resident Council meeting on 10/30/25. Review of Resident Council Minutes, dated 11/12/25, indicated: Old Business:-Call bell response time- not resolved; -staff using cellphones and earbuds- not improved; -reports of staff being unfriendly- not resolved; -residents report milk arrives warm; -staff frequently speak other languages in common areas. There was no Resident Council meeting held in December 2025. Review of Resident Council Minutes, dated 1/7/26, indicated: -Old Business- call bell response time not resolved, staff using cell phone and earbuds not resolved, reports of staff being unfriendly not resolved; New Business:-Residents report milk arrives warm- still occurring; -Residents report that staff frequently speak other languages in common areas- not resolved. Review of the Resident Council Minutes, dated 1/29/26, indicated: Old Business:-call light response time is too long- not resolved; -staff using cellphones and earbuds- not resolved; -reports of staff being unfriendly-not resolved; -food arriving cold- not resolved; -milk is warm. There was no Resident Council meeting held in February 2026. Review of Resident Council Minutes, dated 3/12/26, indicated: Old business:-call light response time is too long; -food is cold and milk is warm; -reports of staff being unfriendly -ongoing and not resolved; -staff using cellphones and earbuds. Further review of the Resident Council Minutes held from October 2025 through March 2026 indicated that:-No grievances were initiated through the Resident Council process despite concerns being raised each month; -Concerns regarding call bell response times were raised at each meeting; and-Concerns regarding staff treating residents with respect and dignity were raised at each meeting. On 3/31/26 at 11:00 A.M., the surveyor held a Resident Group meeting with 13 residents in attendance, and all units of the facility were represented. During the meeting,-12 out 13 residents acknowledged they felt call bells were not answered timely and nothing was being done about it. The residents confirmed this had been brought up previously at multiple meetings with no resolution or improvement. -12 out of 13 residents felt staff continued to be unfriendly and disrespectful. The residents were unable to state whether a resolution had been attempted. -12 out of 13 residents, including the Resident Council President, spoke about their food arriving cold and their milk arriving warm. They were unable to state whether a resolution had been made despite bringing it up at multiple meetings. During an interview on 3/31/26 at 2:37 P.M., the Activity Director said she would verbally tell the Administrator of the old and new business discussed at each the meeting. She said there was no form to communicate the Resident Council concerns to department heads. The Activity Director said she had never initiated a grievance since being hired in January. She said there was no Resident Council Group in February. The Activity Director said she had heard the same concerns being brought up at the Resident Council Group and had told the Administrator. She said common concerns included staff being unfriendly and speaking another language in front of residents, long call bell wait times, and food temperatures. During an interview at 4/1/26 at 3:31 P.M., the Administrator said he did not have a reason for these issues not being addressed each month. He said he reviewed the Resident Council Minutes but expects there to be a response form completed by the Activity Director after each meeting and provided to the department head responsible for the resolution. He expected the residents to receive, at the start of each meeting, follow-up regarding resolutions and outcomes of concerns and grievances initiated. He said the meeting that was supposed to occur in December was rescheduled for January, so two meetings were held in January, and no meeting was held in February. He said Resident Council meetings should be held monthly, and residents should be informed of changes and have input.Refer to F867

Based on interview and record review, the facility failed to ensure a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident was developed to include the minimum healthcare information necessary to properly care for a resident including, initial goals based on admission orders, and failed to ensure the resident and/or their representative were provided with a summary of the baseline care plan for three Residents (#21, #36, and #33), out of a total sample of 18 residents. Specifically, the facility failed:1. For Resident #21, to address a left femur fracture and surgical wound care on the Baseline Care Plan and failed to ensure the Resident and/or their representative were provided copies of the Medication list and Baseline Care Plan;2. For Resident #36, to address bilateral lower extremity contractures on the Baseline Care Plan and failed to ensure the resident and/or their representative were provided a copy of the Medication list; and3. For Resident #33, to address care and management of diabetes with a feeding tube and failed to ensure the Resident and/or their representative were provided copies of the summary of the Baseline Care Plan. Findings include: Review of the facility's policy titled Care Plans-Baseline dated as last revised 6/2025 indicated but was not limited to the following: -A baseline care plan is developed to meet the residents' immediate needs. -To assure the residents' immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the residents' admission. -The resident and/or their representative will be provided with a summary of the baseline care plan. 1. Resident #21 was admitted to the facility in January 2026 with diagnoses which included fracture of the left femur, surgical aftercare, and spastic quadriplegic cerebral palsy. Review of the Minimum Data Set (MDS) Assessment, dated 2/12/26, indicated Resident #21 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, had a surgical wound, and was a risk for pressure ulcers. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #21 had a femur fracture, had surgery on 1/15/26 to repair the fracture, and required monitoring and wound care to the incision. Review of the Skilled Charting Evaluation, dated 1/30/26, indicated Resident #21 had two surgical incisions, was anxious, and required four staff to provide care. Review of the Physician's Orders failed to indicate monitoring of the incisions and/or wound care orders per the Discharge Summary had been implemented. Review of the Baseline Care Plan failed to indicate Resident #21 had a left femur fracture and two new surgical incisions requiring nursing care. Review of the Initial Interdisciplinary Care Meeting Evaluation, dated 2/10/26, failed to indicate that the Resident or their representative was provided a copy of the summary of Medications or the Baseline Care Plan. During an interview on 3/31/26 at 2:33 P.M., Nurse #5 said post-op orders and how to care for the Resident should have been part of the initial plan of care. During an interview on 3/31/26 at 2:47 P.M., Unit Manager #1 said the fracture and post-op wound care orders should have been part of the care plan to ensure staff knew how to care for him/her and they were not. During an interview on 4/1/26 at 10:37 A.M., Physician #1 said he would expect the femur fracture and surgical wound care to have been part of the care plan since admission as that is basic care needs and the reason for admission. During an interview on 4/1/26 at 1:23 P.M., the Staff Development Coordinator (SDC) said the baseline care plan should be developed within 48 hours and include all basic needs the staff need to know to care for the residents, including fractures and surgical wounds. During an interview on 4/1/26 at 2:27 P.M., the Director of Nurses (DON) said the Baseline Care Plan is developed from the Nursing admission Assessment. She said it should be done within the first 48 hours and include resident care needs, including but not limited to fractures and surgical wound care. She said the Resident or family should have been given a copy of their medication list and care plan and she was unsure why they were not provided to the Resident. 2. Resident #36 was admitted to the facility in April 2025 with diagnoses which included chronic pain syndrome, unilateral osteoarthritis of the left hip, and failure to thrive. Review of the MDS Assessment, dated 2/12/26, indicated Resident #36 scored 3 out of 15 on the BIMS indicating he/she had severe cognitive impairment, was dependent for care, was at risk for pressure ulcers, had impairment of the lower extremities, and had a diagnosis of orthopedic conditions. Review of the Hospital Discharge summary, dated [DATE], indicated he/she could not walk, had progression of left hip arthritis, which was severe, and had pain. Review of the Nurse's Note, dated 4/25/25, indicated Resident #36 had bilateral lower extremity contractures. Review of the Baseline Care Plan failed to indicate Resident #36 had bilateral extremity contractures. Review of the 72-hour Meeting Form, dated 6/10/25, failed to indicate the Resident and/or their representative were provided a copy of the summary of Medications with the Baseline Care Plan. During an interview on 3/31/26 at 2:33 P.M., Nurse #5 said contractures should be part of the initial plan of care. During an interview on 3/31/26 at 2:47 P.M., Unit Manager #1 said contracture management should be part of the care plan, and it was not. She said everything related to care needs should be on there. During an interview on 4/1/26 at 1:23 P.M., the SDC said the baseline care plan should be developed within 48 hours and include all basic needs the staff need to know to care for the resident, including contractures. During an interview on 4/1/26 at 2:27 P.M., the DON said the Baseline Care Plan is developed from the Nursing admission Assessment. She said it should be done within the first 48 hours and include resident care needs, including but not limited to contracture management. She said the Resident or family should be given a copy of their medication list and care plan. She said they need to ensure the copies are provided unless they don't want them, and in that case, staff should be documenting that the Resident/family declined the copies when offered. 3. Resident #33 was admitted to the facility in February 2026 with diagnoses of type II diabetes and gastrotomy status (G-tube). Review of Resident #33's medical record failed to indicate that Baseline Care Plans were in place within 48 hours of admission or that Comprehensive Care Plans were developed and implemented to address type II diabetes or G-Tube status. Review of Resident #33's care plan indicated a care plan for Type II Diabetes was initiated nine days after the Resident was admitted and included but was not limited to the following: Focus: diabetes: potential for hyperglycemia/hypoglycemia Type II Diabetes, date initiated 2/19/26 Goal: Resident's skin integrity will be maintained, and Resident will be free of symptoms of hyperglycemia and/or hypoglycemia, date initiated 2/19/26 Interventions: Administer insulin according to established parameters by a physician, date initiated 2/19/26; administer medications as ordered. See medication administration record. Monitor effectiveness and side effects, date initiated 2/19/26; check blood glucose levels per physician's order, date initiated 2/19/26, monitor for signs and symptoms of hyperglycemia and/or hypoglycemia, date initiated 2/29/26 During an interview on 3/31/26 at 10:57 A.M., Unit Manager #1 said the baseline care plans are initiated upon admission by the nurse completing the admission. She said then they are reviewed and revised within 48 hours of the resident being admitted . She said she wasn't sure who was responsible for giving a copy of the summary of the baseline care plan. During an interview on 3/31/26 at 1:00 P.M., the DON said it is a team approach to completing the baseline care plans and not one person is responsible for ensuring it's completion. She said the social workers are responsible for offering a copy of the summary of the baseline care plan. She said she was not sure why Resident #33's was not completed and why there was no care plan for care and management of their type II diabetes specific to a resident with a feeding tube. During an interview on 4/1/26 at 9:40 A.M., the Regional Nurse said she expects that baseline care plans are being completed within 48 hours of a resident's admission by the interdisciplinary team. She said she expects the nurses to initiate the baseline care plan. During an interview on 4/1/26 at 10:57 A.M., Social Worker #1 said an evaluation titled IDT initial care plan meeting should have been initiated and it was not completed. She said she is not sure if the resident was offered a summary of the Baseline Care Plan, but everyone should be offered a copy. The summary provides information on care and management of the resident and goals of care. During an interview on 4/1/26 at 11:40 A.M., the Resident Representative said she did not receive a copy of the Baseline Care Plan. She said even though she does not read English she has family members who do and would have liked a copy of the summary. Refer to F684

Based on interview and record review, the facility failed to ensure a person-centered individualized comprehensive care plan was developed and implemented for one Resident (#36), out of a total sample of 18 residents. Specifically, the facility failed for Resident #36, to develop a care plan to address bilateral lower extremity contractures for 11 months and to develop a care plan for the potential for skin breakdown for two months. Findings includeReview of the facility's policy titled Care Planning-Interdisciplinary Team (IDT), dated as last revised 3/2025, indicated the facility's Care Planning/IDT is responsible for the development of an individualized comprehensive care plan for each resident and the care plan is based on the residents' comprehensive assessment and is developed by the IDT. Resident #36 was admitted to the facility in April 2025 with diagnoses which included chronic pain syndrome, unilateral osteoarthritis of the left hip, and failure to thrive. Review of the Minimum Data Set (MDS) Assessment, dated 2/12/26, indicated Resident #36 scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment, was dependent for care, was at risk for pressure ulcers, had impairment of the lower extremities, and had a diagnosis of orthopedic conditions. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #36 could not walk, had progression of left hip arthritis, which was severe, and had pain. Review of the Nurse's Note, dated 4/25/25, indicated Resident #36 had bilateral lower extremity contractures. Review of the Comprehensive Care Plan failed to indicate Resident #36 had bilateral lower extremity contractures. Additionally, the Potential Alteration in Skin Integrity Care Plan was resolved in April 2025 (three days after admission), an Actual Alteration in Skin Integrity Care Plan was developed in April 2025 and resolved in January 2026, leaving him/her without a care plan for Skin Integrity for over two months (1/16/26 through 4/1/26). During an interview on 3/31/26 at 2:33 P.M., Nurse #5 said contractures, positioning, and skin care should be part of the care plan and the care plan does not indicate care needs related to the contractures or skin. During an interview on 3/31/26 at 2:47 P.M., Unit Manager #1 said contractures and skin care management should be part of the care plan, and it was not. She said everything related to care needs should be on there. She said he/she has been contracted since admission and cannot straighten their legs at all. She said they use pillows for positioning and that should all be on the care plan and it was not. During an interview on 4/1/26 at 1:13 P.M., Nurse #4 said contractures and skin care management should be on the care plan and they are not. During an interview on 4/1/26 at 1:23 P.M., the Staff Development Coordinator (SDC) said the contracture should have been there since admission with specific care needs and everyone should have a Potential Alteration in Skin Integrity Care Plan. During an interview on 4/1/26 at 2:27 P.M., the Director of Nurses (DON) said the contracture management should have been on the care plan since admission. Additionally, she said everyone should have a potential for skin breakdown care plan and that should not have been discontinued.

Based on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of Residents on 4 out of 4 units and for one Resident (#23), out of 18 sampled residents. Specifically, the facility failed:1. For Resident #23, to ensure that staff offered and encouraged engagement in activities according to their comprehensive assessment and identified preferences; and 2. To ensure staff provided a meaningful and engaging activity program, including materials for self-directed activity, for residents on Sunday in the month of March.Findings include:Review of the facility's policy titled Recreation Evaluation, last revised 11/24, indicated but was not limited to the following:-A recreation evaluation is conducted as part of the comprehensive assessment to develop an activities plan that reflects the choices and interests of the resident.-The recreation evaluation is used to develop an individual activities care plan that will allow the resident to participate in activities of his/her choice and interest.-Each activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs.1. Resident #23 was admitted to the facility in April 2024 with diagnoses including dementia.Review of the Minimum Data Set (MDS) assessment, dated 1/16/26, indicated the Staff Assessment for Cognitive Impairment was conducted, and the Resident has severely impaired cognitive function.Review of the most recent Recreation Assessment indicated no recreation specific care plan was initiated. Review of Resident #23's care plan indicated the following:Focus: Resident has a potential for alteration in psychosocial well-being/coping mechanisms due to dementia with agitation, dated 4/29/24, last revised 10/15/25Goal: Resident will communicate with individuals outside of the facility through alternative modes through the next review, dated 5/7/25Intervention: Resident specific activities (left blank), date initiated 5/1/24During the following days and times, the surveyor observed Resident #23 in bed with their eyes open with no stimulation (radio or television on) while other facility activities were being offered:3/30/26 at 10:33 A.M. and 4:03 P.M.3/31/26 at 9:00 A.M.During an interview on 3/26/26 at 12:58 P.M., Resident #23's representative said there are rarely any activities for anyone with a cognitive impairment. She said she has seen the facility offer trivia and Bingo but there are very few things that appeal to someone with dementia within their skill level. She said the Resident spends a lot of time in his/her room or sitting in the small dining room in his/her wheelchair sometimes not even facing the television when she has visited the Resident.During an interview on 3/31/26 at 9:01 A.M., Certified Nursing Assistant (CNA) #1 said Resident #23 stays in bed most days until after breakfast, and then he/she will spend most of the morning in the dining room with the television on with other residents. She said he/she enjoys music activities but cannot recall if there have been any activities that included music in the month of March. During an interview on 3/31/26 at 9:32 A.M., the Activities Assistant said she does not really know the Residents that do not attend group activities. She said Resident #23 doesn't participate in group activities and she does not know how to offer activities with someone that can't participate. She said she passes out the daily chronicle, word searches, coloring pages, and snacks to residents but does not have anything available to offer Resident #23 unless the Resident Representative brings him/her to an activity. During an interview on 3/31/26 at 12:30 P.M., the Activity Director said there was no care plan initiated for Resident #23's specific interests. She said the Resident does enjoy music and there is one program in the month of March that includes musical entertainment. She said she is not sure how staff would know what the Resident's specific interests and preferences if information is not available on the recreation assessment or the care plan. She said she wasn't very familiar with the Resident or their interests. She said she uses other disciplines' information or hospital discharge paperwork to identify the Resident's interests. She said she previously recorded information that was on previous recreation assessments. During an interview on 4/1/26 at 9:31 A.M., the Regional Nurse said the Activity Director was hired in January and was encouraged to reach out to other sister homes for guidance of activity director duties. She said she expects that Resident Recreation Assessments are completed and a recreation care plan is developed, implemented, and personalized for the Resident's specific activity interests. 2. During the initial screening process residents indicated the weekends can be boring at the facility and there are no activities offered on Sunday. Residents also indicated there were no cultural offerings for non-English speaking residents. There were no materials provided or available in other languages. During an interview on 3/26/26 at 10:12 A.M., the Activity Director said she does not have staff available on Sunday. She said she works Monday through Friday, and her assistant works Tuesday through Saturday. She said on Sunday the Resident Council President puts on a religious service in the dining room. She said residents have to be self-sufficient on that day and engage in activities independently on Sundays. She said she has no materials or activity programs available in other languages at this time, but it is something she could look into. She said she knows there are residents in the building whose primary language is Spanish, Portuguese, and Haitian Creole. There is no way to ensure they are being offered since there is no designated staff for Sunday. It would be up to the residents to coordinate amongst themselves. Review of the March activity calendar indicated the following for each Sunday:9:30 A.M.- Daily Chronicle, no designated staff responsible for distributing. 10:00 A.M.- Coffee Social, no designated staff responsible coordinating.11:00 A.M.- Religious Service, Resident Council president turns on Catholic mass.2:00 P.M.- Resident Choice, no designated staff to assist in facilitating or provide materials. During the Resident Group Meeting held on 3/31/26 at 11:00 A.M., residents reported the weekends felt long and boring. Residents reported there are no activities staff available to provide supplies to residents on Sunday. Residents said they have initiated an independent crochet group on Sunday, but they are not sure what other residents do who do not crochet or watch Catholic Mass. They said there are no materials available offered in other languages besides English. During an interview on 4/1/26 at 9:31 A.M., the Regional Nurse said she expects there are materials or activities provided to Resident's to meet their needs seven days a week across all cultures. She said she was aware there was an open activity position but unaware that revisions have not been made to the department to provide recreational activities for the residents every day. She said she would expect there to be staff designated to assist with the activities on the calendar to ensure they are being offered. Refer to F680

Based on document review and interview, the facility failed to ensure that services were provided in accordance with professional standards for one Resident (#3) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of a total sample of two residents with G-tubes in the facility, to maintain patency and prevent complications of the G-tube. Resident #3 had to have their G-tube replaced four times between January and March 2026 due to clogging. Findings include: Review of the facility's policy titled Enteral Nutrition, dated as revised 4/2024, indicated but was not limited to the following: - Nursing staff is assigned to specific enteral feeding responsibilities, including but not limited to flushing with water at appropriate intervals, monitoring for complications along with taking corrective actions if complications are identified Review of the facility's policy titled Administering Medications Through an Enteral Tube, dated as revised 9/2024, indicated but was not limited to the following: - request liquid forms of medications from the pharmacy- dilute medications and flush the tube with water- prepare medication - dilute powered or crushed medications at the bedside with 15-30 milliliters (ml) of water (or prescribed amount), if administering more than one medication flush with 5ml (or prescribed amount) of water in between each medication, after the last medication flush the tubing with 15ml or prescribed amount of water The facility did not have a policy on general care and management of G-tubes. Resident #3 was admitted to the facility in October 2025 with diagnoses including: Cerebral infarct (stroke), hemiplegia and hemiparesis affecting right side, diabetes mellitus type 2, protein-calorie malnutrition, dysphagia (difficulty swallowing), and gastrostomy status (presence of a G-tube). Review of the Minimum Data Set (MDS) for Resident #3, dated 2/6/26, indicated the Resident was severely cognitively impaired as determined by staff interview, received enteral G-tube feedings for 51% or more of their nutritional needs daily, had a history of stroke with hemiplegia/hemiparesis with impairment on one side affecting their upper and lower extremities, and was dependent on staff for care with bathing, dressing, mobility and toileting. On 3/26/26 at 8:18 A.M., the surveyor observed Resident #3 in bed with the head of the bed elevated approximately 30 degrees and his/her Nepro enteral feeding infusing without difficulty at 55ml per hour. Observation of the pump indicated the pump delivering the Nepro was also set up to deliver intermittent water flushes every four hours at 175ml. During an interview on 3/26/26 at 12:20 P.M., the Healthcare proxy (HCP) for Resident #3 said the Resident had been hospitalized a couple of times recently with a blocked G-tube. Review of the current orders for Resident #3 included but were not limited to the following: NPO (nothing by mouth) diet related to dysphagia (11/16/24)Enteral feed order: Nepro at 55ml per hour up at 8:00 A.M., down at 4:00 A.M. - 20 hour feed; every four hours provide free water flushes of 175ml (1/29/26)May crush medications (meds) within crushable guidelines and mix each med in 5ml of water (11/16/24)Flush tube with 5ml of water in between each med (11/16/24)May give 30ml of water by feeding tube before and after medication administration (11/16/24)Acidophilus oral capsule 100millligrams (mg) give two capsules by G-tube three times a day (9/19/25)Baclofen tablet 5mg two times a day by G-tube (12/30/25)Cyanocobalamin tablet 250micrograms (mcg) 1 tablet one time daily by G-tube (11/16/24)Eliquis oral tablet 5mg two times a day by G-tube (11/16/24)Ferrous-gluconate oral tablet 325mg 1 tablet by G-tube one time a day (2/25/26)Hydroxychloroquine sulfate oral tablet 200mg by G-tube every other day (alternating with 300mg) (11/16/24)Hydroxychloroquine sulfate oral tablet 300mg by G-tube every other day (10/15/25)Lansoprazole oral tablet delayed release disintegrating 30mg one time a day dissolve tab in 10ml of water and administer within 15 minutes of dissolving (3/27/26)Levothyroxine sodium oral tablet 150mcg give 0.5 tablet by G-tube in the morning - dose 75mcg (6/30/25)Lisinopril oral tablet 10mg by G-tube once daily (9/19/25)Melatonin 3mg tablet give one tab by G-tube at bedtime (11/16/24)Metformin HCl 500mg oral tablet one tab two times a day by G-tube (5/26/25)Metoprolol tartrate oral tablet 25mg one tab two times a day by G-tube (12/30/25)Mirtazapine oral tablet 15mg give at bedtime by G-tube (11/16/24)Prednisone tablet 2.5mg give once daily by G-tube - administer with 5mg tablet to equal 7.5mg (3/12/25)Prednisone tablet 5mg give one daily by G-tube - administer with 2.5mg tablet to equal 7.5mg (3/12/25) The medication orders indicated the Resident was receiving 16 pills scheduled daily through the G-tube and none in liquid formulation in accordance with the standard of practice and facility policy. Review of the medical record indicated the following transfers to the hospital for Resident #3 related to his/her G-tube being clogged: 1/11/26: G-tube clogged, transported to the hospital, returned with G-tube replaced while at the hospital1/12/26: G-tube blocked, transported to the hospital, returned with G-tube replaced while at the hospital3/15/26: G-tube blocked, transported to the hospital, returned with G-tube replaced while at the hospital3/27/26: G-tube blocked, transported to the hospital, returned with G-tube replaced while at the hospital Further review of the medical record failed to indicate that the facility had made attempts to request Resident #3's medications in liquid formulation. On 3/27/26 at 8:05 A.M., the surveyor observed Resident #3 in the process of being transferred to the hospital by emergency medical services (EMS). The surveyor observed Nurse #2 giving report to EMS and heard Nurse #2 tell EMS that that morning the Nurse had flushed the Residents' G-tube without difficulty, but upon administering the medications through the G-tube the tube became clogged, and she attempted to clear the clog with ginger ale but was unsuccessful. She informed EMS the Resident is NPO and requires enteral nutrition through the tube for 20 hours a day and that had not been started yet related to the tube being blocked. During an interview on 3/27/26 at 2:50 P.M., Nurse #2 said she sent the Resident to the hospital that morning with a clogged G-tube. She said she was flushing the G-tube without any problems and when she went to administer the third medication it wouldn't go in. She said she could feel a blockage in the tube and tried to massage the tube to get the blockage to move but was unsuccessful so she got advice from a more seasoned nurse to put ginger ale in the tube to see if that would help and it was also unsuccessful. She said she follows the advice of more experienced nurses because she is a new graduate and started at the facility about six months ago. She said she did not contact the provider prior to putting ginger ale in the Residents' tube and didn't tell them she had tried that specifically just told them the tube was clogged and then received an order to send the Resident to the hospital for evaluation. She said she wasn't aware she needed an order to put ginger ale in the Resident's G-tube to attempt to clear the blockage.Review of the Hospital After Visit Summary for Resident #3, dated 3/27/26, indicated but was not limited to the following:History: patient currently residing in a nursing facility, had his/her G-tube replaced here about two weeks ago for clogging, today his/her staff reports attempted to place meds and the G-tube was cloggedDischarge instructions: G-tube was clogged with a significant amount of pill fragments and particles, please make sure that you are appropriately flushing the tube after administering any medications or feeds. Tube has been replaced and confirmed in proper placement. During an interview on 3/31/26 at 11:55 A.M., the Staff Development Coordinator (SDC) said she had been in her role at the facility between 15 and 18 months and had not done any official competencies with the licensed nurses on management of a G-tube to prevent clogging of the tube. She said the nurses complete computerized learning and training. She said she wasn't aware that Resident #3 had gone to the hospital to have his/her G-tube replaced related to being clogged four times in the last three months. She said nurses should not be administering anything through a G-tube in an attempt to dislodge or dissolve the blockage of Resident #3's tube without an order from the physician or on call provider and making those decisions is outside of the nurses' scope in this setting. She said she is not aware of any current performance improvement plans, education plans or quality assurance activities for the prevention of clogged G-tubes at this time. During an interview on 3/31/26 at 12:43 P.M., the Dietitian said she knows Resident #3 well and is involved with their care. She said the Resident had been nutritionally stable even with the clogging of the G-tube. She said she did have a conversation at one point with the nursing staff related to thoroughly flushing the G-tube, but she isn't sure she documented that anywhere. She said in her experience and professional opinion a G-tube clogging is typically related to inadequate flushing or flushing not occurring correctly during medication administration. During an interview on 3/31/26 at 1:05 P.M., the Physician said in his opinion the Resident #3's issues with his/her G-tube clogging is related to the staff not being well trained and likely not thoroughly crushing the pills to a fine powder, dissolving them in water and then flushing the tube as ordered. He said he is aware the Resident had required multiple hospitalizations for a clogged G-tube and replacement of that tube and that is not acceptable. He said he was surprised and it is unfortunate that the pharmacy had not recommended or provided the facility with the liquid formulations of the prescribed medications, but he was looking into changing the Resident's medications today and determining the risk of each individual medication at being able to contribute to a clogged G-tube. He said he was not aware that the nursing staff were placing ginger ale into the Resident's G-tube in an effort to unclog it and it was scary to think they are attempting these techniques without speaking to the providers and obtaining orders. He said to the best of his knowledge the Resident does not have an anatomical or pathophysiological reason for his/her tube to be at high risk of clogging. Review of the monthly pharmacy medication regimen reviews from October 2025 through March 2026 failed to indicate any recommendations made by the pharmacy consultant for a change in the formulation of the Resident's medications from pill form to liquid form. During an interview on 3/31/26 at 2:26 P.M., the Pharmacy consultant said she had recently seen Resident #3 for a monthly regimen review. She said although Resident #3 receives all their meds through their G-tube and the medications are all provided in pill form, she would not necessarily recommend changes to the medications or their form if there had been no concerns with the tube and the Resident was tolerating them well. She said she was unaware the Resident had numerous episodes of a clogged G-tube in the last three months resulting in a tube change. She said she was unsure about any further information and would have to look up the Resident's information and call the surveyor back. At the time of exit the pharmacy consultant had not called with any further information. During an interview on 4/1/26 at 7:21 A.M., the Director of Nurses said the facility should have identified the ongoing issue of Resident #3's G-tube clogging off and intervened in some way in an attempt to prevent that but had not. She said no nurse should be putting anything into a G-tube without a physician's order and that was not in line with the facility practice. She said the facility had not provided any hands on or competency observations for G-tube management. Refer to F867

Based on observation, interview, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility failed to:1. Develop and implement appropriate plans of action for resident concerns communicated at Resident Council; and2. Identify, develop, and implement appropriate plans of action for one Resident (#3) hospitalized four times in the past three months due to a clogged feeding tube. Findings include:Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), last revised 6/24, indicated but was not limited to the following:-Our QAPI plan addresses: resident indicators, grievances, resident care, dining experience, activities, laundry, resident council, and resident and family feedback. -The information gathered is analyzed and compared to benchmarks and/or targets established by the facility.-Daily interdisciplinary team (IDT) notes are reviewed for adverse events/concerns. -If the change to the process have not results in the goal of the performance improvement project (PIP), further changes are made and monitoring of the process takes place again. 1. Review of the Resident Council Minutes for November 2025 through March 2026 indicated that when asked, the residents responded that they could not get help or care without waiting a long time and call lights were not always answered in a timely manner. The minutes also indicated that when asked, the residents responded the staff does not treat them with respect and dignity.During a group meeting with 11 residents on 3/31/26 at 11:00 A.M., the residents said they did not feel call lights were being answered timely with varying response times from 30 minutes to two hours. Eleven out of 11 residents felt the call light wait times were too long. Eleven out of 11 residents felt the staff do not treat them with respect and dignity, and 9 out of 11 residents referred to the staff as unfriendly. During an interview on 3/31/26 at 1:30 P.M., the Activities Director said sometimes during Resident Council meetings the residents would say they waited a long time for call lights to be answered and residents felt the staff were unfriendly. She said she verbally provided the information to the Administrator.During an interview on 4/1/26 at 3:00 P.M., the Administrator said the resident's input was used for the QAPI process through resident conversations, grievances, and Resident Council. He said residents had voiced concerns with long call light wait times for about five months and he was aware of the customer service concerns since November. He said call light wait time was an active QAPI, but he did not have a PIP for the surveyor to review since data was still being collected through audits which were implemented last week. He reviewed the facility form utilized for PIPs and said there was not one for call light wait times. He said that staff education was being completed to improve customer service satisfaction and reduce call bell wait times. He said staff have been educated multiple times, but no other plans were implemented. He said there have been no revisions despite the issues persisting since November. He said he had begun collecting data, but it has not been analyzed, and no plans of action have been developed. During an interview on 4/1/26 at 3:50 P.M., the Regional Nurse said she is a member of the governing body and expects that the facility is identifying repeat trends and using feedback from residents to develop interventions to improve areas of concern identified during Resident Council. She said she expects that if the issue persists then there should be a reevaluation of the project and interventions.2. Resident #3 was admitted to the facility in October 2025 with diagnoses including Cerebral infarct (stroke) and gastrostomy status (presence of a G-tube).Review of Resident #3's medical record indicated he/she was transferred to the hospital related to his/her G-tube being clogged four times over the past three months on 1/11/26, 1/12/26, 3/15/26, and 3/27/26. During an interview on 3/31/26 at 11:55 A, M., the Staff Development Coordinator (SDC) said she wasn't aware of a pattern occurring regarding hospitalizations of a resident related to a clogged G-tube. She said there is currently no QAPI on G-tubes or preventing their clogging. She said it was not identified as a concern despite the multiple hospitalizations. She said it would seem like there is a problem with providing care and management of a resident with a G-tube since this one Resident has been hospitalized four times.During an interview on 4/1/26 at 7:21 A.M., the Director of Nursing (DON) said the facility should have identified the ongoing issue of the G-tube clogging and reviewed the manner in which they were clogging to identify the root cause for the hospitalizations. She said there was no QAPI identified for the care and management of residents being hospitalized with a clogged feeding tube. During an interview on 4/1/26 at 3:50 P.M., the Regional Nurse said she is a member of the governing body and expects there should be identification of the care and management of feeding tubes related to multiple hospitalization. She said she expects that adverse events are reviewed and a root cause is identified.

Based on record review and staff interview, the facility failed to ensure the Resident Representative (Guardian) was not extended authority of decision making beyond the extent required by the court to consent to the administration of an antipsychotic medication for one Resident (#33), from a total sample of 18 residents. Specifically, Resident #33 was administered Olanzapine (Zyprexa) after the legal guardian did not retain authority to consent to the medication. Findings include:Resident #33 was admitted to the facility in January 2026 with a diagnosis of dementia without behavioral disturbance. Review of the medical record indicated Resident #33 had a family member appointed as their permanent legal guardian and a Treatment Plan for the use of antipsychotic medications was implemented. Review of the court approved Treatment Plan for Resident #33 indicated if not sooner extended, it shall expire on 1/21/26.Review of the Informed Consent for Psychotropic Administration form indicated the Guardian of Resident #33 consented to the use of Zyprexa on 2/10/26.Review of the medical record included a Physician's Order to start Zyprexa 2.5 milligrams on 2/10/26.Review of the medical record, including progress notes, failed to indicate the facility had submitted any documentation to the court to change the Treatment Plan to be extended past the expiration date of 1/21/26. During an interview on 3/30/26 at 12:34 P.M., Social Worker #1 said the Resident should not receive an antipsychotic medication without the Roger's Treatment plan being active and updated. She said she wasn't sure how this was missed during the Resident's admission to the facility. She said the nurses are responsible for obtaining the orders and perhaps one of them did not have the knowledge about the process for a resident with a legal guardian and antipsychotic medication. She said there was not an updated Treatment Plan in progress.During an interview on 3/30/26 at 2:00 P.M., the Regional Nurse said she expects there to be a process in place for ensuring residents with court appointed legal guardians have the authority to consent for antipsychotic use.

Based on observation, interview, and document review, the facility failed to ensure the call bell device was operational and in reach on the Resident's functional side for one Resident (#3), out of 18 sampled residents. Findings include: Review of the facility's policy titled Answering Call Lights, dated as revised 1/2024, indicated but was not limited to the following: -demonstrate call light use as needed-when a resident is in bed provide the call light within easy reach of the resident-report all defective call lights to the nurse promptly Resident #3 was admitted to the facility in October 2025 with diagnoses including cerebral infarct (stroke) and hemiplegia (complete paralysis) and hemiparesis (partial weakness) affecting right side. Review of the Minimum Data Set (MDS) assessment for Resident #3, dated 2/6/26, indicated but was not limited to the following: -Section C: Cognition was severely impaired, according to a staff interview-Section GG: Impairment on one side of the body for both upper and lower extremities, dependent for upper body dressing-Section I: Diagnosis of stroke, hemiplegia/hemiparesis - yes Review of the current care plans for Resident #3 indicated the Resident suffers from right sided hemiplegia. On 3/26/26 at 8:18 A.M., the surveyor observed Resident #3 lying in bed with his/her call light button tied to the 1/4 siderail on the Resident's right side. The Resident smiled at the surveyor and followed requests but did not verbally respond to the surveyor. Resident #3 was unable to move his/her right side upon prompting by the surveyor and could not reach the call light with his/her left hand when prompted. Upon further inspection of the call light cord, it was found to be broken with the exposed wire on the floor, detached from the plug that remained in the wall socket. The call bell cord was not functioning. During an interview on 3/26/26 at 12:20 P.M., the Healthcare Proxy for Resident #3 said he believed the Resident could use the call light if it were by his/her left side, but likely inconsistently due to their cognitive decline. Throughout the survey, the surveyor made the following observations of Resident #3's availability of a functioning call device:3/27/26 at 7:51 A.M., the Resident was in bed with the broken call light attached on the Resident's right upper siderail and at 11:51 A.M., the broken call light device was attached to the right upper 1/4 siderail.3/31/26 at 7:44 A.M. and 10:34 A.M., the Resident was in bed with the broken call light device attached on the Resident's right side to the upper siderail.3/31/26 at 12:06 P.M., 1:49 P.M., and 3:09 P.M., the Resident was out of bed in his/her wheelchair with their broken call light out of reach and no alternative device available for the Resident to be able to call for assistance if needed. During an interview on 3/27/26 at 7:29 A.M., the Maintenance Director said there is a process for preventative maintenance rounds and nursing is supposed to report any issues to him verbally or through the TELS system (a comprehensive facility management and maintenance computer system to manage work orders and environmental compliance in healthcare facilities). Review of the facility TELS work history report from 12/1/25 through 3/31/26 failed to indicate any issues were reported to the Maintenance Director through the TELS system. During an interview on 3/31/26 at 8:31 A.M., Certified Nursing Assistant (CNA) #2 said all residents have some type of device to call for assistance whether it be a button, call pad, or hand bell. She said call bells are supposed to be in reach of the resident whether or not they are capable of using it. She said she isn't sure if Resident #3 consistently used his/her call device. During an interview on 3/31/26 at 8:33 A.M., CNA #3 said all residents are required to have some type of call bell available and in reach to use. She said Resident #3 would be able to use a call bell if he/she wanted to, but she has experienced the roommate call for the Resident in the past. She said in the event that any type of equipment is broken or not functioning in the residents' rooms needs to be reported to the Maintenance man either verbally or through the computer system which the CNAs can access through POC (the facility computer program in which the CNAs document). During an interview on 3/31/26 at 8:34 A.M., CNA #4 said all residents are required to have a call bell within reach at all times when they are in their rooms. She said she believed Resident #3 would be able to use the call bell, but she doesn't see that happen too often. During an observation with interview on 3/31/26 at 10:34 A.M., the surveyor observed CNA #3 in Resident #3's room preparing to get the Resident ready for the day. CNA #3 said the Resident wouldn't be able to use the call bell since it was positioned on the Resident's right side and the call bell should be on the Resident's left side since he/she cannot use their right arm. Upon attempting to move the call bell, she said the bell was broken and the cord had broken away from the wall. CNA #3 said Maintenance would need to be made aware and she reported the broken call bell to Nurse #3 while the surveyor was present. During an observation with interview on 3/31/26 at 10:36 A.M., the surveyor observed Nurse #3 enter Resident #3's room and attempt to reinsert the cord. Nurse #3 said the cord was broken and he would have to alert Maintenance so it could be repaired or replaced. Nurse #3 said the Resident should have some type of call bell available to them at all times while in the room and the device would have to be placed on his/her left side since their right side was non-functioning. On 3/31/26 at 12:06 P.M., 1:49 P.M., and 2:52 P.M., the surveyor observed that Resident #3 continued to have no functioning call bell in reach since it was brought to the staff's attention at 10:34 A.M. this morning. During an interview on 3/31/26 at 3:09 P.M., CNA #5 said she knows Resident #3 very well and works with them frequently. She said the Resident is not capable of using his/her right arm at all because it is paralyzed, but the Resident can use their left arm and could only use a call bell if it was within reach of the Resident's left arm/hand. She said all residents are supposed to have a call bell in reach at all times while they are in their rooms. During an interview on 3/31/26 at 3:11 P.M., Nurse #3 said he had forgotten to notify Maintenance of Resident #3's call bell being broken and he did not provide an alternative device to the Resident to use. Therefore, the Resident did not have access to a call device all day. During an interview on 3/31/26 at 3:47 P.M., the Administrator observed Resident #3's call bell cord with the surveyor and was informed the surveyor had made these observations throughout the survey. He said, Oh my god, that is a huge safety concern and that shouldn't be like that, he continued to say his expectation was staff should ensure residents have the availability of a functioning call bell in reach at all times while they are in their rooms and that if the residents don't have a functioning device in reach, they cannot alert the staff to potential needs and that was a problem. He said when the issue was identified by staff earlier today, he would expect staff report it immediately and provide an alternative device on the resident's functioning side so he/she would have something available to use. He said that wasn't what occurred in this instance.

Based on observation, document review, and interview, the facility failed to ensure for one Resident (#14), out of a total sample of 18 residents, that their wheelchair was maintained in a clean and safe manner. Findings include: Resident #14 was admitted to the facility in April 2018 and had diagnoses including diabetes mellitus type 2 and muscle wasting and atrophy.Review of the Minimum Data Set (MDS) assessment, dated 2/13/26, indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15 and used a manual wheelchair for mobility. Review of the current care plans for Resident #14 indicated but was not limited to the following: PROBLEM: Activities of daily living deficit as evidenced by weakness, decreased strength and endurance, fatigues easily, muscle weakness and impaired balance. INTERVENTION: Locomotion: Wheelchair - supervisionDuring an observation with interview on 3/26/26 at 8:01 A.M., the surveyor observed Resident #14 sitting on the edge of his/her bed in their room with their wheelchair locked beside the bed. The upper left backrest of the wheelchair was torn away from the wheelchair base with a screw and metal circle washer exposed. The right side of the wheelchair sheet was worn and frayed with no vinyl covering the threading and tearing away from the wheelchair base. The right and left arm rests on the wheelchair were cracked and torn exposing the foam underneath the vinyl covering. The Resident said he/she uses the wheelchair daily and it isn't in good condition. The Resident said he/she hopes that someone will fix it because the cracked arm rests pinch their arms at times. The surveyor observed Resident #14's wheelchair as follows: -3/27/26 at 8:23 A.M., Resident sitting in his/her wheelchair in their room; wheelchair remains with damaged back rest, seat, and arm rests.-3/31/26 at 2:56 P.M., Resident sitting in his/her wheelchair, wheelchair remains in disrepair with frayed torn backrest and hardware exposure, a worn frayed seat, and cracked/torn arm rests.During an interview on 3/27/26 at 7:29 A.M., the Maintenance Director said there is a process for preventative maintenance rounds and nursing is supposed to report any issues with resident equipment to him verbally or through the TELS system (a comprehensive facility management and maintenance computer system to manage work orders and environmental compliance in healthcare facilities). He said monthly environmental rounds are completed with the Administrator and any identified issues are corrected. He said the Director of Rehabilitation (DOR) monitors resident equipment and will let him know if any parts need to be ordered and for whom and he will fix resident assistive devices at that time. During an interview on 3/31/26 at 8:33 A.M., Certified Nurse Assistant (CNA) #3 said if something is found broken or there is a problem with equipment in the resident's room staff are to notify Maintenance, either verbally or by putting it into the computer system, to correct the issue. She said specifically for wheelchairs that they are cleaned on a schedule by Housekeeping and she believes Housekeeping would also report any issues of equipment in bad condition. During an interview on 3/31/26 at 10:53 A.M., the Housekeeping Director said there is a schedule followed for Housekeeping to clean all wheelchairs in the facility once a month and they are all completed in one week. She said if her staff tell her about an issue with a wheelchair that is in poor condition with rips, tears, or things of that nature she reports that verbally to the DOR so he can look at it and speak with Maintenance to get it taken care of. Review of the facility TELS work history report from 12/1/25 through 3/31/26 failed to indicate any issues were reported to the Maintenance Director through the TELS system. Review of the monthly environmental rounds provided by the facility from January 2026 through March 2026 failed to indicate that any assistive devices in use by residents, such as wheelchairs, were observed or evaluated during the environmental round process. During an interview on 4/1/26 at 8:04 A.M., the DOR said he does not have a formalized or scheduled process for looking at resident assistive devices like wheelchairs for any repairs. He said there is no defined process, but he looks while he is out on the units in the process of his normal day and if he notices something he notifies the Maintenance Director so it can be repaired or replaced. During an interview on 3/31/26 at 3:47 P.M., the Administrator said once a month himself and the Maintenance Director complete environmental rounds to identify any safety issues and they walk the building and look to ensure the rooms look like rooms they would be willing to sleep in. He said looking at resident equipment or assistive devices is not completed during this time by him. He said he believed that quarterly the DOR was also looking at resident assistive devices, including wheelchairs, and any identified problems like the equipment being in poor condition would be reported to Maintenance through the TELS system and then repaired or replaced. He said reports of resident equipment being in disrepair was also something they discuss at morning meeting. He observed Resident #14's wheelchair with the surveyor and said the condition of the wheelchair was a safety hazard with the backrest pulling away from the frame and the seat fraying at the connection and the cracked torn arm rests are also a concern. He said it seemed the facility was not picking up on these things as they should and no piece of equipment should get in this condition without being reported by staff for repair.

Based on interviews and record review, the facility failed to ensure that one Resident (#23), out of a total sample of 18 residents, was provided the right to participate in their care plan process. Specifically, the facility failed to ensure that Resident #23 was invited to participate in their individual care plan meeting or provide a rationale as to why the participation of the Resident/Resident Representative was determined not practicable for the development of the care plan.Findings include:Review of facility's policy titled Care Planning- Interdisciplinary Team, last revised 3/2025, indicated but was not limited to the following:-The facility's care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. -The resident, the resident's family and/or the resident's legal representative are encouraged to participate in the development of and revisions to the resident's care plan. Resident #23 was admitted to the facility in April 2024 with diagnoses which included dementia.During an interview on 3/26/26 at 12:58 P.M., Resident #23's Representative said she has not been invited to a care conference since the fall. She said she knows they are supposed to occur quarterly but there has been a revolving door of staff and she still hasn't met with the new team. She said she has not been able to provide input into Resident #23's plan of care.During an interview on 3/26/26 at 10:12 A.M., the Activities Director said she has not attended a care plan meeting since her hire date in January and was unsure of the process or who was responsible. During an interview on 3/31/26 at 9:16 A.M., Social Worker #1 said her agency identified on 3/26/26, the first day of the recertification survey, that care plan invitations were not being sent to the resident representatives or residents. She said she has conducted care plans without the interdisciplinary team because it is difficult to identify who is responsible for attending. She said there has been some turnover in the department which has resulted in inconsistency of care plans and meetings. She said she lets the team know in morning meeting when the care plan meetings are but cannot physically be responsible for getting someone there. She said she believes everyone is very busy and once staff knew family members or residents were not attending, they felt like they didn't need to be present. During an interview on 3/31/26 at 9:40 A.M., the Director of Nurses said the interdisciplinary team is expected to participate in care plan meetings. She said she knows there have been three social workers responsible for ensuring attendance so there may be some inconsistency. She said she expects someone from nursing is attending, there is not one designated nursing representative to attend weekly, but whoever is available to go. She said sometimes the meetings are on Wednesday and sometimes they are on Thursday; she is not sure the team is always aware. She said she is aware of the inconsistency with the care planning process. She said she cannot provide any additional documentation to support that meetings were held with the interdisciplinary team and resident/resident representatives were invited.During an interview on 4/1/26 at 9:36 A.M., the Regional Nurse said her expectation is the care plans are interdisciplinary and that residents and families are invited to participate in the development and review of the care plan.

Based on record review and interview, the facility failed to ensure for one Resident (#21), out of a total sample of 18 residents with an alteration in skin integrity, specifically post-op surgical incisions, received necessary treatment and services to promote healing. Specifically, the facility failed to transcribe and implement wound care per the Hospital Discharge Summary, to develop and implement a care plan for the alteration in skin integrity, to ensure specific bathing/showering requirements related to the surgical incision were on the Kardex, to complete accurate admission, re-admission, and weekly skin assessments, and to monitor, assess and identify signs/symptoms of an infection until he/she was seen by the Wound Care Physician two weeks after admission for unrelated wounds and the clinical signs of infection were identified and a treatment implemented. Findings include: Review of the facility's policy titled Prevention and Management of Pressure Ulcers/Injuries, dated as last revised 11/2024, indicated but was not limited to the following:-The purpose of this policy is to ensure a resident receives care consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing.-Conduct a skin assessment on admission, including skin integrity, any evidence of existing or developing ulcers or injury, any other skin issues, and areas of impaired circulation due to pressure, positioning, or medical devices.-Licensed nurses conduct weekly skin evaluations.-Develop the resident centered care plan and interventions based on risk factors identified, the condition of the skin, and the resident's overall clinical condition.-Monitor wound for changes or complications and notify the provider if noted.-At least weekly, an evaluation should be documented. Including at minimum the location, size, drainage, pain, description of the wound bed, description of wound edges and surrounding tissue.DEFINITIONS:-Exudate/Drainage: Purulent: thick or thin, opaque, tan, or yellow product of inflammation that contains pus (e.g., leukocytes (white blood cells), bacteria, and liquified necrotic (dead tissue) debris).-Infected: refers to the presence of micro-organisms in sufficient quantity to overwhelm the defense of viable tissues and produce the signs and symptoms of infection.-Debridement: the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Review of the facility's policy titled Charting and Documentation, dated as last revised 11/2024, indicated but was not limited to the following:-The following information is to be documented in the resident medical record as warranted: Objective observations, treatments or services performed, changes in the resident's condition, and progress toward or changes in the care plan goals and objectives.-Documentation in the medical record will be objective, complete, and accurate. Resident #21 was admitted to the facility in January 2026 with diagnoses which included fracture of the left femur, surgical aftercare, and spastic quadriplegic cerebral palsy. Review of the Minimum Data Set (MDS) Assessment, dated 2/12/26, indicated Resident #21 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact, had a surgical wound, and was at risk for pressure ulcers. Review of the Nursing admission Evaluation and progress note, dated 1/29/26, indicated Resident #21 refused to have a skin assessment completed. Review of the Skilled Charting Evaluation, dated 1/30/26, indicated Resident #21 had two surgical incisions with medi-strips ((steri-strips) adhesive wound closure strips to secure, close, and support incisions) 7 centimeters (cm) and 2cm, was anxious, and required four staff to provide care. The evaluation failed to indicate the number of medi-strips in place and failed to include a description of the wound/incision lines or surrounding tissue. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #21 had a femur fracture, had surgery on 1/15/26 to repair the fracture, and required monitoring and wound care to the incision. Specifically, the Hip Fracture Discharge Instructions indicated the following:-The dressing will stay on until 7 days post-op. It can then be removed, and the incision can be left open to air. It is ok to shower once the dressing is removed UNLESS there is wound drainage. Orthopedics should remove the staples in 12-14 days, then secure the wound with benzoin and steri-strips.-If there is wound drainage, you should have a dressing on.-You may shower after discharge.-Do not soak, take tub baths, use hot tubs, or swimming pools for six weeks after surgery.-For showers, after the dressing is removed: Do not get wound wet IF there is active wound drainage. Allow the water to run over the incision, but DO NOT apply any soaps or lotions to the incision area. Do not scrub the incision. Pat dry gently with a towel.-Follow up with the surgeon in two weeks.-Please call the surgeons office with fever >101.4, increasing wound redness or swelling, drainage from the incision, persistent calf pain, operative extremity pain not controlled by an increase in pain medications, or any questions or concerns. Review of the Physician (MD)/Nurse Practitioner (NP) progress notes indicated but were not limited to the following:-1/30/26: New admission for Left Hip Fracture status post open reduction and internal fixation (ORIF-surgical repair) with trochanter nail insertion on 1/15/26. Plan: Surgical Site to be monitored for signs/symptoms of infection.-1/31/26: He/she reports persistent pain in the left hip/thigh region. Plan of Care: Monitor the incision. Review of the Physician's Orders failed to indicate monitoring of the incisions and post-op orders per the Discharge Instructions had been implemented. Review of the Care Plan failed to indicate Resident #21 had a left femur fracture and two surgical incisions requiring assessment and monitoring, or specific bathing/showering instructions per the Discharge Instructions. Review of the Resident Care Card (Kardex) failed to indicate specific bathing/showering instructions per the Discharge Instructions. Resident #21 was transferred to the hospital on 2/4/26 and returned on 2/9/26 for medical concerns unrelated to the surgical wound. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #21 had recently had surgery to repair hip fracture at a different hospital and declined to have the discharging provider evaluate his/her wounds. Review of the Medical Record failed to indicate a Nursing re-admission Evaluation had been completed and failed to indicate a skin assessment had been completed. The facility failed to evaluate the post-op incisions and failed to ensure post-op orders were obtained and implemented upon his/her return from the hospital. Review of the Skilled Charting Evaluations for January and February 2026 indicated femur fracture 2 surgical incisions with medi-strips in place. First Incision 7cm in length and second incision 2cm in length. Each evaluation contained this exact same notation from the initial evaluation on 1/30/26. The evaluations failed to describe the current status of the wound/incision and surrounding tissue. Review of the Nursing Progress Notes for January and February 2026 indicated but were not limited to the following:-Resident #21 occasionally would refuse care and education was provided.-Resident #21 had other non-surgical wounds.-The notes failed to indicate any description of the surgical incisions.-2/12/26: The nurse spoke to Resident #21 about wound care services and that he/she had previously refused them and consent was obtained.-The notes failed to indicate Wound Physician services were offered and declined previously.-2/13/26: Resident #21 was seen by the Wound Physician and the post-surgical wound to the left hip was cultured and care plan was updated. The note failed to indicate a description of the wound.-2/18/26 Resident #21 went to an Orthopedic Appointment and was prescribed Doxycycline (antibiotic) for surgical wound infection.-The notes failed to indicate any description of the infected surgical incisions. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate any orders had been implemented for the left hip incisions and failed to indicate any assessment/monitoring for signs/symptoms of infection from 1/29/26 through 2/11/26.-2/11/26 at 3:50 P.M: New Order: Monitor left hip incision site steri-strips in place for signs/symptoms of infection every shift. Review of the Weekly Skin Evaluations, dated 2/12/26 and 2/19/26, failed to indicate Resident #21 had a surgical wound on his/her left hip. Review of the Wound Physician Evaluation, dated 2/13/26, indicated but was not limited to the following:-Resident #21 has wounds on his/her left posterior calf, left hip, and right lateral ankle. Status post left hip surgery in January and now has mild dehiscence (premature separation of the edges of a surgical incision often occurring 1-2 weeks post-operation caused by infection, tension, or poor healing, symptoms include pain, drainage and visible gaps) with purulent drainage of the incision. He/she has a follow up with the surgeon.-Focused Wound Exam: Post-Surgical Wound of the Left HipEtiology: post-surgicalDuration: greater than three daysSize: 1 x 0.5 x 0.4cmExudate (drainage): moderate purulentPain: ModerateInfection Assessment: One or more signs of clinical infection.Estimated time to heal: 4-6 monthsCare Goals: decrease wound area, improve granulation (new healing tissue, manage pain, manage exudate, maintain skin integrity.Investigations/Recommendations: Deep wound culture. Review of the Non-Pressure Ulcer Evaluation, dated 2/13/26, indicated Resident #21 had a surgical incision on their left hip, he/she had been seen by the Wound Physician, and a treatment was in place. Review of the Orthopedic Appointment Referral, dated 2/18/26, indicated left hip surgical site infection. New orders: Obtain a Computed Tomography (CT) Scan of left femur (3D imaging used to diagnose internal injuries/infections) and Doxycycline 100 milligrams (mg) twice daily for empiric Methicillin-resistant Staphylococcus Aureus (MRSA) coverage. Review of the MD/NP progress note, dated 2/18/26, indicated: According to the Patient and the surgeon's recommendations, the surgical site on the left hip is showing signs of a superficial infection. The surgeon recommended starting antibiotic therapy. The left hip was examined and has no drainage, but the surrounding skin is erythematous (red) and warm to the touch. I concur with the surgeon's recommendations, start Doxycycline 100mg twice daily for 10 days for possible MRSA. Order a CT to rule out a deeper infection. During an interview on 3/26/26 at 10:25 A.M., Resident #21 said they had trauma from the fall/fracture at the other facility and did not really want to talk about it. He/she said they like to keep to themselves and would prefer the staff not bother him/her so much. Resident #21 said sometimes they refuse care because someone else was just in here and it is a lot to move and it's painful, so he/she wished the staff would coordinate with each other better. Resident #21 was seen by the Wound Doctor on 3/27/26 and the wound was resolved. During an interview on 3/31/26 at 2:33 P.M., Nurse #5 said post op orders and how to care for the Resident should have been obtained from the physician on admission. She said monitoring the incision for signs/symptoms of infection, monitoring the dressing, specific showering instructions all should have been in the care plan and on the TAR. She said the TAR is where all the orders go, so staff knew how to care for the resident. Additionally, she said the bathing/showering instructions should have been on the Kardex for the aides and they were not. During an interview on 3/31/26 at 2:47 P.M., Unit Manager #1 said the fracture and post-op wound care orders should have been part of the care plan to ensure staff knew how to care for him/her and they were not. Additionally, she said the orders from the discharge instructions should have been written and put onto the TAR, so the nurses must sign off on them and they were not. She said she didn't think he/she had a dressing on the left hip on admission, but they were doing daily dressing changes when care was done. She said it doesn't look like there was an order for a dressing until he/she was seen by the Wound Doctor, but they had been covering it. She was unsure why the orders were not implemented. During an interview on 4/1/26 at 10:37 A.M., Physician #1 said he would expect the femur fracture and surgical wound care to have been part of the care plan since admission as that was basic care needs and the reason for admission. He said his expectation is for the Discharge Instructions from the hospital to be followed, orders written and implemented, and if the orders were unclear or needed clarifying the nurses should reach out. He said there should always be post-op monitoring for signs/symptoms of infection orders written. Additionally, he said every resident with a wound (surgical and non-surgical) is referred to the Wound Physician and he would expect if one declined that service the facility would notify him to ensure the wounds were evaluated by a clinician for appropriate treatment. He said wound descriptions and signs of infection should have been identified and documented by the staff and a call placed to the MD/NP for orders, it should not have waited until the Wound Doctor was in to be evaluated. He said the documentation can be an issue and that needs to improve. During an interview on 4/1/26 at 11:03 A.M., Nurse #4 said she did not recall when they started putting a dressing on the left hip. Additionally, she said the wound/incisions should have been described in the evals or notes and they were not and on re-admission a new Nursing Evaluation and Skin Check should have been done and orders written per the discharge orders and they were not. During an interview on 4/1/26 at 1:23 P.M., the Staff Development Coordinator (SDC) said the baseline care plan should be developed within 48 hours and include all basic needs the staff need to know to care for the residents, including fractures and surgical wounds and his/her care plan did not include that information. She said the post-op orders from the Discharge Instructions should have been written and on the TAR and the Kardex should have the information the aids need to know to care for the resident and they were not. She said the Admit, Re-Admit Evaluations and weekly skin checks should include all wounds and description of them and they do not. Additionally, she said a non-pressure evaluation should be done on every non-pressure wound, including surgical wounds, on admission and weekly and was not sure why there was not one done until he/she was seen by the Wound Doctor. She said she only does the evaluations for the residents that are seen by the Wound Doctor. She said they refer everyone with wounds to the Wound Doctor, except surgical wounds. She said the referral to the Wound Doctor was for his/her other wounds and the Wound Doctor evaluated the hip incision on the initial visit too. She said the Wound Doctor identified that the wound was infected and dehiscing, but we (facility staff) should have identified that and obtained treatment orders first. During an interview on 4/1/26 at 2:27 P.M., the DON said the Baseline Care Plan is developed from the Nursing admission Assessment. She said it should be done within the first 48 hours and include resident care needs, including but not limited to fractures and surgical wound care and it did not include that information. She said the Nursing admission Evaluation should have been done and included wound information on Admit and Re-Admit, the skin checks and non-pressure evaluations should also have included wound descriptions and they did not. She said the discharge orders should have all been implemented and they were not. She said there was one order written on admission, but it was entered a lab order, and it did not contain all the instructions anyhow. She said the documentation of the wound/incision should have included size, color, number of staples/sutures/steri-strips, dressing, and the plan and the only thing documented was the length of the incisions if anything. She said anytime orders are unclear or need to be clarified the provider should be called to obtain orders and the orders should be put on the TAR. She said they review all the admission and re-admissions for accuracy and was not sure how/why this was missed. She said there were not any orders on TAR until 2/11 and then after he/she was seen by the Wound Physician and the wound was determined to be infected a dressing was ordered. She said Resident #21 did refuse care sometimes, but the orders for this surgical wound were never implemented, so the refusal of care was for other wounds and/or personal care. She said this should have been identified by our staff and orders implemented prior to the Wound Doctor's evaluation.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's order for an x-ray of his/her sacrum/pelvis, the Facility failed to ensure that he/she was provided with radiology services consistent with his/her Physician's Orders, when the x-ray was not obtained.Findings Include:Review of Resident #1's Physician Progress Note, dated 12/07/25, indicated that his/her Stage 3 (full-thickness skin loss that extends through the dermis and into the subcutaneous tissue) sacral pressure injury appeared necrotic (tissue death within the wound) and to obtain an x-ray of his/her sacrum/pelvis to evaluate for osteomyelitis (serious bone infection).Review of Resident #1's Physician Orders, dated 12/07/25, indicated to obtain x-ray of the pelvis and sacrum.Review of Resident #1's Medical Record indicated that from 12/07/25 to 12/15/25 (when Resident #1 transferred to Hospital for evaluation) there was no documentation to support that the x-ray of his/her pelvis and sacrum had been completed as ordered by the Physician.During an interview on 01/06/26 at 3:45 P.M., Nurse #2 said that the Physician saw Resident #1 on 12/07/25 late in the evening and ordered an x-ray of his/her sacrum and pelvis. Nurse #2 said that she ordered the x-ray through their Radiology Providers portal site on the computer the same day that the Physician ordered the x-ray. Nurse #2 said that the x-ray was not completed before the end of her shift on 12/07/25 and that she was unaware that Resident #1's x-ray had not been completed. Review of Resident #1's medical record indicated there was no documentation to support nursing followed up on the x-ray to see if and when it had been conducted, or to obtain and report the results to the physician.During an in-person on 01/06/26 at 4:05 P.M. and a subsequent telephone interview on 01/12/26 at 3:32 P.M., the Director of Nurses (DON) said that if an x-ray is not ordered as STAT (without delay, immediately) it may take a few days for the x-ray to be completed.The DON said that she followed up with their Radiology (x-ray) Provider and was informed that they cancelled Resident #1's x-ray because they did not have a credentialed radiologist to read the x-ray results. The DON said that the x-ray provider did not inform anyone at the facility that they cancelled Resident #1's x-ray. The DON said that it was her expectation that x-rays be obtained as ordered by the Physician.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had developed open areas to his/her sacrum and left buttocks, and who was dependent on the physical assistance of staff with Activities of Daily Living (ADL), the Facility failed to ensure they maintained a complete and accurate medical record, when 1) there was conflicting nursing documentation related to his/her wounds and 2) Certified Nurse Aide (CNA) ADL Flow Sheets, daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets left blank.Findings include:Review of the Facility's Policy tilted, Charting and Documentation, dated as revised November 2024, indicated the following:-services provided to the resident to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record;-objective observations, treatments or services performed, are documented in the resident medical record;Resident #1 was admitted to the Facility in October 2025, diagnoses included cellulitis of left orbit, acute kidney failure with tubular necrosis, bipolar disorder, unspecified dementia, depression, muscle wasting and atrophy, anxiety and dysphagia.Review of Resident #1's Care Plan, titled ADL Self Care Deficit, dated 10/11/25, indicated he/she required maximal physical assistance of staff for transfers and bed mobility and was dependent on the physical assistance of staff for dressing, grooming, toileting and bathing.Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 10/17/25, indicated that Resident #1 was dependent on the physical assistance of staff for bathing, dressing and personal hygiene, and required substantial/maximal physical assistance of staff for transfers.1) Review of Resident #1's Nurse Progress Notes, for the following dates indicated that Resident #1's skin was intact, and he/she does not have any pressure injuries. -October: 10/28/25, 10/29/25 and 10/30/25, -November :11/02/25 through 11/30/25, -December: 12/01/25 through 12/06/25, 12/08/25, 12/10/25, and 12/12/25.Review of Resident #1's Weekly Skin Evaluation, dated 11/14/25, indicated that his/her skin was clean and intact.However, documentation in the Nursing Progress Notes and one of the Weekly Skin Evaluation, conflicted with Nursing Documentation on Resident #1's Pressure Ulcer Evaluations, which indicated that he/she had multiple pressure injuries.Review of Resident #1's Pressure Ulcer Evaluations indicated the following:- 10/27/25, 11/03/25, 11/10/25, 11/17/25, 11/24/25, 12/01/25, and 12/08/25 indicated that he/she had a Stage 3 (full-thickness skin loss that extends through the dermis and into the subcutaneous tissue) pressure injury on his/her sacrum.-11/10/25, indicated he/she had a Stage 2 (partial-thickness skin loss that affects both the epidermis and the dermis) pressure injury on his/her right sacrum;-11/24/25, indicated he/she had a Stage 2 pressure injury on his/her left sacrum;-12/01/25, indicated he/she had a Stage 3 pressure injury on his/her left sacrum;-12/08/25, indicated he/she had a Stage 3 pressure injury left buttock;During an interview on 01/06/26 at 2:50 P.M., the Staff Development Coordinator (SDC) said that Resident #1 had a Stage 3 pressure injury to his/her sacrum. The SDC said there have been issues with the nurse's documentation regarding the skin condition of residents in the nurse progress notes and that nurses are checking off that the resident's skin is intact and that there are no skin issues when the resident has open areas or pressure injuries. The SDC said that the nurses are supposed to check off that the skin is not intact whenever a resident has an open area and then describe the wound in the progress notes and check off that the resident has a pressure injury in the Electronic Medical Record (EMR).During an interview on 01/06/26 at 3:29 P.M., Nurse #1, who wrote many of the Nurse Progress Notes in Resident #1's Medical Record, said that Resident #1 had a Stage 3 or 4 pressure area on his/her coccyx. Nurse #1 said that she documented in Resident #1's medical record that his/her skin was intact and that he/she did not have any pressure injuries. Nurse #1 said that she inaccurately documented in Resident #1's medical record and said she should have checked off that his/her skin was not intact and that he/she had pressure injuries when she documented Resident #1's skin condition.During an interview on 01/06/26 at 4:05 P.M., the Director of Nurses (DON) said that said that Resident #1 had a Stage 3 pressure injury to his/her sacrum. The DON said there have been issues with the nurse's documentation regarding the skin condition of residents in the nurse progress notes and that nurses were checking off that the resident's skin is intact and that there were no wounds when the resident had open areas or pressure injuries. The DON said that it was her expectation that the documentation in the resident medical record be accurate and that all the documentation is consistent.2) Review of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated 10/11/25 through 10/31/25, indicated that for the following shifts, documentation on the flow sheets for all ADL care areas was incomplete:-7:00 A.M. to 3:00 P.M. - 3 days (out of 21) ADL care areas were left blank-3:00 P.M. to 11:00 P.M. - 1 day (out of 21) ADL care areas were left blank-11:00 P.M. to 7:00 A.M. - 6 days (out of 21) ADL care areas were left blankReview of Resident #1's CNA Documentation Record (ADL Flow Sheets), dated 11/01/25 through 11/30/25, indicated that for the following shifts, documentation on the flow sheets for all ADL care areas was incomplete:-7:00 A.M. to 3:00 P.M. - 2 days (out of 30) ADL care areas were left blank-3:00 P.M. to 11:00 P.M. - 2 days (out of 30) ADL care areas were left blank-11:00 P.M. to 7:00 A.M. - 5 days (out of 30) ADL care areas were left blankDuring an interview on 01/06/26 at 2:05 P.M., Certified Nurse Aide (CNA) #1 said that the documentation of ADL's is done in Point of Care (POC) in the Electronic Medical Record (EMR) and has to be completed by the end of the shift.During an interview on 01/06/26 at 2:25 P.M., CNA #2 said that the documentation of ADL's is done in POC in the EMR and has to be completed by the end of the shift.During an interview on 01/06/26 at 4:05 P.M., the Director of Nurses (DON) said CNA's document the ADL's they provided to the residents in POC in the EMR and that daily documentation should not be incomplete. The DON said it was her expectation that the CNA's should be documenting all care provided to residents by the end of every shift and should not be left blank.

Based on interviews and record review, the facility failed to ensure staff maintained accurate documentation for four Residents (#37, #50, #32, and #23), out of a total of 18 sampled residents. Specifically, the facility failed to: 1. For Resident #37, ensure November 2024 through January 2025 Medication Administration Records (MAR) were accurate and reflected the administration of multiple medications according to physician's orders; 2. For Resident #50, ensure December 2024 and January 2025 MAR were accurate and reflected the administration of multiple medications according to physician's orders; 3. For Resident #32, ensure November 2024 through January 2025 Treatment Administration Records (TAR) accurately reflected the administration of multiple treatments according to physician's order; and 4. For Resident #23, ensure November 2024 through January 2025 MAR accurately reflected the administration of multiple medications according to physician's orders. Findings include: Review of the facility's policy titled Charting and Documentation, dated 8/2019, indicated but was not limited to the following: -Documentation in the medical record may be electronic, manual or a combination. -The following information is to be documented in the resident medical record as warranted: -Objective observations; -Medications administered; -Treatments or services performed -Documentation in the medical record will be objective, complete, and accurate. 1. Resident #37 was admitted to the facility in May 2024 with diagnoses including hypertension, diabetes mellitus, depression, and chronic kidney disease. Review of Physician's Orders included but was not limited to: -Ascorbic Acid Tablets (used for wound healing) 500 milligrams (mg), twice a day (6/13/24) -Atorvastatin Calcium (lowers cholesterol) 40 mg, once daily in the evening (5/10/24) -Calcium Carbonate (antacid) 500 mg, 2 tablets two times a day (8/14/24) -Clopidogrel Bisulfate (antiplatelet blood-thinning drug) 75 mg, once daily (5/10/24) -Cyanocobalamin (Vitamin B12) 500 micrograms (mcg), 2 tablets once daily (5/10/24) -Famotidine (acid reducer) 20 mg, at bedtime (5/10/24) -Finasteride (blocks the action of an enzyme called 5-alpha reductase) 5 mg, once daily (5/10/24) -Folic acid (B-viamin to treat folate deficiency anemia) 1 mg, once daily (5/10/24) -Januvia (antidiabetic agent) 25 mg, once daily (5/23/24) -Magnesium Oxide (mineral that aids in blood sugar levels) 400 mg, twice a day (5/10/24) -Melatonin (for sleep) 5 mg, at bedtime (5/10/24) -Protonix (treats high levels of stomach acid) 40 mg, once daily (5/23/24) -Zoloft (antidepressant) 50 mg, once daily (5/10/24) Review of November 2024 through January 2025 MAR indicated the following medications were not signed off as administered as evidenced by several blank, unsigned boxes corresponding to the dates and times medications were to be administered on 53 occasions as follows: -Ascorbic Acid: 11/19/24, 11/26/24, 12/12/24, 12/22/24, 1/7/25 -Atorvastatin Calcium: 12/11/24, 12/12/24, 12/20/24, 12/28/24, 1/7/25 -Calcium Carbonate: 11/19/24, 11/26/24, 12/12/24, 12/22/24, 12/28/24, 1/7/25 -Clopidogrel Bisulfate: 11/19/24, 11/26/24, 12/22/24 -Cyanocobalamin: 11/19/24, 11/26/24, 12/22/24 -Famotidine: 12/11/24, 12/12/24, 12/20/24, 12/28/24, 1/7/25 -Finasteride: 11/19/24, 11/26/24, 12/22/24 -Folic acid: 11/19/24, 11/26/24, 12/22/24 -Januvia: 11/19/24, 11/26/24, 12/22/24 -Magnesium Oxide: 11/19/24, 11/26/24, 12/12/24, 12/22/24, 12/28/24, 1/7/25 -Melatonin: 12/11/24, 12/12/24, 12/20/24, 12/28/24, 1/7/25 -Protonix: 11/19/24, 11/26/24, 12/22/24 -Zoloft: 11/19/24, 11/26/24, 12/22/24 2. Resident #50 was admitted to the facility in July 2023 with diagnoses including dementia, diabetes mellitus, and depression. Review of Physician's Orders included but was not limited to: -Amlodipine Besaylate (lowers blood pressure) 5 mg, once daily (1/13/25) -Amlodipine Besaylate 5 mg, twice daily (2/28/24, Discontinued 1/13/25) -Atorvastatin Calcium 40 mg, once daily in the evening (12/27/24) -Carvedilol (for blood pressure) 12.5 mg, one half tablet 2 times per day (2/26/24) -Cholecalciferol (vitamin D deficiency) 25 mcg, 2 tablets once daily (1/13/25) -Cholecalciferol 25 mcg, 2 tablets once daily (7/25/23, Discontinued 1/9/25) -Furosemide (diuretic) 40 mg, once in the morning (10/2/24) -Gabapentin (for pain) 100 mg, 3 times a day (10/2/24) -Hydralazine HCL (to treat high blood pressure) 10 mg, 2 tablets 3 times a day (12/27/24) -Memantine HCL (used to treat memory loss) 5 mg, 2 times a day (7/23/24) -Protonix 40 mg, once daily (12/27/24) -Sennosides-Docusate Sodium (laxative) 8.6-50 mg, once daily (7/24/23) -Sertraline HCL (Used for depression) 50 mg, once daily (7/24/23) -Spironolactone (diuretic) 25 mg, once daily (11/5/23) -Trazodone HCL (antidepressant) 50 mg, once daily (7/24/23) -Xarelto (blood thinner) 10 mg, once daily (1/14/25) -Xarelto 2.5 mg, once daily (8/23/23, Discontinued 12/27/24) -Aspirin Chewable (blood thinner) 81 mg, once daily (7/25/23, Discontinued 1/14/25) -Celecoxib (anti-inflammatory) 200 mg, once daily (10/8/24, Discontinued 12/27/24) -Multivitamin with Iron 1 tablet daily (7/25/23, Discontinued 12/27/24) -Ascorbic Acid Tablets 500 mg, 2 times a day (2/26/24, Discontinued 12/27/24) -Bumetanide (diuretic) 1 mg, 2 times a day (7/12/24, Discontinued 12/27/24) -Lactobacillus (probiotic) 1 capsule, 2 times a day (7/25/23, Discontinued 12/27/24) -Polyethylene Glycol 3360 powder (for constipation) 17 grams (gm), 2 times a day (12/27/24) -Heparin Sodium Solution (anticoagulant) 5000 Unit per Millimeter, inject 5000 units every 8 hours (12/27/24, Discontinued 1/14/25) Review of December 2024 and January 2025 MAR indicated the following medications were not signed off as administered as evidenced by several blank, unsigned boxes corresponding to the dates and times medications were to be administered on 148 occasions as follows: -Amlodipine Besaylate twice daily: (day dose) 12/9/24, 12/22/24, 12/25/24, 12/26/24 (evening dose) 12/8/24,12/11/24,12/12/24,12/17/24,12/18/24,12/24/24,12/25/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24 -Amlodipine Besaylate once daily: 1/1/25, 1/7/25 -Atorvastatin Calcium: 1/1/25, 1/7/25 -Carvedilol: (day dose) 12/9/24, 12/22/24, 12/25/24, 12/26/24 (evening dose) 12/8/24,12/11/24, 12/12/24,12/17/24,12/18/24,12/24/24,12/25/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 -Cholecalciferol: 12/9/24, 12/22/24, 12/25/24, 12/26/24 -Furosemide: 12/3/24, 12/5/24, 12/12/24, 12/18/24, 12/23/24, 12/24/23, 12/25/24, 12/26/24, 1/11/25 -Gabapentin: (morning dose) 12/9/24, 12/22/24, 12/25/24, 12/26/24 (afternoon dose) 12/9/24, 12/22/24, 12/25/24, 12/26/24 (evening dose) 12/8/24, 12/11/24, 12/12/24, 12/17/24, 12/18/24, 12/24/24, 12/25/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 -Hydralazine: (evening dose) 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 -Memantine (day dose) 12/9/24, 12/22/24, 12/25/24, 12/26/24 (evening dose) 12/8/24, 12/11/24, 12/12/24, 12/17/24, 12/18/23, 12/2/24, 12/25/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 -Protonix: 1/11/25 -Sennosides-Docusate Sodium: 12/8/24, 12/11/24, 12/12/24, 12/17/24, 12/18,24 12/24/24, 12/25/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 -Sertraline: 12/9/24, 12/22/24, 12/25/24, 12/26/24 -Spironolactone: 12/9/24, 12/22/24, 12/25/24, 12/26/24 -Trazadone: 12/8/24, 12/11/24, 12/12/24, 12/17/24, 12/18/24, 12/24/24, 12/25/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 -Xarelto 2.5 mg: 12/9/24, 12/22/24, 12/25/24, 12/26/24 -Aspirin Chewable: 12/9/24, 12/22/24, 12/25/24, 12/26/24 -Celecoxib: 12/9/24, 12/22/24, 12/25/24, 12/26/24, 12/27/24 -Multivitamin with Iron 12/9/24, 12/22/24, 12/25/24, 12/26/24 -Ascorbic Acid: (day dose) 12/9/24, 12/25/24, 12/26/24 (evening dose) 12/8/24, 12/11/24, 12/12/24, 12/17/24, 12/18/24, 12/24/24, 12/25/24 -Bumetanide: (day dose) 12/9/24, 12/25/24, 12/26/24 (evening dose) 12/8/24, 12/11/24, 12/12/24, 12/17/24, 12/18/24, 12/24/24, 12/25/24 -Lactobacillus: (day dose) 12/9/24, 12/22/24, 12/25/24, 12/26/24 (evening dose) 12/8/24, 12/11/24, 12/12/24, 12/17/24, 12/18/24, 12/24/24, 12/25/24 -Polyethylene Glycol: (evening dose) 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 -Heparin: (morning dose) 1/11/25 (evening dose) 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/7/25 During an interview on 1/16/25 at 1:45 P.M., Nurse #3 said she was unaware there was an issue with documentation on the MARs. Nurse #3 said she could only see what she was assigned to give that shift. Nurse #3 said when a Resident was out of the facility she could document that on the MAR. Nurse #3 said the internet goes out periodically, but she was not told the procedure to document on a paper MAR. Nurse #3 said nurses needed to document on the MAR at the end of their shift. During an interview on 1/17/25 at 7:25 A.M., the Director of Nurses (DON) said she was aware there was an issue with the documentation of medication administration on the MARs and did not know why the nurses were not consistently documenting on them. The DON said she could not verify if it was an issue with the internet connection or if a resident had been out of the facility. The DON said there is an emergency protocol for when the internet was unavailable. The DON said she had not been notified of any computer issues. The DON said when a resident is out of the facility it should be noted on the MAR. The DON said the expectation is that the nurses should be documenting on the MAR before they leave their shift for the day. 28450 3. Resident #32 was admitted to the facility in May 2021 with diagnoses including Traumatic Spinal Cord Dysfunction, Neuromuscular Dysfunction of bladder, obstructive and reflux uropathy (Obstructive uropathy is a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). Review of the Minimum Data Set (MDS) assessment, dated 11/18/24, indicated Resident #32 has a suprapubic catheter in place. Review of the January 2025 Physician's Orders included but was not limited to: 1) clean around suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) daily; and 2) suprapubic catheter care, every shift for monitoring. Review of Resident #32's November 2024 through January 2025 TAR failed to indicate: - the suprapubic catheter was cleaned, drain sponge had been changed and documented as done on 11/8/24, 11/11/24, 11/15/24, 11/22/24, 11/30/24, and 12/6/24, as ordered (4/12/23); and - the suprapubic catheter care every shift for monitoring on 12/6/24, 12/2/24, and 1/10/25 had been provided and documented as ordered (9/18/24) During an interview on 1/14/25 at 11:00 A.M., Nurse #9 said anytime a treatment is provided it should be documented on the TAR to reflect the date and time it was done. During an interview on 1/17/25 at 10:25 A.M., Nurse #7 said the nurses are to document anytime a treatment is provided. During an interview on 1/17/25 at 7:25 A.M., the DON said she was aware there was an issue with the documentation of treatment administration on the TARs and did not know why the nurses were not consistently documenting them. The DON said the expectation is that the nurses should be documenting on the TAR before they leave their shift for the day. 48084 4. Resident #23 was admitted to the facility in October 2024 with diagnoses which included Diabetes Mellitus with other specified complications, Type 2 Diabetes Mellitus with diabetic neuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated he/she had a diagnosis of Diabetes Mellitus and took insulin. Review of the physician orders indicated but were not limited to the following: -Acidophilus (probiotic/GI health) give one capsule, one time a day for 14 days (11/8/24) -Atorvastatin 80 mg, once daily at bedtime (10/29/24) -Cholecalciferol 1000-unit tablet (vitamin), 2 tablets one time a day (10/29/24) -Duloxetine HCL Capsule 30mg (for depression), give 90mg one time a day (10/29/24) -Famotidine 40mg, one time a day (11/21/24) -Famotidine 20mg one time a day (10/29/24-11/20/24) -Jardiance 10mg (lowers blood sugar), one time a day (10/29/24) -Lantus SoloStar Insulin (lowers blood sugar), inject 7 units at bedtime (11/21/24) -Levofloxacin 750mg (antibiotic), one time a day for pneumonia for 10 days (11/8/24) -Magnesium Oxide 400mg, one time a day (10/29/24) -Multivitamin tablet, one time a day (10/29/24) -Nicotine 14mg Patch, apply once daily (11/9/24) -Tamsulosin 0.8mg (for prostate), one time a day (10/29/24) -Trazodone 50mg, at bedtime (10/29/24) -Tresiba Insulin (lowers blood sugar), inject 7 units one time a day (10/29/24-11/20/24) -Calcium Carbonate 500mg, two times a day (10/29/24) -Eliquis 5mg (blood thinner), two times daily (10/29/24) -Guaifenesin ER tablet 600mg (for mucus/congestion), twice daily (10/29/24) -Metformin 500mg (lowers blood sugar), two times a day (10/29/24) -Tramadol 50mg (pain), two times a day (10/29/24-11/14/24) -Benzonatate 100mg (for cough), three times a day (10/29/24) -Gabapentin 600mg, three times a day (10/29/24) -Tramadol 50mg (for pain), three times a day (11/14/24) -Ipratropium/Albuterol 0.5mg/2.5mg (respiratory), - 3ml inhale four times a day (11/5/24) -Phenytoin 100mg (seizures), every six hours (10/29/24) Review of the November 2024 through January 2025 MARs indicated the following medications were not signed off as administered, as evidenced by blank, unsigned boxes corresponding to the dates and times medications were to be administered on 236 occasions as follows: -Acidophilus: November 4 of 14 opportunities. -Atorvastatin: November 4 of 30 opportunities; December 4 of 19 opportunities; January 2 of 14 opportunities. -Cholecalciferol: November 2 of 30 opportunities. -Duloxetine HCL: November 2 of 30 opportunities. -Famotidine: November 4 of 30 opportunities; December 4 of 37 opportunities; January 2 of 14 opportunities. -Jardiance: November 2 of 30 opportunities. -Lantus Insulin: November 2 of 10 opportunities; December 2 of 19 opportunities; January 2 of 14 opportunities. -Levofloxacin: November 2 of 10 opportunities. -Magnesium Oxide: November 2 of 30 opportunities. -Multivitamin: November 2 of 30 opportunities. -Nicotine 14mg Patch: November 2 of 20 opportunities. -Tamsulosin: November 2 of 30 opportunities. -Trazodone: November 4 of 30 opportunities; December 4 of 19 opportunities; January 2 of 14 opportunities. -Tresiba Insulin: November 2 of 20 opportunities. -Calcium Carbonate: November 6 of 60 opportunities; December 4 of 37 opportunities; January 1 of 29 opportunities. -Eliquis: November 6 of 60 opportunities; December 3 of 33 opportunities; January 1 of 29 opportunities. -Guaifenesin: November 6 of 60 opportunities; December 4 of 37 opportunities; January 1 of 29 opportunities. -Metformin: November 7 of 60 opportunities; December 4 of 37 opportunities; January 1 of 29 opportunities. -Tramadol: November 4 of 26 opportunities. -Benzonatate: November 11 of 90 opportunities; December 4 of 55 opportunities; January 2 of 43 opportunities. -Gabapentin November 11 of 90 opportunities; December 4 of 56 opportunities; January 2 of 44 opportunities. -Tramadol: November 5 of 48 opportunities; December 4 of 55 opportunities; January 3 of 44 opportunities. -Ipratropium/Albuterol Nebulizer: November 21 of 102 opportunities; December 18 of 68 opportunities; January 4 of 58 opportunities. -Phenytoin: November 20 of 120 opportunities; December 19 of 76 opportunities; January 2 of 58 opportunities. During an interview on 1/16/25 at 3:54 P.M., Nurse #1 said the MAR should not have any blanks, every mediation should be signed off as administered, held, refused etc. During an interview on 1/21/25 at 1:23 P.M., the DON said when a nurse administers medications, they should document that it was administered on the MAR. She said the MAR should not have any holes (blank/unsigned boxes).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections for three Residents (#50, #61, and #46), out of a total sample of 18 residents. Specifically, the facility failed: 1a. For Resident #50, to ensure staff performed hand hygiene when indicated, adhered to Contact Precautions, and sanitized shared medical equipment (blood pressure cuff) after use; and b. For Resident #61, to ensure staff performed hand hygiene when indicated, adhered to Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities), and sanitized shared medical equipment (blood pressure cuff) after use; and 2. For Resident #46, to ensure Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) equipment was maintained in a clean and sanitary manner to decrease the risk of potential contamination and infection. Findings include: 1. Review of the facility's policy titled Infection Control Guidelines for Nursing Procedures, dated as last revised 7/2024 indicated but was not limited to the following: -Standard Precautions are the minimum infection prevention practices that apply to all resident care, regardless of suspected or confirmed infection status of the residents, in any setting where health care is delivered. Standard Precautions include hand hygiene, use of personal protective equipment (PPE), sterile instruments and devices, and clean and disinfected environmental surfaces. -Transmission Based Precautions (TBP) will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. TBP will be initiated when there is reason to believe that a resident has a communicable infectious disease. TBP may include Contact Precautions, Droplet Precautions, Airborne Precautions, or Enhanced Barrier Precautions (EBP). Types of TBP: Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident care items in the resident's environment. Examples of such infections include infection with MDROs. -PPE: In addition to wearing gloves as outlined under Standard Precautions, don (put on) disposable gown when entering the room. After removing gloves, gown, and washing hands do not touch potentially contaminated environmental surfaces. -Resident Care Equipment: When possible, dedicate the use of non-critical resident care equipment items such as a stethoscope, sphygmomanometer (blood pressure cuff), thermometer to a single resident to avoid sharing between residents. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. ENHANCED BARRIER PRECAUTIONS (EBP): Infection Control intervention designed to reduce transmission of MDROs. EBP is indicated for nursing home residents with any of the following: Infection or colonization with an MDRO when Contact Precautions do not otherwise apply, Chronic wounds, Indwelling medical devices, including but not limited to IV, feeding tubes, trach, drains, and urinary catheters. -PPE: use of gown and gloves during high-contact resident care activities that may provide opportunities for transmission of MDROs via staff hands and clothing. Examples of high contact resident activities are dressing, bathing, showering, transferring, changing linen, personal hygiene, toileting/brief change, device care, Central line. -Resident Care Equipment: If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub: -Before and after direct contact with residents -Prior to donning and post doffing (removing) gloves -Before preparing or handling medications -After contact with the resident's skin -After contact with objects (medical equipment) in the immediate vicinity of the resident a. Resident #50 was admitted to the facility in December 2024 with diagnoses which included acute osteomyelitis of the ankle and foot (infection to the bone), surgical amputation, and chronic ulcer of the left lower leg. Review of the Physician's Orders indicated but were not limited to the following: -Maintain CONTACT precautions due to MRSA use of gown and gloves every shift. (12/27/24) Review of the Comprehensive Care Plan indicated but was not limited to the following: -Resident has actual impairment to the skin related to constant picking. Multiple scabbed areas to bilateral lower extremities. (Revision 11/29/24) -Alteration in skin integrity related to patient non-compliance with treatment and retraumatizing healing wound via picking at skin. Post surgical wound right foot status post amputation of great and second toe with wound vac in place. (Revision 1/9/25) -Resident has MRSA in the right foot wound. Contact Isolation; Instruct family/visitors to wear gown/gloves during physical contact with resident. Wash hands before leaving room. On 1/15/25 at 8:25 A.M., the surveyor observed a Contact Precautions sign posted at the door to Resident #50's room. Review of the Contact Precautions sign indicated the following: STOP: Contact Precautions: Everyone Must: -Clean their hands, including before entering and when leaving the room. -Providers and Staff must also: Put on gloves and gown before room entry. -Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 1/15/25, the surveyor observed Nurse #4 administer medications to Resident #50 as follows: -8:26 A.M., Nurse #4 poured the medications for Resident #50 at the medication cart outside the resident's room. -8:37 A.M., Nurse #4 entered the room with the medication cup and a cup of water with no PPE on (no gloves or gown). She proceeded to check Resident #50's blood pressure with a wrist cuff, move items around on the bedside/overbed table, and adjust his/her bed linens covering lower extremities with exposed and visible wounds/scabs. The cuff did not read the blood pressure, so the cuff was repositioned and taken again. The medications were administered. Nurse #4 exited the room without performing hand hygiene (HH) and returned to the medication cart, placing the blood pressure cuff on top of the cart. -8:42 A.M., without performing HH, Nurse #4 proceeded to access the electronic Medication Administration Record (eMAR) on the computer, opened the medication cart, opened the narcotic box, removed Oxycodone (narcotic for pain), signed the narcotic book and at 8:46 A.M. re-entered Resident #50's room without performing HH or donning PPE. She administered the medication and exited the room without performing HH. On 1/15/25, the surveyor made additional observations during the medication pass of staff entering Resident #50's room as follows: -8:36 A.M., Certified Nursing Assistant (CNA) #1 entered the room without performing HH and without PPE on. She collected the breakfast tray, exited the room and placed the tray in the meal cart. Without performing HH, she entered the next room to collect the breakfast tray. -9:01 A.M., Housekeeper #2 entered the room with gloves on but no gown and proceeded to sweep the room, adjust personal items on the Resident's bedside/overbed table, including trash, and exit the room without performing HH. b. Resident #61 was admitted to the facility in July 2024 with diagnoses which included peripheral vascular disease, absence of left leg below the knee, and gangrene. Review of the Physician's Orders indicated but were not limited to the following: -EBP every shift. (10/9/24) Review of the Comprehensive Care Plan indicated but was not limited to the following: -Skin: Actual alteration in skin integrity related to admitted with surgical wound left below the knee amputation. (Revision 12/3/24) -EBP (10/24/24) On 1/15/25 at 8:46 A.M., the surveyor observed an EBP sign posted at the door to Resident #61's room. Review of the EBP Precautions sign indicated the following: STOP: EBP: Everyone Must: -Clean their hands, including before entering and when leaving the room. -Providers and Staff must also: Put on gloves and gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing brief or assisting with toileting, Device Care or use, Wound Care On 1/15/25, the surveyor observed Nurse #4 administer medications to Resident #50 and then continue on to administer medications and provide care to Resident #61 as follows: -8:47 A.M., Nurse #4 logged back into the eMAR and reviewed the medication list for Resident #61. She walked away from the medication cart (still without performing HH) and entered the nurses' station, retrieved two cartons of Glucerna (liquid nutritional supplement) from the cabinet and returned to the medication cart. Without performing HH, she proceeded to pour the medications for Resident #61. Nurse #4 was unable to locate one over the counter (OTC) medication needed, so she proceeded to lock the medication cart and walk to the medication storage room (still without performing HH). She entered the medication storage room, located the OTC medication and returned to the medication cart. Nurse #4, without performing HH, finished pouring the medications for Resident #61. Nurse #4 entered the room without PPE, placed the medication cup on the beside/overbed table, exited the room and returned to the medication cart in the hallway to retrieve the blood pressure cuff from the top of the cart. Nurse #4 re-entered the room without PPE or performing HH and without cleaning the blood pressure cuff proceeded to check Resident #61's blood pressure, administered medications, and exited the room. She placed the blood pressure cuff back on the top of the medication cart without cleaning it. -9:00 A.M., without performing HH, Nurse #4 then opened a small canvas bag to retrieve a thermometer and an oximeter. She placed those items on the top of the medication cart. She accessed the eMAR and started to prepare medications for the next resident and was stopped by the surveyor. During an interview on 1/15/25 at 9:00 A.M., Nurse #4 said she did not know why Resident #50 had a Contact Precautions sign hanging up and did not think he/she was on true precautions. She said she thought Residents #50 and #61 were both on EBP for wounds. Additionally, she said they do not have to wear PPE for medication administration. She said during the medication pass she tries to do HH before entering a room at least every few residents. She said usually it's every 2-3 unless there is a treatment, then HH is done. She said she does not perform HH between every resident. Nurse #4 said the blood pressure cuff is usually wiped down with an alcohol-wipe every three residents or so. During an interview on 1/15/25 at 9:26 A.M., CNA #1 said Resident #50 was on Contact Precautions, but they did not need PPE to enter the room or to deliver/collect trays. She said they only needed to wear PPE (gloves, gown, and mask) when providing care. During an interview with Housekeeper #2 and the Director of Housekeeping #1 on 1/15/25 at 9:17 A.M., Housekeeper #2 said she did not speak English well and indicated she would get the supervisor to assist. The Director of Housekeeping #1 said Housekeeper #2 should have had full PPE on to enter Resident #50's room due to Contact Precautions. She said Housekeeper #2 doesn't speak good English but would need more education on what PPE is needed in the Precaution rooms. During an interview on 1/15/25 at 12:29 P.M., the Director of Nurses (DON) and Consulting Staff #1 said with Contact Precautions staff should perform HH prior to entering the residents' room and have PPE on for resident contact/care. Consulting Staff #1 said Housekeeping should be okay just sweeping but touching the environment they should have PPE on. Additionally, she said the sign does indicate to don PPE prior to entering the room, so they all should have it on based on that. They said with EBP staff should be performing HH prior to entering the room and PPE should be used when providing resident care/contact with the area (i.e. wound). The DON said equipment should be cleaned between residents if shared and HH should be performed between every resident and when entering/exiting any room with a precaution sign. During an interview on 1/15/25 at 2:43 P.M., Nurse #4 said Resident #50 is on Contact Precautions and therefore she should have had full PPE on to enter the room, administer meds, check his/her blood pressure, and adjust the bed linens. Additionally, she said the blood pressure cuff should have been sanitized before being used for the next resident and it was not. 49425 2. Review of the facility's policy titled Infection Control Guidelines for Nursing Procedures, dated as revised 7/2024, indicated but was not limited to the following: -Standard precautions are the minimum infection prevention practices that apply to all resident care areas Resident #46 was admitted to the facility in September 2024 with diagnoses including dysphagia (difficulty swallowing liquid or food), and intercranial hemorrhage (bleeding in the brain). Review of the Minimum Data Set (MDS) assessment, dated 11/13/24, indicated Resident #46 had a feeding tube and the portion of the total calories the resident received through a feeding tube was 51% or more. On 1/14/25 at 2:57 P.M., the surveyor observed a piston syringe (needleless syringe to administer fluids through a feeding tube) lying on the Resident's bedside table, uncovered and undated. The syringe did not have a protective barrier underneath it potentially exposing it to environmental contaminants. Review of the Physician's Orders indicated Resident #46 had the following orders related to the feeding tube supplies: -Change piston syringe every night shift During an observation with an interview on 1/16/25 at 7:43 A.M. Nurse #2 and the surveyor observed a piston syringe lying uncovered and undated on top of Resident #46's nightstand, potentially exposed to environmental contaminants. Nurse #2 said the syringes are supposed to be stored in individual bags that are labeled with the Resident's name and date. She said they are coming in one large bag now and she has nothing to store it in, so she places it on the table. During an interview on 1/16/25 at 2:39 P.M., the Director of Nursing (DON) said all G-tube supplies should be stored in a sanitary manner with a protective barrier, to reduce the risk of contamination. She said it also should have the Resident's name and date labeled on it, and it is to be changed every 24 hours.

Based on observation and interview, the facility failed to maintain a safe and clean environment in the designated smoking area by not properly disposing of cigarette butts in designated safe ashtrays. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) circular letter, dated November 10, 2011, titled Smoking Safety in Long Term Care Facilities indicated but was not limited to the following: -The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions and non-smoking residents from secondhand smoke. -The Life Safety Code (NFPA 101, 2000 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design. On 1/16/25 at 10:40 A.M., the surveyor observed the outside smoking area as follows: -Along the entire border of the smoking area there were hundreds of cigarette butts observed in the bushes lining the smoking area. -White glass bowls, stained with a black substance and ashes were in the bushes. -Plastic outdoor self-extinguishing ashtray with bucket at its base. The neck of the ashtray was disconnected from the bucket leaving the cigarette butts exposed. -On two of the outdoor tables there were one white glass bowl and three clear glass bowls with numerous cigarettes butts. There were no covers to the bowls. -Cigarette butts disposed of in the trash can lined with a plastic bag containing empty cigarette boxes. -Cigarette butts in the planter by the door to the facility. During an interview on 1/16/25 at 10:45 A.M., Resident #51 said the ashtrays blew over with the wind and the top of the ashtray blew off, blowing cigarette butts everywhere. During an interview on 1/16/25 at 10:50 A.M., the Maintenance Director (MD) said he cleans up the smoking area every Monday and Friday. He said when he comes out on Mondays it is worse. The MD said the residents know they are supposed to dispose of cigarettes in the ashtrays, but they don't. He said when he tells the residents they must dispose of cigarettes in the ashtray, they tell him they have rights, and they don't listen. The area needs to be kept cleaner. During an interview on 1/16/25 at 11:35 A.M., the MD said the outdoor ashtray was missing a screw and that's why the top came off, and he removed all the open ashtrays from the tables. During an interview on 1/16/25 at 11:55 P.M., the Administrator said he was not aware of the numerous cigarettes on the ground or the screw missing from the ashtray. He said there is a staff member out there supervising all smoking sessions.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#23), out of 18 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address the care and management of Resident #23's Diabetes Mellitus (non-insulin dependent diabetes). Findings include: Review of the facility's policy titled Care Plans: Comprehensive Person-Centered, dated as last revised 1/2024, indicated but was not limited to the following: -A comprehensive care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial, and functional needs. -The care plan interventions are derived from information gathered from the comprehensive assessment. -The comprehensive care plan will identify problem areas and their causes as warranted and developing interventions that are targeted and meaningful to the resident. Resident #23 was admitted to the facility in October 2024 with diagnoses which included Diabetes Mellitus with other specified complications, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and unspecified fall. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #23 had a diagnosis of Diabetes Mellitus, took insulin, and had recent falls. The MDS failed to indicate that the Brief Interview for Mental Status (BIMS) had been completed to determine cognitive status. Further review of the medical record indicated a BIMS assessment was completed on 1/15/25, and Resident #23 scored 4 out of 15, indicating severe cognitive impairment. Review of the Hospital Discharge Summary, dated 10/28/24, indicated: Reason for Exam: status post fall with hypoglycemia (low blood sugar) noted. Given poor intake developed hypoglycemia. Diabetic medication regime was adjusted inpatient and discharged to facility for rehab and further management on a diabetic diet with hypoglycemic protocol. Review of the Physician's Orders indicated but were not limited to the following: -Jardiance Oral Tablet 10 milligrams (mg) by mouth one time a day (10/29/24) (lowers blood sugar) -Metformin HCL 500 mg by mouth two times a day. (10/29/24) (lowers blood sugar) -Lantus SoloStar subcutaneous Solution Pen-Injector 100 units/milliliter (ml) inject 7 units subcutaneously at bedtime. (11/20/24) (long-acting insulin to lower blood sugar) Review of the Comprehensive Care Plan failed to indicate a care plan for Diabetic Management had been developed for Resident #23. During an interview on 1/16/25 at 3:54 P.M., Nurse #1 said Resident #23 should have had a care plan since admission for Diabetes and was unsure why he/she did not have one. Additionally, she said he/she should have diabetic monitoring orders, and he/she did not have those either. During an interview on 1/21/25 at 1:03 P.M., the Director of Nurses (DON) said a Resident with a diagnosis of diabetes should have a care plan in place, monitor blood sugars as ordered, administer medications as ordered, and have a diabetic order set in place, including monitoring for hypo/hyperglycemia and parameters of when to notify the physician.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for two Residents (#54 and #23), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #54, to ensure the facility implemented the consultant eye doctor's recommendations for eye drops; and 2. For Resident #23, to ensure physician requested/recommended treatments were entered into the electronic medical record and implemented. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #54 was admitted to the facility in May 2023 with diagnoses which included diabetes, dry eye, and presbyopia (gradual, age related loss of eyes to focus on nearby objects). Review of the Minimum Data Set assessment, dated 8/14/24, indicated Resident #54 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. Review of the consultant progress note titled Eye Care Group, dated 11/28/24, indicated but was not limited to the following: -New medication order: Refresh Dry Eye Therapy oph. Solution, apply one drop both eyes twice daily for indefinitely. Review of the Physician's Orders from 11/28/24 through 1/21/25, indicated there were no orders for Refresh Dry Eye Therapy. During an interview on 1/14/25 at 3:08 P.M., Resident #54 said he/she was seen by the eye doctor who ordered eye drops, but he/she has never received them. Resident #54 said it has been weeks since he/she saw the eye doctor. During an interview on 1/16/25 at 5:05 P.M., the Director of Nursing (DON) said when a resident has new orders from a consultant physician, the nurse should notify the resident's physician, and the orders should be written and the medication ordered. During an interview on 1/16/25 at 5:10 P.M., Resident #54 was upset and said to the surveyor and the DON, the eye doctor recommended eye drops and he/she still has not received them. The facility does not have a policy for consultant physician appointments. 48084 2. Resident #23 was admitted to the facility in October 2024 with diagnoses which included Diabetes Mellitus with other specified complications, Type 2 Diabetes Mellitus with diabetic neuropathy, and unspecified fall. Review of the MDS assessment, dated 11/1/24, indicated Resident #23 had a diagnosis of Diabetes Mellitus, took insulin, and had recent falls. The MDS failed to indicate that the Brief Interview for Mental Status (BIMS) had been completed to determine cognitive status. Further review of the medical record indicated a BIMS assessment was completed on 1/15/25 and Resident #23 scored 4 out of 15, indicating severe cognitive impairment. Review of the Hospital Discharge Summary, dated 10/28/24, indicated: Reason for Exam: status post fall with hypoglycemia (low blood sugar) noted. Given poor intake developed hypoglycemia. Diabetic medication regime was adjusted inpatient and discharged to facility for rehab and further management on a diabetic diet with hypoglycemic protocol. Review of the Physician's Orders indicated but were not limited to the following: -Health Care Proxy (HCP) invoked (11/26/24) -Diet: Soft bite sized food, one to one supervision with cues for multiple swallows, cue for cough after thin liquids. Follow Aspiration Precautions every shift. (12/26/24) -Jardiance Oral Tablet 10 milligram (mg) by mouth one time a day (10/29/24) (lowers blood sugar) -Metformin HCL 500 mg by mouth two times a day. (10/29/24) (lowers blood sugar) -Lantus SoloStar subcutaneous Solution Pen-Injector 100 units/milliliter (ml) inject 7 units subcutaneously at bedtime. (11/20/24) (long-acting insulin to lower blood sugar) Review of the physician's progress notes indicated the following: -10/31/24: Chief Complaint: Fall with recent history or alcohol intoxication and polypharmacy (use of multiple medications usually more than five to treat medical conditions). Appears in a poor general state. -11/1/24: Chief Complaint: Recent pneumonia with continued cough. Admission orders: Monitor glucose levels and adjust diabetic medications as needed. -11/7/24: Chief Complaint: Routine follow up: Plan: Diabetes Management: reinforce dietary modifications and ensure compliance with antidiabetic medications. Arrange HbA1c (hemoglobin A1C-blood test to show average blood glucose level over the last two to three months) -11/8/24: Chief Complaint: pneumonia: Plan: Start Levaquin 750 mg daily for 10 days, start probiotic daily for 14 days, repeat chest x-ray (CXR) after completion of Levaquin (11/19/24), and repeat complete blood count (CBC) and compete metabolic panel (CMP) (blood tests) after completion of Levaquin (11/19/24). Nursing made aware of new orders. New orders will be input into Point Click Care (PCC-the electronic medical record). -11/14/24: Chief Complaint: routine follow up: white blood cell count (WBC) remains elevated, currently on Levaquin for suspected infection. Plan: Repeat WBC on the next lab day to assess trend. 1/2/25: Chief Complaint: routine follow up: Recent hospitalization : Diabetes Mellitus Plan: continue current regimen, monitor glucose levels closely, HbA1c follow up in 3 months. -1/7/25: Chief Complaint: Progress Note 30/60 day: Diabetes Management: Continue Lantus and Metformin. Monitor blood glucose levels regularly. Further review of the medical record failed to indicate blood glucose monitoring was implemented, failed to indicate the lab work was scheduled (HbA1c, CBC, CMP), and failed to indicate the repeat CXR was scheduled. During an interview on 1/16/25 at 3:54 P.M., Nurse #1said the physician's progress notes get uploaded directly into PCC and the nurses on the floor do not routinely go in and read them. She said there is no Unit Manager and is unsure if anyone reads the notes on a regular basis. She said regarding the orders the physician wants written, they are relayed to nursing either verbally or sometimes they write them on a physician order sheet and leave them for us. She said she did not know why these orders from their progress notes were never clarified and carried out. Review of the progress notes failed to indicate communication between the provider and nursing had taken place to clarify the frequency of requested glucose monitoring. During an interview on 1/17/25 at 9:07 A.M., Physician #1 said the plan/orders written in his notes is reviewed with the nurse and his expectation is for the order to be entered into PCC. He said he usually communicates his plan verbally. Additionally, he said Resident #23 was hospitalized with hypoglycemia and had medication adjustments made. He said his expectation is that the hypoglycemic protocol was in place and CBGs were ordered to monitor his/her blood sugars to adjust medication as needed. He said he was not aware the CBGs were not ordered nor the follow up labs and CXR and did not know why they were not done as they should have been.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed for Resident #30, to obtain a physician's order for wound care on admission, develop and implement a pressure ulcer care plan on admission, to assess and monitor a pressure ulcer, to obtain orders for wound consultant recommendations-including medications, treatments and lab work, to transcribe orders for wound care accurately, and to provide wound care per physician's orders resulting in the progression of a deep tissue injury (DTI- intact skin with localized area of persistence non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to a Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) six times larger with eschar/necrotic tissue (dead/devitalized tissue). Findings include: Review of the [NAME] Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018 indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated as last revised 11/2017, indicated but was not limited to the following: -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any change in condition. -Conduct a comprehensive skin assessment upon admission, including skin integrity-any evidence of existing or developing pressure ulcers or injuries. -Inspect the skin on a daily basis and identify any signs of developing pressure injuries (i.e., non-blanchable erythema) and inspect pressure points (sacrum, heels, buttocks, and coccyx, etc.) -Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. -Evaluate, report and document potential changes in the skin. -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018, indicated but was not limited to the following: -The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can immediately be addressed, and which will take time to modify. -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risk for pressure ulcers/injuries. -The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. -Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. -Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool -Conduct a comprehensive skin assessment with every risk assessment. -If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of skin alteration in skin. -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if the current interventions are deemed inadequate. -The following information should be recorded in the resident's medical record utilizing facility forms: a. The type of assessment(s) conducted. b. The date and time and type of skin care provided. c. Any change in condition of identified. d. The condition of the resident's skin. e. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration is noted. f. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. g. Notify attending MD if new skin alteration noted. Review of the facility's policy titled Dressings, Dry/Clean, dated as last revised 4/2018, indicated but was not limited to the following: -Verify that there is a physician's order for this procedure. -Review the resident's care plan, current orders, and diagnoses to determine if there are any special resident needs. -The following equipment and supplies will be necessary when performing this procedure: clean dressing, cleaning solution as ordered, and personal protective equipment (PPE). Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised 11/2017, indicated but was not limited to the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Incorporate identified problem areas. d. Incorporate risk factors associated with identified problems. e. Reflect treatment goals, timetables, and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. -Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. -The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS assessment). -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes. -The Interdisciplinary Team must review and update the care plan when there has been a significant change in the residents' condition and when the desired outcome is not met. Resident #30 was admitted to the facility in June 2023 with diagnoses including dementia, diabetes mellitus, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/23, indicated Resident #30 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Review of the Admission Nursing Evaluation V16, dated 6/27/23, indicated Resident #30 was totally dependent on staff for bed mobility, eating, toileting, and required a mechanical lift for transfers. Further review of the evaluation indicated Resident #30 had a pressure injury to the sacrum (bottom of spine above tailbone) measuring 1 centimeter (cm) in length x 0.5 cm in width x 0 cm in depth. The pressure injury was staged as a Suspected Deep Tissue Injury. The evaluation was signed by the nurse on 7/7/23, 10 days after the resident was admitted to the facility. Section C: Skin Integrity was signed by nurse on 8/11/23, 45 days after the resident was admitted to the facility. Review of the Admission Physician Order Summary, dated 6/28/23, failed to indicate a treatment order for the pressure injury to Resident #30's sacrum. Review of the care plans for Resident #30 failed to indicate a Pressure Ulcer/Injury care plan had been initiated upon admission. Review of the Weekly Skin evaluation, dated 7/4/23, indicated Resident #30 had a pressure area to the right buttock, no measurements were documented. The evaluation was signed by the nurse on 7/8/23. Review of the Pressure Ulcer Evaluation, dated 7/4/23, indicated Resident #30 had an Unstageable Pressure Ulcer to the sacrum, measuring 1.7 cm x 0.9 cm x 0 cm. Wound description included: -Date first observed: 7/14/23 (sic) -Exudate/Drainage: Moderate Serous -Wound Bed: Eschar -Notes: cleanse, apply calcium alginate and cover with foam dressing daily -Type of Evaluation: Weekly Evaluation of Existing Skin Condition -Signed by the nurse on 8/11/23 Review of the June 2023 and July 2023 Treatment Administration Record (TAR) failed to indicate a treatment for the pressure ulcer from 6/27/23 through 7/7/23. The Resident had gone 10 days with no treatment in place for the pressure ulcer; during that time, the wound had progressed from an intact DTI measuring 1 cm x 0.5 cm x 0 cm on 6/27/23 to an Unstageable pressure ulcer with moderate serous drainage and eschar measuring 1.7 cm x 0.9 cm x 0 cm on 7/4/23. Further review of the TAR indicated a treatment order as follows: -Apply House Barrier on buttocks twice daily skin protection/redness. (7/7/23). Review of additional Weekly Skin Evaluations for July 2023, indicated the following: -7/11/23, no documentation of the pressure ulcer, Signed by the nurse 7/18/23. -7/18/23, no documentation of the pressure ulcer, Signed by the nurse 7/23/23. -7/25/23, Weekly Skin Evaluation was not completed. Review of additional Pressure Ulcer Evaluations for July 2023, indicated the following: -7/11/23, Pressure Ulcer Evaluation was not completed. -7/18/23, indicated Resident #30 had a resolved pressure area. -Date first observed: 7/18/23, Signed by nurse on 7/20/23 No additional Pressure Ulcer Evaluations were completed in July 2023. Review of the Wound Consultant Progress Note, dated 7/20/23, indicated the Resident was not seen. No further Wound Consultant visits were completed in July 2023. Review of the Nurse's notes from 6/27/23 - 7/30/23 failed to indicate the pressure ulcer had been assessed and monitored for changes. Further review of a Nurse's Note, dated 7/31/23, indicated the Resident's skin was intact, the Resident did not have any ulcers, and wound care was provided in between buttock cheeks near the rectum. No further description or assessment of the wound or wound care provided was documented. Further review of the TAR indicated Resident #30 did not have any orders for wound care to the pressure ulcer on his/her sacrum. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse, who is also the Unit Manager and Assistant Director of Nurses (ADON), said Resident #30 was admitted with the wound and she was not made aware of it until weeks later. Additionally, she said there was no treatment ordered on admission and there should have been. She said the Barrier cream treatment ordered on 7/7/23 was not appropriate for a pressure ulcer as that is for prevention, and this wound should have had a dressing on it. She also said there was no care plan initiated on admission and that it was not done until she re-opened the Nursing Admission Evaluation V16 on 8/11/23 to fix it (45 days after admission). She said on the Pressure Ulcer Evaluation, dated 7/4/23, the date first observed should have been the admitted and not 7/14/23, that was wrong, and that she should not have written the treatment memo in the notes section of the Pressure Ulcer Evaluation because she was backdating the evaluation, and that dressing recommendation was from the 8/10/23 Wound Doctor visit. Additionally, she said when she and the Wound Physician did rounds on 7/20/23 they did not see Resident #30 because the wound was not visible, probably because of poor lighting, but it had to have been there as it was a big deep open wound the next time. She said they must have missed it. She said the usual process is: On admission after the Nursing Admission Evaluation V16 is done, an order is obtained for a treatment, the care plan is initiated directly from the Nursing Admission Evaluation V16, the nurse then notifies me and the Director of Nurses, the Wound Doctor is added to the Resident profile so the Resident would be seen on weekly wound rounds and weekly Pressure Ulcer Evaluations should be done. She said in this case none of those things happened. She said she was not made aware of the wound until weeks later when it was much bigger and that is when the wound care physician was added to the profile and the Resident was added to weekly wound rounds. She said adding the Wound Doctor to the Resident profile is our fail safe because it triggers the Wound Doctor to see the Resident, but in this case that did not happen for several weeks. She said Resident #30 should have had weekly Pressure Ulcer Evaluations done from admission and he/she did not. During an interview on 12/4/23 at 11:27 A.M., the Director of Nurse (DON) said a treatment should have been ordered on admission and it was not. She said her expectation is if there is no order from the hospital, the nurse calls the primary care physician to obtain an appropriate order. She said a care plan should have been initiated and it was not, and the wound doctor should have been added to the Resident's profile and added to weekly rounds and that did not happen either. Additionally, the DON said the order written on 7/7/23 for House Barrier Cream was not an appropriate order for a pressure injury, the area should have had a dressing on it for protection. The DON said usually she or the Wound Nurse will review the Nursing Admission Evaluations V16 for completion and to ensure any wounds have orders, care plans, and are added to wounds rounds; however, in this case none of those things were done and Resident #30's wound got worse and much larger. AUGUST 2023 Review of the Weekly Skin Evaluations for August 2023 indicated the following: -8/29/23, no documentation of the pressure ulcer. Review of the Pressure Ulcer Evaluations for August 2023, indicated the following: -8/3/23, Pressure Ulcer Evaluation was not completed. -8/10/23, Resident #30 had a Stage 3 Pressure Ulcer (full thickness loss of skin, in which subcutaneous fat mat be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present), measuring 6.3 cm x 4.4 cm x 0 cm. Notes: Cleanse, apply calcium alginate and cover with border dressing daily. -8/18/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 6 cm x 3.6 cm x 0.1 cm. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Wound Cleanser and Calcium Alginate secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 milligrams (mg) twice daily, Prevalon Boots. -Signed by nurse on 8/21/23 Review of the Wound Consultant Physician Evaluation and Management Summary, dated 8/3/23, indicated but was not limited to the following: -Resident #30 had an Unstageable Deep Tissue Injury (DTI) to the sacrum. -Wound Etiology: Pressure -Duration: greater than 7 days Wound Size: 7.6 cm x 5.5 cm x not measurable cm (Depth is immeasurable due to the presence of tissue overgrowth.) -Dressing Treatment Plan: Primary Dressing: Silver Sulfadiazine (antibiotic cream used to treat and/or prevent infection) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound (relieve pressure); Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days (vitamins to aid in wound healing); Pre-Albumin (blood test to determine if your body is getting enough protein which aids in wound healing). Review of the medical record including Medication Administration Record (MAR), TAR, and physician's orders failed to indicate the treatment order was obtained for the Silver Sulfadiazine and foam dressing to the sacrum or any other new order for wound care. Additionally, the medical record failed to indicate the additional recommendations to off-load the wound, Vitamin C and Zinc Sulfate, or the lab work were ordered. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/10/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 6.3 cm x 4.4 cm x not measurable cm (Depth is immeasurable due to the presence of nonviable tissue and necrosis.) -Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate (promotes formation of granulation tissue, re-epithelialization (cell growth to help healing), and helps to minimize bacterial infections) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots (heel booties with a heel cut out used to float heels off the mattress and relieve pressure to prevent pressure ulcers). -Surgical Excisional Debridement to remove necrotic tissue and establish the margins of visible tissue. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record failed to indicate an order was obtained for the antimicrobial cleanser and foam dressing. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/18/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 6 cm x 3.6 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record indicated the wound care order was changed on 8/22/23 with a start date of 8/23/23 as follows: Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. This was 12 days after the recommendations were made on 8/10/23 and the antimicrobial cleanser was still not ordered as recommended. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/24/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 5.9 cm x 3.2 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) (cleanser that creates a moist environment and loosens contaminated exudate within the wound bed to allow natural healing to take place) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician's orders indicated the following: -Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (8/24/23; Discontinued 8/25/23) -Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) -Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate the recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/31/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 5.5 cm x 3.5 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe). Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician's orders indicated the following: -Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) -Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. A care plan titled Pressure Ulcer was initiated on 8/11/23, 45 days after admission. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the Pressure Ulcer Evaluation on 8/3/23 should have been done and it was not. Additionally, she said the recommendations from the Wound Doctor on 8/3/23 should have been addressed and they were not, and the Resident continued to have a progressing wound without an appropriate treatment. She said she does wound rounds and usually writes the orders, but these were missed. Additionally, she said the order written on 8/11/23 for Calcium Alginate should have had the recommended cleanser and the foam dressing as part of the order and it did not and the recommendation to off-load wound, Vitamin C and Zinc Sulfate, Pre-Albumin lab work and Prevalon Boots all should have been addressed and they were not. She also said the orders should be written with the specific cleanser recommended as Wound Cleanser, Antimicrobial Wound Cleanser and Vashe Wound Cleaner are all different cleansers. She also said she took over doing wound rounds because things like this were not getting done. During an interview on 12/4/23 at 11:27 A.M., the DON said the Pressure Ulcer Evaluation should be done weekly and it was not. She also said the order on 8/11/23 should have had the appropriate cleanser and foam dressing as part of the order and she missed that, therefore the order was incorrect. The DON said the type of cleanser needs to be specific as Wound Cleanser, Antimicrobial Wound Cleanser, and Vashe are all different cleansers. Additionally, she said all the recommendations made by the wound doctor should have been addressed and they were not. SEPTEMBER 2023 Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/7/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7.5 cm x 3.3 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR, physician's orders, and care plan failed to indicate off-load wound or Prevalon Boots had been addressed. Further review of the medical record including MAR, TAR and physician's orders indicated the following: -Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23; Discontinued 9/4/23) -Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (9/4/23). -Ascorbic Acid (Vitamin C) 500 mg twice daily (9/5/23) -Pre-Albumin blood test was drawn on 9/11/23, results were critically low. The Vashe cleanser was ordered 11 days after it was recommended. The Vitamin C was ordered 33 days after it was recommended. The Pre-Albumin blood test was drawn 39 days after it was recommended. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/14/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7.5 cm x 3 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the medical record including MAR, TAR, and physician's orders indicated the following: -Bootie/Heel Protectors on as tolerated every shift. (8/25/23; Discontinued 9/13/23) -Prevalon Boots in place at all times (9/13/23) Review of the care plan indicated the following: -Off-load wound was added to the care plan (9/15/23) The Bootie/Heel Protectors were ordered 15 days after the Prevalon Boots were recommended. The Prevalon Boots were ordered 34 days after they were recommended. Off-load wound was added to the care plan 43 days after it was recommended. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/21/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7 cm x 3 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/28/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7 cm x 3 cm x 0.3 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the Physician's Orders indicated the recommendations for Zinc Sulfate had still not been addressed since first recommended on 8/3/23. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the recommendation to off-load wound, Vitamin C and Zinc Sulfate, Pre-Albumin lab work and Prevalon Boots all should have been addressed when recommended and they were not. The expectation is the orders are obtained within a day or two and they were not. and they were not. During an interview on 12/4/23 at 11:27 A.M., the DON said all the recommendations made by the wound doctor should have been addressed by the day after the Wound Doctor visit and they were not. OCTOBER 2023 Review of the Weekly Skin Evaluations for October 2023 indicated the following: -10/17/23, no documentation of the pressure ulcer. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 10/5/23, indicated but was not limited to the following: -Resident #30 had Stage 4 Pressure wound to the sacrum. -Wound Size: 6.6 cm x 2.8 cm x 1.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots, Pre-Albumin blood test. Review of the Physician's Orders failed to indicate the recommendation for Pre-Albumin lab work was addressed. -10/12/23 no visit note - Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 10/19/23, indicated but was not limited to the following: -Resident #30 had Stage 4 Pressure wound to the sacrum. -Wound Size: 3.9 cm x 1.4 cm x 0.8 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply twice daily and as needed; Hypochlorous acid solution (Vashe) apply twice daily and as needed. Secondary Dressing: Silicone Bordered Foam apply twice daily and as needed. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots, Pre-Albumin blood test. -Sharp debridement refused by family. Review of the medical record including MAR, TAR, and physician's orders failed to indicate the recommendation to increase frequency of dressing change from once daily to twice daily and for the Pre-Albumin lab work were addressed. - Review of the Wound Consultant Physician Evaluation and Management Summary, dated 10/26/23, indicated but was not limited to the following: -Resident #30 had Stage 4 Pressure wound to the sacrum. -Wound Size: 3.9 cm x 1.5 cm x 1 cm with undermining: 1.4 cm at 1 o'clock -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply twice daily and as needed; Hypochlorous acid solution (Vashe) apply twice daily and as needed. Secondary Dressing: Silicone Bordered Foam apply twice daily and as needed. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots, Pre-Albumin blood test. -Sharp debridement refused by family. Review of the Physician's Orders results failed to indicate an order for the Pre-Albumin blood test was obtained since recommended on 10/5/23. Further review of the medical record including TAR and physician's orders failed to indicate the treatment was changed from once daily to twice daily as recommended on 10/19/23. The order to change the treatment from once a day to twice a day was obtained on 10/27/23 after it was recommended again by the wound physician on 10/26/23 (8 days after it was initially recommended). During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the recommendation to increase the dressing change from once to twice daily and the Pre-Albumin lab work should have been addressed when recommended and they were not. During an interview on 12/4/23 at 11:27 A.M., the DON said all the recommendations made by the wound doctor should have been addressed by the day after the Wound Doctor visit and they were not. She said recommendations for lab work should be ordered for the next lab day as the lab comes a couple times a week. NOVEMBER 2023 -Review of the Wound Consultant Physician Evaluation and Management Summary, dated 11/2/23, indicated but was not l[TRUNCATED]

Based on observation, interviews, policy review, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed for Resident #30, to obtain a physician's order for wound care on admission, develop and implement a pressure ulcer care plan on admission, to assess and monitor a pressure ulcer, to obtain orders for wound consultant recommendations-including medications, treatments and lab work, to transcribe orders for wound care accurately, and to provide wound care per physician's orders resulting in the progression of a deep tissue injury (DTI-intact skin with localized area of persistence non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to a Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) six times larger with eschar/necrotic tissue (dead/devitalized tissue). Findings include: Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated as last revised 11/2017, indicated but was not limited to the following: - Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any change in condition. - Conduct a comprehensive skin assessment upon admission, including skin integrity, any evidence of existing or developing pressure ulcers or injuries. - Inspect the skin on a daily basis and identify any signs of developing pressure injuries (i.e., non-blanchable erythema) and inspect pressure points (sacrum, heels, buttocks, and coccyx, etc.) - Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. - Evaluate, report and document potential changes in the skin. - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018, indicated but was not limited to the following: - The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can immediately be addressed, and which will take time to modify. - Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risk for pressure ulcers/injuries. - The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. - Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. - Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool - Conduct a comprehensive skin assessment with every risk assessment. - If a new skin alteration is noted, initiate a pressure or non-pressure form related to the type of skin alteration in skin. - Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if the current interventions are deemed inadequate. - The following information should be recorded in the resident's medical record utilizing facility forms: a. The type of assessment(s) conducted. b. The date and time and type of skin care provided. c. Any change in condition of identified. d. The condition of the resident's skin. e. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration is noted. f. Documentation in medical record addressing MD notification id new skin alteration noted with change of plan of care, if indicated. g. Notify attending MD if new skin alteration noted. Review of the facility's policy titled Dressings, Dry/Clean, dated as last revised 4/2018, indicated but was not limited to the following: - Verify that there is a physician's order for this procedure. - Review the resident's care plan, current orders, and diagnoses to determine if there are any special resident needs. - The following equipment and supplies will be necessary when performing this procedure: clean dressing, cleaning solution as ordered, and personal protective equipment (PPE). Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised 11/2017, indicated but was not limited to the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Incorporate identified problem areas. d. Incorporate risk factors associated with identified problems. e. Reflect treatment goals, timetables, and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. - Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. - The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS assessment). - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes. - The Interdisciplinary Team must review and update the care plan when there has been a significant change in the residents' condition and when the desired outcome is not met. Resident #30 was admitted to the facility in June 2023 with diagnoses including dementia, diabetes mellitus, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/23, indicated Resident #30 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. JUNE 2023 Review of the Admission Nursing Evaluation V16, dated 6/27/23, indicated Resident #30 was totally dependent on staff for bed mobility, eating, toileting, and required a mechanical lift for transfers. Further review of the evaluation indicated Resident #30 had a pressure injury to the sacrum (bottom of spine above tailbone) measuring 1 centimeter (cm) in length x 0.5 cm in width x 0 cm in depth. The pressure injury was staged as a Suspected Deep Tissue Injury. The evaluation was signed by the nurse on 7/7/23, 10 days after the Resident was admitted to the facility. Section C: Skin Integrity was signed by nurse on 8/11/23, 45 days after the Resident was admitted to the facility. Review of the Admission Physician's Order Summary, dated 6/28/23, failed to indicate a treatment order for the pressure injury to Resident #30's sacrum. Review of the care plans for Resident #30 failed to indicate a Pressure Ulcer/Injury care plan had been initiated upon admission. JULY 2023 Review of the Weekly Skin evaluation, dated 7/4/23, indicated Resident #30 had a pressure area to the right buttock, no measurements were documented. The evaluation was signed by the nurse on 7/8/23. Review of the Pressure Ulcer Evaluation, dated 7/4/23, indicated Resident #30 had an Unstageable Pressure Ulcer to the sacrum, measuring 1.7 cm x 0.9 cm x 0 cm. Wound description includes: - Date first observed: 7/14/23 (sic) - Exudate/Drainage: Moderate Serous [watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage] - Wound Bed: Eschar [dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color and may appear scab-like] - Notes: cleanse, apply calcium alginate and cover with foam dressing daily - Type of Evaluation: Weekly Evaluation of Existing Skin Condition - Signed by the nurse on 8/11/23 Review of the June 2023 and July 2023 Treatment Administration Record (TAR) failed to indicate a treatment for the pressure ulcer from 6/27/23 through 7/7/23. The Resident had gone 10 days with no treatment in place for the pressure ulcer; during that time, the wound had progressed from an intact DTI measuring 1 cm x 0.5 cm x 0.0 cm on 6/27/23 to an Unstageable pressure ulcer with moderate serous drainage and eschar measuring 1.7 cm x 0.9 cm x 0.0 cm on 7/4/23. Further review of the TAR indicated a treatment order as follows: - Apply House Barrier on buttocks twice daily skin protection/redness. (7/7/23). Review of the Physician's Orders for Resident #30 indicated: - Weekly Skin Check every Tuesday (7/20/23). Review of additional Weekly Skin Evaluations for July 2023 indicated the following: - 7/11/23, no documentation of the pressure ulcer, Signed by the nurse 7/18/23. - 7/18/23, no documentation of the pressure ulcer, Signed by the nurse 7/23/23. - 7/25/23, Weekly Skin Evaluation was not completed. Review of additional Pressure Ulcer Evaluations for July 2023 indicated the following: - 7/11/23, Pressure Ulcer Evaluation was not completed. - 7/18/23, indicated Resident #30 had a resolved pressure area. Wound description included: a. Date first observed: 7/18/23 b. Type of Evaluation: Weekly Evaluation of Existing Skin Condition c. Signed by nurse on 7/20/23 No additional Pressure Ulcer Evaluations were completed in July 2023. Review of the Wound Consultant Progress Note, dated 7/20/23, indicated the Resident was not seen. No further Wound Consultant visits were completed in July 2023. Review of the Nurses' Notes from 6/27/23 - 7/30/23 failed to indicate the pressure ulcer had been assessed and monitored for changes. Further review of a Nurse's Note, dated 7/31/23, indicated the Resident's skin was intact, the Resident did not have any ulcers, and wound care was provided in between buttock cheeks near the rectum. No further description or assessment of the wound or wound care provided was documented. Further review of the TAR indicated Resident #30 did not have any orders for wound care. The Resident had an order for House Barrier Cream to buttocks twice daily for skin protection/redness. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse, who is also the Unit Manager and Assistant Director of Nurses (ADON), said Resident #30 was admitted with the wound and she was not made aware of it until weeks later. Additionally, she said there was no treatment ordered on admission and there should have been. She said the Barrier cream treatment ordered on 7/7/23 was not appropriate for a pressure ulcer as that is for prevention, and this wound should have had a dressing on it. She also said there was no care plan initiated on admission and that it was not done until she re-opened the Nursing Admission Evaluation V16 on 8/11/23 to fix it (45 days after admission). She said on the Pressure Ulcer Evaluation, dated 7/4/23, the date first observed should have been the admitted and not 7/14/23 that was wrong and that she should not have written the treatment memo in the notes section of the Pressure Ulcer Evaluation because she was backdating the evaluation and that dressing recommendation was from the 8/10/23 Wound Doctor visit. Additionally, she said when she and the Wound Physician did rounds on 7/20/23 they did not see Resident #30 because the wound was not visible, probably because of poor lighting, but it had to have been there as it was a big, deep, open wound the next time. She said they must have missed it. She said the usual process is: On admission after the Nursing Admission Evaluation V16 is done, an order is obtained for a treatment, the care plan is initiated directly from the Nursing Admission Evaluation V16, the nurse then notifies me and the Director of Nurses, the Wound Doctor is added to the Resident profile so the Resident would be seen on weekly wound rounds and weekly Pressure Ulcer Evaluations should be done. She said in this case none of those things happened. She said she was not made aware of the wound until weeks later when it was much bigger and that is when the wound care physician was added to the profile and the Resident was added to weekly wound rounds. She said adding the Wound Doctor to the Resident profile is our fail safe because it triggers the Wound Doctor to see the Resident, but in this case that did not happen for several weeks. She said Resident #30 should have had weekly Pressure Ulcer Evaluations done from admission and he/she did not. During an interview on 12/4/23 at 11:27 A.M., the Director of Nursing (DON) said a treatment should have been ordered on admission and it was not. She said her expectation is if there is no order from the hospital, the nurse calls the primary care physician to obtain an appropriate order. She said a care plan should have been initiated and it was not, and the wound doctor should have been added to the Resident's profile and added to weekly rounds and that did not happen either. Additionally, the DON said the order written on 7/7/23 for House Barrier Cream was not an appropriate order for a pressure injury, the area should have had a dressing on it for protection. The DON said usually she or the Wound Nurse will review the Nursing Admission Evaluations V16 for completion and to ensure any wounds have orders, care plans, and are added to wounds rounds; however, in this case none of those things were done and Resident #30's wound got worse and much larger. AUGUST 2023 Review of the Weekly Skin Evaluations for August 2023 indicated the following: - 8/29/23, no documentation of the pressure ulcer. Review of the Pressure Ulcer Evaluations for August 2023, indicated the following: - 8/3/23, Pressure Ulcer Evaluation was not completed. - 8/10/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 6.3 cm x 4.4 cm x 0 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Cleanse, apply calcium alginate and cover with border dressing daily. - 8/18/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 6 cm x 3.6 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Wound Cleanser and Calcium Alginate secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 milligrams (mg) twice daily, Prevalon Boots. d. Signed by nurse on 8/21/23 Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/3/23, indicated but was not limited to the following: - Resident #30 had an Unstageable Deep Tissue Injury (DTI) to the sacrum. - Wound Etiology: Pressure - Duration: greater than 7 days - Wound Size: 7.6 cm x 5.5 cm x not measurable cm (depth is immeasurable due to the presence of tissue overgrowth). - Exudate: light serous - Granulation tissue: 100% - Dressing Treatment Plan: Primary Dressing: Silver Sulfadiazine (antibiotic cream used to treat and/or prevent infection) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound (relieve pressure); Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days (vitamins to aid in wound healing); Pre-Albumin (blood test to determine if your body is getting enough protein which aids in wound healing.) Review of the medical record including Medication Administration Record (MAR), TAR, and physician's orders failed to indicate the treatment order was obtained for the Silver Sulfadiazine and foam dressing to the sacrum or any other new order for wound care. Additionally, the medical record failed to indicate the additional recommendations to off-load the wound, Vitamin C and Zinc Sulfate, or the lab work were ordered. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/10/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound (appears as full thickness loss of skin, in which subcutaneous fat mat be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) to the sacrum. - Wound Size: 6.3 cm x 4.4 cm x not measurable cm, (depth is immeasurable due to the presence of nonviable tissue and necrosis). - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 100% - Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate (promotes formation of granulation tissue, re-epithelialization (cell growth to help healing), and helps to minimize bacterial infections) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots (heel booties with a heel cut out used to float heels off the mattress and relieve pressure to prevent pressure ulcers). - Surgical Excisional Debridement to remove necrotic tissue and establish the margins of visible tissue. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record failed to indicate an order was obtained for the antimicrobial cleanser and foam dressing. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/18/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 6 cm x 3.6 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 80% - Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record indicated the wound care order was changed on 8/22/23 with a start date of 8/23/23 as follows: Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. This was 12 days after the recommendations were made on 8/10/23 and the antimicrobial cleanser was still not ordered as recommended. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/24/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 5.9 cm x 3.2 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 30% - Granulation Tissue: 70% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) (cleanser that creates a moist environment and loosens contaminated exudate within the wound bed to allow natural healing to take place) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician's orders indicated the following: - Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (8/24/23; Discontinued 8/25/23) - Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) - Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate the recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/31/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 5.5 cm x 3.5 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 80% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe). Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician orders indicated the following: - Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) - Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. Review of the care plan titled Pressure Ulcer was initiated on 8/11/23, 45 days after admission. The care plan indicated but was not limited to the following: - FOCUS: Pressure Ulcer: Ulceration or interference with structural integrity of layers of skin caused by prolonged pressure. - GOAL: Show no signs of infection. - INTERVENTIONS: Follow facility protocol/regime for treating breaks in skin integrity/pressure ulcers, Turn and reposition with skin care every two hours, and use two-person transfer and use turn sheet to avoid friction/shearing of resident skin. (8/11/23) Additional interventions include Air Mattress set at 150, Monitor for changes and update provider as warranted, Treatment as ordered, and Wound MD as needed (8/22/23). During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the Pressure Ulcer Evaluation on 8/3/23 should have been done and it was not. Additionally, she said the recommendations from the Wound Doctor on 8/3/23 should have been addressed and they were not, and the Resident continued to have a progressing wound without an appropriate treatment. She said she does wound rounds and usually writes the orders, but these were missed. Additionally, she said the order written on 8/11/23 for Calcium Alginate should have had the recommended cleanser and the foam dressing as part of the order and it did not and the recommendation to off-load wound, Vitamin C and Zinc Sulfate, Pre-Albumin lab work and Prevalon Boots all should have been addressed and they were not. She also said the orders should be written with the specific cleanser recommended as Wound Cleanser, Antimicrobial Wound Cleanser and Vashe Wound Cleaner are all different cleansers. She also said she took over doing wound rounds because things like this were not getting done. During an interview on 12/4/23 at 11:27 A.M., the DON said the Pressure Ulcer Evaluation should be done weekly and it was not. She also said the order on 8/11/23 should have had the appropriate cleanser and foam dressing as part of the order and she missed that, therefore the order was incorrect. The DON said the type of cleanser needs to be specific as Wound Cleanser, Antimicrobial Wound Cleanser, and Vashe are all different cleansers. Additionally, she said all the recommendations made by the wound doctor should have been addressed and they were not. SEPTEMBER 2023 Review of the Pressure Ulcer Evaluations for September 2023 indicated the following: - 9/1/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 5.5 cm x 3.5 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. d. Signed by nurse on 9/4/23 - 9/8/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7.5 cm x 3.3 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. -9/14/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7.5 cm x 3 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 60% Granulation 30% Skin 10%; Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. -9/22/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7 cm x 3 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Wound Progress: Improved evidence by decreased surface area Surface Area 21.00cm2 Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 20% Skin 60%; Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. -9/28/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7 cm x 3 cm x 0.3 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Wound Progress: Exacerbated. Increase in depth Surface Area 21.00cm2 Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 25% Granulation 25% Skin 50%; Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. Review of the Wound Consultant Physician Evaluation and Management Summary, dated 9/7/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7.5 cm x 3.3 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 80% - Wound Progress: Exacerbated due to generalized decline of patient, nutritional compromise, patient non-compliant with wound care. - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR, physician's orders, and care plan failed to indicate off-load wound or Prevalon Boots had been addressed. Further review of the medical record including MAR, TAR and physician's orders indicated the following: - Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23; Discontinued 9/4/23) - Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (9/4/23). - Ascorbic Acid (Vitamin C) 500 mg twice daily (9/5/23) - Pre-Albumin blood test was drawn on 9/11/23, results were critically low. The Vashe cleanser was ordered 11 days after it was recommended. The Vitamin C was ordered 33 days after it was recommended. The Pre-Albumin blood test was drawn 39 days after it was recommended. Review of the Nurse's Note, dated 9/11/23, indicated the Nurse Practitioner was notified of the Pre-Albumin lab results and new orders were obtained for a Liquid Protein supplement, Ensure Plus supplement drink three times daily, High Protein/Low Salt Diet. (Protein aids in wound healing). (39 days after the lab work was recommended.) Further review of the medical record including TAR, nurse's notes, physician's progress notes, and care plan failed to indicate Resident #30 was non-compliant with wound care as noted in Wound Summary dated 9/7/23. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/14/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7.5 cm x 3 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 60% - Granulation Tissue: 30% - Skin: 10% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the medical record including MAR, TAR, and physician's orders indicated the following: - Bootie/Heel Protectors on as tolerated every shift. (8/25/23; Discontinued 9/13/23) - Prevalon Boots in place at all times (9/13/23) Review of the care plan indicated the following: - Off-load wound was added to the care plan (9/15/23) The Bootie/Heel Protectors were ordered 15 days after the Prevalon Boots were recommended. The Prevalon Boots were ordered 34 days after they were recommended. Off-load wound was added to the care plan 43 days after it was recommended. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/21/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7 cm x 3 cm x 0.1 cm - Cluster Wound: open ulceration area of 8.4cm2 - Periwound radius: Surrounding DTI (purple/maroon) - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 20% - Skin: 60% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/28/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7 cm x 3 cm x 0.3 cm - Cluster Wound: open ulceration area

Based on records reviewed and interviews, for one of three sampled resident's (Resident #2), the Facility failed to ensure he/she was provided with a safe discharge when on 5/27/21, Resident #2 was discharged home with a medication reconciliation list which included an inaccurate dosage of [MEDICATION(S)] (antidepressant medication), his/her physician;s orders were for 90 milligrams (mg) daily, but the Facility's discharge summary instruction were for Resident #2 to take 270 mg daily (three times the physician ordered dose). Resident #2 became nauseous and lightheaded and required hospitalization due to an overdose of [MEDICATION(S)]. Findings include: The Facility's Policy titled, Discharge Medications, dated as last revised November 2017, indicated the following: -medications shall be sent with the resident upon discharge; -the charge nurse shall verify that the medications are labeled consistent with current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -the nurse will reconcile pre-discharge medications with the resident's post-discharge medications and the medication reconciliation will be documented; -the nurse shall review medication instructions with the resident, family member before the resident leaves the facility; -the nurse shall complete the medication disposition record including: Resident name, name of each medication, the prescription number of each medication, quantity of each medication, strength of each medication and any special instructions. The Facility's Policy titled, Discharge Summary and Plan, dated as last revised November 2017, indicated that a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The Policy indicated that the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications and the medication reconciliation will be documented. Resident #2 was admitted to the Facility in November 2009, medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's signed Medication Reconciliation with Discharge Summary, dated 5/27/21, indicated that Resident #2 was discharged home and his/her medication instruction for [MEDICATION(S)] was written as follows; [MEDICATION(S)] 30 mg capsules, three capsules three times a day, (for a total of 270 mg daily). Review of a Grievance/Complaint Form filed on behalf of Resident #2, dated 5/29/21, indicated that Resident #2 was discharged home with an inaccurate medication reconciliation form which included the wrong dosage of [MEDICATION(S)]. Review of a Hospital Discharge Summary, dated 5/30/21, indicated that on 5/29/21 Resident #2 presented to the emergency room complaining of nausea and light headedness. The Summary indicated that Resident #2 was admitted to the telemetry unit for monitoring, required intravenous fluid for [CONDITION(S)] (condition where sodium levels in the blood are lower than normal) and had an unintentional overdose of [MEDICATION(S)]. During an interview on 7/07/21 at 10:14 A.M., the Psychiatric Nurse Practitioner (NP) said that Resident #2 had been receiving [MEDICATION(S)] 90 mg daily while in the facility. The Psychiatric NP said that Resident #2 was discharged home on 270 mg of [MEDICATION(S)] a day in error and said that is a lot of medication. The Psychiatric NP said that the maximum daily dose of [MEDICATION(S)] is 120 mg. During an interview on 7/07/21 at 1:23 P.M., Nurse #1 said that she completed Resident #2's Medication Reconciliation with Discharge Summary Form. Nurse #1 said that she accidentally transcribed the wrong dosage of [MEDICATION(S)] on the form that was sent home with Resident #2. During an interview on 7/07/21 at 1:34 P.M., Nurse #2 said that she went to review Resident #2's Medication Reconciliation Form with him/her but Resident #2 said that he/she already knew his/her medications. Nurse #2 said she did not compare Resident #2's Medication Reconciliation Form with his/her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/08/21 at P.M., the Director of Nurses (DON) said that Nurse #1, who was an Agency Nurse, completed Resident #2's Medication Reconciliation with Discharge Summary Form and transcribed the wrong dosage of [MEDICATION(S)] on the form that was sent home with him/her. The DON said that Nurse #2, who also was an Agency Nurse, did not review Resident #2's Medication Reconciliation Form with Resident #2 and sent the form home with Resident #2 with the incorrect dosage of [MEDICATION(S)]. The DON said that her expectation is that the nurse who discharges the resident review the Medication Reconciliation with Discharge Summary Form with the resident or resident representative prior to the resident being discharged home.

Based on record review, observation and staff interview, the facility failed to ensure that Residents maintain acceptable parameters of nutrition, including weight for 1 sampled Resident (#66), from a total sample of 20 Residents. Findings include: Resident #66 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set, with a reference date of 2/4/19, indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 10 of 15 reflecting moderately impaired for cognition, no documented behaviors, required supervision and assist for eating, weighed 138.8 pounds, was 66 inches tall and did not have a significant weight loss that was not prescribed by a physician. Review of the medical record indicated that on 3/8/19, the Dietitian documented in a progress note that the Resident was noted to have a weight loss 17.3 lbs(12.5%) in one month. The progress note indicated that she would have the nursing staff obtain a re-weigh of the Resident to determine accuracy of the weight loss. The note indicated that the Resident had experienced a weight gain during the last year, which was encouraged. No change was made to the plan of care, as the dietician indicated she would follow up. Further review of the medical record failed to indicate a re-weight was obtained following the 3/7/19 significant weight loss. Review of the weight record history indicated the Resident weighed 124 lbs on 2/5/18 and showed a gradual weight increase throughout the year, which included the weight of 138.8 lbs on 2/4/19 and 121.5 lbs on 3/5/19. The Resident's diet was a regular diet with pureed solids and had been provided a protein supplement twice a day. According to his/her intake record the consistently consumed 75 to 100 % of his/her meals. Review of the care plans failed to include a plan of care for risk of weight loss or actual weight loss. However, a care plan initiated on 2/21/19 identified problems with the Resident's swallowing and included interventions to monitor oral intake and weights. During interview on 3/14/19 at 10:00 A.M., the Dietician said that the CNA (Certified Nursing Assistants) usually obtained the weight and the floor nurse and/or Unit Manager enters the weights. She said that she checks weights when she is in and follows up on Resident's that trigger a weight gain or loss. She said that the Facility's policy did not included parameters of what constituted a significant weight gain or weight loss or parameters for staff to follow for a re-weight. In addition, the Facility staff including the Dietician would not be aware of a change in weight until an additional weight or follow-up was obtained and entered into the system. The Dietician said that she would request a re-weight and rely on the staff to obtain it and enter the weight. During a subsequent interview on 3/19/19 at 11:15 A.M., the Dietician was asked about Resident #66's weight and had she gotten a reweigh. She said she would check and further discussion indicated that the expectation would have been for the nursing staff to obtain an additional weight within a day of the weight signifying a significant change. The Dietician followed up and indicated that no weight had been taken after her request on 3/7/19. She said that the nursing staff obtained a weight on 3/19/19 and the weight was 118 lbs, with a reweigh of 118 lbs, and additional weight loss of 3.5 lbs in 2 weeks and a total of 20 lbs in a little more than a month. The Dietician agreed this was an error in treatment for [REDACTED].

Based on observation, record review, and interviews, the facility failed for 1 sampled Resident (Resident #11), of 3 applicable Residents with pressure ulcers, from a total sample of 18 Residents, to follow the facility's skin care policies to prevent the development of a Stage IV pressure ulcer. Findings include: For Resident #11, the facility failed to identify a left heel Stage IV pressure ulcer, despite documentation of diabetic foot care and application of A & D ointment daily. The facility also failed to provide weekly skin checks according to the facility's Skin Integrity Policy. Review of the facility Skin Integrity Guidelines Program indicated the following: Documentation of Weekly Skin Evaluation/Observations is a complete head to toe skin review completed by the licensed nurse. The accuracy and thoroughness of the weekly skin review will assist in timely identification of skin at risk and initiation of a plan of care. *Licensed nurse will be responsible for performing a skin evaluation/observation weekly. *If patient is refusing or choosing not to receive treatment, review risks, benefits and alternatives. Re-evaluate and attempt other interventions. Resident #11 was admitted to the facility in 2/2015 with the following Diagnoses: [REDACTED]. Resident #11 developed a left heel, Stage IV pressure ulcer with eschar (dead tissue) which measured 4 centimeter (cm.) by 5 cm. and which was identified by a nursing student caring for the Resident on 4/27/15 (and not the CNA staff who documented diabetic foot care and application of A & D ointment). Review of the admission Norton Pressure Ulcer Scale Assessment on indicated an initial, but inaccurate score of 13. A score of 11-15 indicates a moderate risk. The Norton assessment was reviewed with the Unit Manager (UM) and the score was re-calculated to include the Resident's low hematocrit and hemoglobin scores (30.6/9.2- normal range is 35-45 & 12-15 respectively), incontinence, 5 or more medications and low [MEDICATION NAME] (2.8 - normal range is 3.2-5.2) for an accurate score of 7, which indicates a high risk of developing a pressure ulcer (score of 10 or less= high risk). The UM said that the original Norton score should have been a 7 not a score of 13. Review of the initial comprehensive Minimum Data Set (MDS) for 2/2015 indicated the following: Brief Interview for Mental Status (BIMS) score = 03 (a score of 0-7 indicates severe cognitive impairment). *Section G (Functional Status) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) indicated 3 or extensive assistance from staff with 2 person physical assistance. Section M (Skin Conditions) indicated that the Resident is at risk of developing pressure ulcers and skin currently intact. The Resident's Care Plan for at risk of pressure ulcer, initiated 3/18/15 due to decreasing bed mobility (one month after admission to the facility), indicated the following interventions: *Float heels (heels were floated with blankets, but were ineffective due to Resident's agitation and non-compliance- no other alternate measures were implemented to off-load heels.) *Conduct weekly skin inspection (Resident refused most skin checks and staff could not explain how diabetic foot care and A & D ointment application could be completed everyday (and electronically signed as completed), but skin checks (to heels) could not be completed. *Turning and Repositioning schedule (electronically signed as completed). (no specialty mattress was initiated despite non-compliance with other interventions). Review of the Wound Evaluation Flow Sheets from 4/27/15 (date of identification) to 6/25/15 (or week 9) indicated the following: 4/30/15/week 1: Wound Type-pressure ulcer (in-house acquired), Stage-suspected deep tissue injury, site- left heel, measurement- 5 centimeters (cm) x 4 cm. pain-score of 5/10 and painful, apply heel protectors. 5/14/15/week 2: 5 cm x 4 cm- not healed-Sureprep to left heel and Prevalon boot (a very soft boot that cradles and off-loads the heel). no date/week 3: 5 cm x 4 cm- area unchanged and measures the same as last week-denies pain-deep purple color. 5/19/15/week 4: 5.2 cm x 4 cm-surrounding tissue is pink and blanching 5/26/15/week 5: 5.2 cm x 4 cm-90 % necrotic (dead tissue), dry, hard black in color. 6/11/15/week 6: 5 cm x 4 cm-area is hard, dry/flat and black in color-resident denies pain. 6/17/15/week 7: 5 cm x 4 cm-deep tissue area is black and some areas lifting. 6/24/15/week 8: 5 cm x 4 cm- pain scale=3, Sureprep to left heel and Prevalon boot. 7/2/15/week 9: 41/2 cm x 4 cm-no depth, black/brown color and some areas lifting. Review of the Weekly Skin Checks indicated the following: 4/10/15: Resident refused skin check at 14:43. Re-approached @ 20:28 and refused again. 4/17/15: Resident refused skin check. 4/24/15: Resident refused skin check. 5/1/15: Resident refused, became physically and verbally abusive. Review of the Quarterly MDS completed in 5/2015 (after identification of left heel Stage IV pressure ulcer 4/27/15) indicated the following: *Section M (Skin Condition): 1 unstageable pressure ulcer with suspected deep tissue injury and eschar (dead tissue). The Nursing Progress Notes from 4/1/15-4/27/15 did not indicate any reports from the CNA staff to the nursing staff about potential skin concerns, despite electronic entries that diabetic foot care, ointment applications and turning and repositioning schedules were being completed everyday. After the identification of the left heel pressure ulcer (4/27/15), a new Pressure Ulcer Care Plan was initiated on 5/1/15 which indicated the following new interventions: *Prevalon boot to left heel at all times except bathing (a pressure relieving boot which cradles the heel and the Resident is compliant with the use). *Foot cradle to bed On 7/8/15 at 8:05 A.M., the Surveyor interviewed the wound nurse. The Surveyor asked how the staff off-loaded the Resident's heels. The wound nurse said that the staff would place put blankets under the Resident's feet, but that he/she was non-compliant and would kick her blankets off the bed. The Care Plan did not indicate alternative interventions, such as the Prevalon boot or specialty mattress (implemented after the identification of the Stage IV left heel ulcer despite being listed as an intervention in the care plan dated 3/2015). The wound nurse could not give an explanation for how the Resident's left heel Stage IV was not identified sooner if staff were doing diabetic foot checks, A & D ointment application to the heels and turning and repositioning on a daily basis. On the afternoon of 7/2/15, with the Director of Nursing and the Wound Nurse, the Surveyor observed the Resident's left heel dressing change. The left heel was observed to be flat, hard and completely necrotic with a measurement consistent with staff documentation (5cm. x 4cm.) Resident #11 was very cooperative with care at this time. The Resident did pull away and requested that staff not press down on the heel area because it hurt. On 7/8/15 at 9:00 A.M., the Surveyor interviewed the Physician's Assistant (PA) over the telephone. The PA said that he did remember observing the Resident's left heel and documented the following in his note dated 4/30/15: Nursing reports patient developed eschar to left heel over the past few days with some discoloration of the great toe. Nursing working to offload and monitor for breakdown. The Surveyor informed the PA that nursing was documenting refusal of skin checks and that the Resident's skin checks had not been performed for one month prior to the identification of the left heel area. The PA said that is not acceptable. The PA also said that an area of eschar does not develop overnight. On 7/8/15 at 6:00 P.M., the Surveyor interviewed the 3:00 P.M.- 11:00 P.M. staff nurse over the telephone, who frequently cared for Resident #11 (skin checks are conducted on the 3:00 P.M.- 11:00 P.M. shift). The staff nurse said that the Resident would become agitated and combative during skin checks in the evening and usually refused. The Surveyor asked what the nurse did when the Resident refused. She said that she was told to document the refusal and that was okay. Surveyor #2 also asked the staff nurse how the Resident could present with a Stage IV pressure ulcer (with an initial measurement of 5cm x 4cm), if CNAs were performing diabetic skin care, ointment application and turning and repositioning daily. The staff nurse said I don't know. The staff nurse said that the CNA's never reported an area of concern to her or other staff nurses. The staff nurse also said that no re-evaluation of interventions (including a possible schedule change to avoid evenings when some residents with dementia become increasingly confused) was discussed or implemented. The staff nurse said that she was aware that a facility skin care policy existed, but had not had a chance to review it.