Every finding on record at Westwood Health and Rehabilitation

Based on record review, Pharmacy Consultant, Medical Director and staff interviews, the facility failed to ensure there was sufficient nursing staff in the facility on 5/16/26 from 1:00 PM to 5:00 PM to administer medications as ordered to the D and E halls for 6 of 32 residents reviewed for medication administration (Resident's #4, #5, #6, #7, #8 and #9).The findings included: This tag is cross referenced to: F658: Based on record reviews, Pharmacy Consultant, Medical Director and staff interviews, the facility failed to administer scheduled medications as ordered by the physician for 6 of 32 residents on the D and E halls that were reviewed for medication administration. (Residents ##4, #5, #6, #7, #8 and #9). The facility's daily assignment sheet dated 5/16/26 revealed the following nursing staff were scheduled to work during the day shift (7:00 AM to 7:00 PM) for medication administration. Nurse #1 was assigned to work on the A and F halls from 7:00 AM to 7:00 PM), Nurse #2 was assigned to work on the B and C halls from 7:00 AM to 7:00 PM, Medication Aide (MA) #1 was assigned to work on the D and E halls from an unknown time and Unit Manager #1 was assigned to work on the D and E halls from an unknown time. The daily nurse staff posted report dated 5/16/26 indicated the resident census was 65. A review of the payroll time reports for 5/16/26 were reviewed and revealed MA #1 clocked in for the shift on 5/16/26 at 7:29 AM and clocked out for the day at 12:54 PM. Unit Manager #1 clocked in for the shift on 5/16/26 at 5:10 PM and clocked out at 7:35 PM.

Based on record reviews, and staff, Pharmacy Consultant, and Medical Director interviews, the facility failed to administer scheduled medications as ordered by the physician for 6 of 32 residents on the D and E halls that were reviewed for medication administration (Residents #4, #5, #6, #7, #8 and #9).The findings included: A. Resident #4 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease with dyskinesia (a movement disorder defined by involuntary and uncontrollable muscle movements). Review of the active physician orders included the following orders:- An order dated 1/15/25 for ropinirole (a medication used to improve muscle control and manage movement) 0.25 milligrams (mg). Give one tablet by mouth three times a day for Parkinson's disease.- An order dated 1/16/25 for Benztropine Mesylate (a medication used to reduce muscle stiffness, body spasms and tremors) 0.5 mg. Give one tablet by mouth in the afternoon for dyskinesia.- An order dated 1/6/25 for Sinemet (a medication used to treat Parkinson's disease) 25-100 mg. Give one tablet by mouth four times a day for Parkinson's disease. Review of the May 2026 Medication Administration Record (MAR) indicated Resident #4 did not receive ropinirole 0.25 mg at 1:00 PM, Benztropine Mesylate 0.5 mg at 1:00 PM or Sinemet 25-100 mg at 2:00 PM on 5/16/26. B. Resident #5 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and hypertension. Review of the active physician orders revealed an order dated 12/16/25 for hydralazine (a medication used to treat high blood pressure) 10 mg. Give one tablet by mouth three times a day for essential hypertension. Hold for systolic blood pressure (the top number of the blood pressure reading) less than 110. Review of the May 2026 MAR indicated that Resident #5 did not receive hydralazine 10 mg at 2:00 PM on 5/16/26. C. Resident #6 was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder. A review of the active physician orders included the following orders:- An order dated 4/3/26 for buspirone (a medication used to treat chronic anxiety) 15 mg. Give one tablet by mouth three times a day for anxiety.- An order dated 5/16/26 for depakote sprinkles (a medication used as a mood stabilizer) 125 mg. Give two capsules by mouth in the afternoon for bipolar disorder. Review of the May 2026 MAR revealed Resident #6 did not receive buspirone 15 mg or depakote sprinkles 125 mg at 2:00 PM on 5/16/26. D. Resident #7 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis and polyneuropathy. A review of the active physician orders included an order dated 12/10/25 for Acetaminophen (a medication used to treat mild-to-moderate pain) 650 mg by mouth three times a day for acute and chronic pain/back pain. The May 2026 MAR was reviewed and revealed Resident #7 did not receive Acetaminophen 650 mg at 1:00 PM as ordered on 5/16/26. E. Resident #8 was admitted to the facility on [DATE] and had diagnoses that included primary open-angle glaucoma of the right eye, other corneal scars and blindness to the right eye. A review of the active physician orders included an order dated 9/5/24 for dorzolamide (a medication used to lower high pressure inside the eye) ophthalmic solution 2%. Instill one drop in both eyes every 8 hours for glaucoma. The May 2026 MAR was reviewed and indicated that Resident #8 did not receive dorzolamide eye drops as scheduled at 2:00 PM on 5/16/26. F. Resident #9 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia, bilateral primary osteoarthritis of the knee and polyneuropathy. The active physician orders included an order dated 11/18/25 for Acetaminophen (a medication used to treat mild-to-moderate pain) 325 mg. Give two tablets by mouth three times a day for chronic pain. A review of the May 2026 MAR indicated that Resident #9 did not receive Acetaminophen at 1:00 PM on 5/16/26. An interview occurred with Nurse #1 on 5/20/26 at 2:55 PM, who indicated that she had worked from 7:00 AM to 7:00 PM on 5/16/26. She stated after 12:45 PM, there were only two nurses (Nurse #2 and herself) in the facility to administer medications due to Medication Aide (MA #1), who was assigned to D and E halls, leaving. Nurse #1 stated there was no effort from MA #1 to provide report or hand off the assignment when she left at 12:45 PM, and additionally she felt uncomfortable being responsible for an additional assignment. Nurse #1 stated she texted the Administrator and interim Director of Nursing (DON) in a group text regarding the staffing situation that morning and again at 12:45 PM, when MA #1 left and was told by the Administrator that they were working on finding a replacement and that medications were caught up till 5:00 PM. Nurse #1 stated that she did not administer any medications to the D and E hall residents from 1:00 PM to 5:00 PM. Nurse #1 indicated that Unit Manager #1 arrived at the facility shortly after 5:00 PM as the replacement for MA #1. Nurse #2 was interviewed on 5/20/26 at 3:08 PM and stated that she worked from 7:00 AM to 7:00 PM on 5/16/26. She stated that MA #1 left around 12:45 PM, leaving only two nurses in the facility to administer medications (Nurse #1 and herself). She recalled MA #1 stated she was only working four hours and made no effort to hand off the assignment when she left at 12:45 PM, for the D and E hall residents. Nurse #2 added that she was uncomfortable being responsible for an additional assignment. Nurse #2 stated that she was aware Nurse #1 had been texting with the Administrator and interim DON regarding the staffing issue and was advised they were working on a replacement for MA #1. Nurse #2 stated that she did not administer any medications to the D and E hall residents from 1:00 PM to 5:00 PM. Nurse #2 stated that Unit Manager #1 was present at the facility at 5:00 PM as a replacement for MA #1. MA #1 was interviewed on 5/20/26 at 3:20 PM and explained that her primary job duty was as medical records during the week, but she assisted as a MA when needed. She stated that on 5/16/26 she was the manager on duty for four hours and arrived at the facility at 7:30 AM. She was contacted by the staffing scheduler close to 8:00 AM and was asked if she could cover the medication cart for D and E halls. She agreed and verified there were two nurses in the facility at that time. MA #1 stated that she left at 12:45 PM saying, All knew that I was working four hours since I was the manager on duty. MA #1 stated that at 12:45 PM, she told the two nurses her time was up and left. MA #1 stated she reached out to the Staffing Scheduler and the Administrator and was told they were working on finding a replacement. MA #1 stated that no one would take her assignment from her. MA #1 further stated that she provided the morning and any lunch time medications that were ordered for residents on the D and E halls on 5/16/26. MA #1 stated that if a medication was not signed out as given at 1:00 PM or 2:00 PM for any resident on D or E hallway, then she didn't provide it to them on 5/16/26. On 5/20/26 at 3:29 PM, an interview was conducted with Unit Manager #1, who recalled she had been called by the Administrator in the afternoon of 5/16/26 and asked if she could cover a medication cart. She let him know that she could be there at 5:00 PM and worked the D and E hall medication cart on 5/16/26 from 5:00 PM to 7:00 PM. An interview occurred with the Staffing Scheduler on 5/20/26 at 3:36 PM, who explained that MA #1 was the manager on duty on 5/16/26, knew she would be at the facility, and asked her if she could cover the D and E hall medication cart that morning. The Staffing Scheduler indicated MA #1 was not prepared to stay for a full shift. She indicated that both the interim DON and Administrator were aware and that attempts to find a replacement for MA #1 were made. The Staffing Scheduler verified Unit Manager #1 was able to come in the facility at 5:00 PM on 5/16/26 and between 1:00 PM and 5:00 PM two nurses were in the facility. A phone interview was conducted with the Pharmacy Consultant on 5/21/26 at 11:35 AM and reviewed medications that were missed on 5/16/26 for Residents #4, #5, #6, #7, #8 and #9. He stated that none of the medications that were not provided on 5/16/26 were considered significant. The Medical Director was interviewed via phone on 5/21/26 at 4:30 PM and reviewed #4, #5, #6, #7, #8 and #9's medications that were not provided on 5/16/26. She stated that she did not consider any of the medications not provided as significant as most of them were provided at other times during the day or the next day. She added that missing a single dose of medication in many chronic conditions would not have resulted in adverse outcomes. A phone interview was completed with the interim DON on 5/21/26 at 12:39 PM, who explained she started at the facility on 5/14/26. The interim DON stated that MA #1 should have taken every opportunity to hand off her assignment on 5/16/26 before leaving the facility at 12:45 PM or have reached out to her (interim DON) if there was an issue. The interim DON added that she was unaware there were issues with nurse staffing on 5/16/26 or she would have come into the facility and taken the assignment for the D and E hall medication cart until a replacement could be secured. A phone interview occurred with the Administrator on 5/21/26 at 12:55 PM and stated that he initiated asking MA #1 to assist with the D and E hall medication cart on 5/16/26 as he knew she would be at the facility as the manager on duty and was aware that she could only work for approximately four hours. The Administrator stated that both he and the Staffing Scheduler were calling staff for a replacement for MA #1 and that he was aware there would be a medication pass in the evening around 5:00 PM. The Administrator indicated he was trying to recruit someone to come in for that afternoon medication pass and wasn't aware there were residents with medications ordered between 1:00 PM and 5:00 PM. The Administrator added that he thought the two nurses on duty 5/16/26 from 7:00 AM to 7:00 PM would've covered the medication cart for any needed medications until the replacement arrived and was not aware that some of the resident's on the D and E halls did not receive their medications as ordered.

Based on observations and staff interviews, the facility failed to label and date food items and maintain food in sealed containers in the kitchen. Specifically, the facility did not label and date cups of orange juice in 1 of 1 walk-in cooler; did not seal and label a box of frozen biscuits with the date opened in 1 of 1 walk-in freezer; did not keep a small container of pimento cheese sealed in 1 of 1 reach-in refrigerator; and seal and label a box of rice with the date opened in the dry storage area. These practices had the potential to affect the safety and quality of food served to residents. The findings included:1. An observation on 2/15/26 at 10:05 AM revealed the following in the reach-in refrigerator: One small metal container of pimento cheese was loosely covered with plastic wrap, leaving it exposed to air. The date written on the wrap was obscured.The [NAME] was interviewed during the initial observation on 2/15/26 at 10:05 AM. She stated the pimento cheese was made the morning of 2/15/26. The cook did not respond when asked about the pimento cheese not being sealed. She was observed removing the pimento cheese from the reach-in refrigerator. She replaced the plastic wrap, wrote a date in permanent marker on the plastic wrap, and attempted to place the container back in the reach-in refrigerator. She was made aware the pimento cheese was not safe to serve because it was unknown how long it had been unsealed.2. An observation on 2/15/26 at 10:15 AM revealed the following in the dry storage area: One 25-pound box of white rice was stored in an unsealed bag open to air and not marked with the date opened.The [NAME] was interviewed during the initial observation on 2/15/26 at 10:15 AM. The [NAME] stated she did not know why the box was open to air and not marked with the date opened.3. An observation on 2/15/26 at 10:25 AM revealed the following in the walk-in cooler: Seven 4-ounce cups of orange juice covered with plastic wrap but unlabeled and undated.The [NAME] was interviewed during the initial observation on 2/15/26 at 10:25 AM. She stated night shift staff prepared orange juice each night and were responsible for labeling and dating it.4. An observation on 2/15/26 at 10:40 AM revealed the following in the walk-in freezer: One box of frozen biscuits was stored in an unsealed bag open to air and not marked with the date opened.The [NAME] was interviewed during the initial observation on 2/15/26 at 10:40 AM. The [NAME] stated she did not know why the box was open to air and not marked with the date opened.On 2/15/26, the Dietary Manager and District Dietary Manager confirmed that all food items should be labeled and dated when prepared, opened, or stored after opening. They stated staff were aware of this requirement and did not understand why it was not followed. They confirmed night shift staff should have labeled and dated the orange juice. A follow-up walkthrough revealed all unlabeled, undated, and unsealed food items had been discarded.On 2/18/26 at 4:27 PM, the Director of Nursing (DON) and Administrator stated they were unaware of the failure to label and date food items. Both acknowledged the requirement and discussed that staff could have used a permanent marker when tape was unavailable. The Administrator stated a better system for labeling and dating food items needed to be implemented. Both reiterated their expectation that kitchen staff follow established protocols.

Based on record review, observation and staff interviews, the facility failed to discard expired medications and date open multiple-dose medications in 2 of 3 medication carts (A and D medication carts) and 1 of 1 medication storage room observed.Findings included: a. On 2/15/26 at 12:35PM, the medication room was observed with the Director of Nursing (DON) and Nurse #2. There was one open undated vial of Apilsol Tuberculin Purified Protein Derivative (PPD) solution stored in the refrigerator (The manufacturer's storage instruction indicated once opened the solution should be discarded within 30 days). b. On 2/15/26 at 2:38 PM, the medication cart for hall A was observed with Nurse #4. The following expired and undated medications were observed in the cart:- One bottle of Nitroglycerin 0.4 milligram (mg) tablet - expiration date 1/2026,- Two Humalog Insulin KwikPens opened and undated (The manufacturer's Insulin storage instruction indicated once opened, Humalog should be stored at room temperature and used within 28 days),- One Insulin Glargine Injection Pen opened and undated (The manufacturer's Insulin storage instruction indicated once opened, Insulin Glargine should be stored at room temperature and used within 28 days),- One Humalog Insulin KwikPen opened with date opened 1/7/26 (The manufacturer's Insulin storage instruction indicated once opened, Insulin should be stored at room temperature and used within 28 days),- One Basagler Insulin KwikPen opened and undated (The manufacturer's Insulin storage instruction indicated once opened, Basagler should be stored at room temperature and used within 28 days),- One Insulin Glargine Injection Pen opened with dated opened 1/7/26 (The manufacturer's Insulin storage instruction indicated once opened, Insulin Glargine should be stored at room temperature and used within 28 days).On 2/15/26 at 3:32 PM, Nurse #4 stated the nurse who opened a medication was responsible for writing the date opened on medications that required dating. She stated night nurses were expected to routinely check medication carts and the medication room and remove expired medications found; however, she indicated overall monitoring of medications was a group effort. Nurse #4 stated she usually looked through the medications on her medication cart but had not had a chance yet today.c. On 2/15/26 at 2: 58PM, the medication cart for hall D was observed with Nurse #6. The following expired and undated medications were observed in the cart:- One Novolin R FlexPen used and undated (The manufacturer's Insulin storage instruction indicated once opened, Novolin R should be stored at room temperature and used within 28 days),- One bottle of 200mg Ibuprofen tablets - expiration date 12/2025.On 2/15/26 at 3:36 PM, Nurse #6 stated monitoring medication carts and medication storage rooms for unlabeled and expired medications was a team effort. She indicated she attempted to check her cart daily but had not checked it yet. She confirmed that the nurse who opened a medication was responsible for dating it and removing any expired medications.An interview was conducted on 2/18/22 at 4:13 PM with the DON revealed night shift nurses were responsible for checking medication carts and the medication storage room nightly for expired medications. The DON further stated the Nurse who opened a medication was responsible for dating it if the medication required dating. She indicated it was her expectation that nurses date medications upon opening and discard expired medications as needed.

Based on record reviews, observations, resident, and staff interviews, the facility failed to treat a resident in a dignified manner when there was a delay in answering a resident 's call light for 1 of 4 residents (Resident #21) reviewed for dignity.The findings included:Resident #21 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus, acute arterial ischemic stroke, multifocal, bipolar I disorder, current manic with psychotic features and Schizophrenia.Resident #21's admission care plan dated 01/23/26 did not have a focus area for behaviors.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21's cognition was intact. Resident #21 required moderate assistance by staff with oral hygiene, ambulating 10 feet, chair/bed to chair transfers, and personal hygiene, maximum assistance by staff with upper body dressing, bed mobility, and toileting transfers, and he was dependent on staff for toileting hygiene, and to shower/bathe self. A continuous observation was completed on 02/16/26 from 11:10 AM until 11:31 AM of Resident #21's call light being on and he was yelling for assistance. (Hey, someone help me, hey come here, I need help.) At approximately 11:16 AM This surveyor was at the doorway of Resident #21's room and advised him I would get him some assistance. Nursing Assistant (NA) #3 was in the room next door to him. She stated she would get to him as soon as possible. Resident #21 started yelling out again and continued to do so until approximately 11:30 AM this surveyor went to the nurses' station where 5 staff members (Medication Aide (MA) #2, Human Resource Coordinator/Nursing Assistant (NA), Nurse #2, NA #4, and NA #5) were at. The nursing staff acknowledged the call bell being on, but they did not know how long it had been on. The call light was observed and heard at the beginning of the hall in front of nurses' station. This surveyor asked the staff if they assisted with answering call lights, MA #2 stated oh he does that, he yells out for assistance, however she did not go to assist Resident #21. Human Resource Coordinator/NA was passing this surveyor approached the nurses' station to assist Resident #21. MA #2 then stated, I don't know I just got up here. This surveyor asked the staff two more times if they assisted with answering call lights, Nurse #2, NA #4, and NA #5 did not respond to this surveyors' questions. An interview was conducted on 02/16/26 at 11:16 AM with Resident #21. He was yelling out Hey, someone help me, hey come here, I need help. This surveyor approached Resident #21's room at the door and advised him I would get him some assistance. Resident #21 stated he had been yelling for assistance for approximately 30 minutes, and no one had come to his room. Resident #21 stated he can see the time on his television and that was how he tracked how long it would take staff. He explained this occurred all the time and it did not matter what concern he needed. He indicated this time he needed to be up for therapy. He went on to say he would wait for up to an hour or more waiting for staff to answer his call light but they just don't care. He then stated it made him upset and frustrated when the staff don't answer his call light.An interview was conducted on 02/18/26 at 4:02 PM with the Director of Nursing (DON). The DON stated she was unaware of the wait times and staff not answering Resident #21's call bell. She was aware that Resident #21 would yell out, scream, and use his call light for assistance. She explained that Resident #21 had mental health conditions that sometimes affected his sense of time. She also stated her expectations were for the call lights to be answered by all staff.

Based on record review, observation, and interviews with staff and Medical Director, the facility failed to provide behavioral healthcare services to a resident with diagnosed mental health disorders and behavioral symptoms for 1 of 1 resident (Resident #21) reviewed for behavioral and emotional needs.The findings included:A review of Resident #21's hospital Discharge summary dated [DATE] revealed he was admitted on [DATE] and discharged on 01/23/26 with discharge diagnosis that included bipolar I disorder-manic. His hospital course included psychiatry was consulted for Extrapyramidal Symptoms (EPS) (involuntary movements such as tremors, rigidity, and restlessness) agitation, and acute mania. Resident #21's discharge summary also included the following:Follow up appointments: Please make sure to follow up with Psychiatric appointments and medication management. Resident #21 was admitted to the facility on [DATE] with diagnosis that included bipolar I disorder, current manic with psychotic features and Schizophrenia.Resident #21's admission care plan dated 01/23/26 did not have a focus area for behaviors.Resident #21's active physician's orders included the following psychotropic medications:- 01/23/26: olanzapine (Zyprexa) Oral Tablet 10 milligram (MG), give 1 tablet by mouth at bedtime for bipolar disorder (atypical antipsychotic medication used to treat schizophrenia and bipolar I disorder). - 01/23/26: Lamotrigine Oral Tablet 25 MG, give 2 tablet by mouth two times a day for Extrapyramidal Symptoms (EPS) (involuntary movements such as tremors, rigidity, and restlessness) (anticonvulsant medication), used to treat bipolar disorder by stabilizing mood. - 01/24/26: Fluphenazine Decanoate Injection Solution 25 milligram (MG)/milliliter (ML), inject 50 mg intramuscularly one time a day every 21 day(s) for bipolar disorder (antipsychotic intramuscular injection used for the long-term management of schizophrenia).An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21's cognition was intact and there were no behaviors coded during the lookback period. Resident #21 was coded for receiving antipsychotic medications. The identification information section was coded as Resident #21 having a level II Pre-admission Screening and Resident Review (PASRR). A review of Resident #21's behavioral documentation located on the medication administration (MAR) from 01/23/26 through 02/13/26 revealed the following:- calling out: 01/28/26, 01/29/26, 01/30/26, and 02/03/26, -screaming and calling out: 01/23/26, 01/26/26, 01/31/26, 02/01/26, 02/04/26, 02/05/26, 02/09/26, 02/10/26, and 02/13/26. A review of Resident #21's medical record from 01/23/26 through 02/16/26 revealed no psychiatric services or other behavioral health care services were provided to the resident.A continuous observation was completed on 02/16/26 from approximately 11:10 AM until 11:31 AM of Resident #21's call light being on and he was yelling for assistance. (Hey, someone help me, hey come here, I need help).An interview was conducted on 02/16/26 at 11:31 AM with Med Aide (MA) #2. Resident #21 was yelling and screaming for assistance and MA #2 stated oh he does that, he yells out for assistance. She further stated she did not know how long Resident #21 had been yelling this time.An interview was conducted on 02/17/26 at 10:00 AM with Nurse #3. She stated that Resident #21 does yell out for assistance, but he didn't utilize his call bell. She verified she was the admitting nurse for Resident #21 however she did not recall seeing the referral for psychiatry services. She explained that when a resident was admitted to the facility the admitting nurse reviewed the hospital discharge summary for several things including follow-up appointments. If there was a referral or follow-up appointment related to psychiatric services or if the resident was on any psychotropic medications a copy of the referral was put in the social workers box for further follow through. She went on to explain that the psychiatry providers came into the building 2-3 times a week. Nurse #3 then stated she did not know how or why Resident #21 had not been seen by psychiatry yet due to his behaviors. Nurse #3 went on to say she documented his behaviors on the medication administration record. An interview was conducted on 02/17/26 at 10:25 AM with the Social Services Director. She verified she had not received a referral order for a psychological consultation for Resident #21. She explained that each month she received a list from the psychiatric provider of all residents who were active indicating they were receiving services, Resident #21 was not on that list. She indicated the psych consent had not been completed as of right now for Resident #21. She explained that if a resident was admitted to the facility with psychotropic medications, a mental health diagnosis, or a referral from the hospital that the admitting nurse would put the information in her mailbox and she would arrange for a consultation. Psych comes in every 2 weeks, and psych talk comes in weekly. Psych would pick them up on the next visit after the referral had been sent to themAn interview was conducted on 02/18/26 at 12:01 PM with the Medical Director. She indicated that it was her expectation for facility residents to receive the care and services necessary to meet their behavioral healthcare needs. An interview was conducted on 02/18/26 at 4:02 PM with the Director of Nursing (DON). She indicated she expected residents to receive the care and services necessary to meet their behavioral healthcare needs. The DON revealed she was unaware Resident #21 had not been referred to or was not being seen by the psychiatric provider.

Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of accidents (Resident #11), and medications (Residents #49 and #21). This was for 3 of 24 residents whose MDS assessments were reviewed. The findings included: 1. Resident #11 was originally admitted to the facility on [DATE] with diagnoses that included history of a stroke and muscle weakness. A review of Resident #11's medical record revealed he had a fall on 12/13/25 with a minor injury of a skin tear to his right arm. The quarterly MDS assessment dated [DATE] indicated Resident #11 had severely impaired cognition. He was coded with one fall with no injury since the previous assessment. On 2/17/26 at 3:03 PM, an interview occurred with the MDS Consultant who had coded the 12/17/25 quarterly MDS assessment. She reviewed the MDS assessment dated [DATE] as well as Resident #11's medical record and confirmed Resident #11 had a fall on 12/13/25 that resulted in a skin tear to his right arm. She indicated that the fall section should have been coded as one fall with a minor injury instead of one fall with no injury and felt it was an oversight. An interview was conducted with the Director of Nursing (DON) on 2/18/26 at 2:42 PM, who stated that it was her expectation for the MDS assessments to be coded accurately for accidents. 2. Resident #49 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder and age-related cataracts. A review of Resident #49's Medication Administration Record (MAR) from 1/16/26 to 1/22/26 revealed he received the following antibiotics: Macrobid 100 milligrams (mg) by mouth once a day. Moxifloxacin 0.5% solution one drop to the left eye every two hours for post cataract removal. The quarterly MDS assessment dated [DATE] revealed Resident #49 was not coded for antibiotic use. On 2/17/26 at 3:03 PM, an interview occurred with the MDS Consultant. She reviewed the January 2026 MAR and confirmed that antibiotic use should have been coded on the quarterly MDS dated [DATE]. The MDS Consultant stated that someone had been assisting remotely to complete this MDS assessment and felt it was an oversight. During an interview on 2/18/26 at 2:42 PM, the DON indicated it was her expectation for the MDS to be coded correctly for antibiotic use 3. Resident #21 was admitted to the facility on [DATE] with diagnosis that included bipolar I disorder, current manic with psychotic features and Schizophrenia. Review of Resident #21's January 2026 active physician orders revealed an order dated 01/24/26 for Fluphenazine Decanoate Injection Solution 25 milligram (MG)/milliliter (ML), inject 50 mg intramuscularly one time a day every 21 day(s) for bipolar disorder (antipsychotic intramuscular injection). There was also an order dated 01/23/26 for Lamotrigine oral tablet 25 MG, give 2 tablets by mouth two times a day for Extrapyramidal Symptoms (EPS) (involuntary movements such as tremors, rigidity, and restlessness) (anticonvulsant medication). Review of the January 2026 medication administration record (MAR) revealed Fluphenazine Decanoate injection was administered on 01/24/26 at 9:00 AM and Lamotrigine oral tablet was administered daily from 01/24/26 through 01/31/26 at 9:00 AM and 5:00 PM. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21's cognition was intact. The medication section was coded for receiving 0 out of 7 injections of any type during the lookback period. The medication section was not coded for receiving an anticonvulsant medication during the lookback period. An interview was conducted on 02/16/26 at 3:26 PM with the Corporate MDS Consultant. She reviewed the admission MDS assessment dated [DATE] along with the January medication administration record (MAR). The Corporate MDS Consultant verified she did not accurately code the admission assessment and stated she overlooked the intramuscular part of the antipsychotic medication order. She explained that she was thinking about antipsychotic medications and not anticonvulsants when she was reviewing the MAR and overlooked the anticonvulsant medication. She indicated she expected the MDS assessments to be coded accurately to reflect Resident #21's medications and needs. An interview was completed on 02/18/26 at 1:32 PM with the Administrator. He stated the MDS should be coded accurately to reflect Resident #21's physical, cognitive, emotional and behavioral conditions, and care needs.

Based on record review and resident, friend and staff and local Law Enforcement Officer interviews, the facility failed to protect a resident's right to be free from misappropriation of resident's property. This affected 1 of 1 resident reviewed for misappropriation (Resident #19).The findings included: Resident #19 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #19 to be cognitively intact without behaviors. An initial allegation report was received by the State Agency from the facility's former Director of Nursing (DON) #2 on 8/29/25 at 4:15 PM. The report read that the facility initially became aware of the incident on 8/29/25 at 4:00 PM and alleged notification that Nurse #1 received a truck bed from Resident #19 with a BIMS of 12 (this score of 12 indicates the resident was cognitively intact). Resident's contact person notified staff that Nurse #1 was not supposed to receive the truck bed or any other of the items in her possession. Police were notified, and the facility investigation was initiated. The incident was reported to local law enforcement on 8/29/25 at 4:15 PM. Nurse #1 was interviewed on 2/17/26 at 12:27 PM and reported she was in Resident #19's room speaking with him and his Friend back in August 2025 when the conversation came up that she needed another vehicle. Nurse #1 stated the Friend told her they had a car they were selling at an auction that she could go and look at to see if she was interested in purchasing it. Nurse #1 stated she went to look at the car and realized the vehicle needed a lot of work done on it, so she was not interested in purchasing it. Nurse #1 stated there was also a truck bed they all discussed so she asked her mechanic to go and look at it to see if it could be used and turned into a bed for her home. Nurse #1 stated she did not ask him to pick it up for her but only asked him to look at it to see if she wanted to buy it. Nurse #1 reported her mechanic took it upon himself to pick it up and bring it to her house. She reported she did not ask him to do that, but he did it anyway. Nurse #1 reported Resident #19's Friend wanted it back, so she put a tarp over it, and it sat in her yard for 2 months before the Friend had it picked up. Nurse #1 reported that she did contact the Friend about returning the truck bed and arrangements were made for him to come and pick it up from her residence. Nurse #1 also reported she knew nothing about a trailer with items in it. Nurse #1 reported that she had received training and was aware that she should not accept gifts from residents. On 2/17/26 at 9:18 AM an interview was conducted with Resident #19 who stated he did tell Nurse #1 she could have the truck bed but could not recall the exact date. Resident #19 reported he did not realize at the time the truck bed was scheduled to go to auction and be sold. Resident #19 reported he told Nurse #1 the next day, she could not have it because it was already promised for auction. Resident #19 reported that Nurse #1 obtained the truck bed after he told her she could no longer have it. Resident #19's Friend was interviewed by phone on 2/17/26 at 11:00 AM and stated he found out Nurse #1 was talking to Resident #19 about a car and a truck bed she could have. The Friend reported when Nurse #1 went to look at the car she also saw a trailer full of stuff she took. The interview further revealed that once the items were noticed missing, the Friend spoke to Resident #19 about missing items and was told that Resident #19 had given Nurse #1 permission to have the truck bed not realizing it was up for auction. The Friend explained he handled all affairs for Resident #19, and it was not okay for her to take those items. The Friend reported he contacted the police but ended up not pressing charges because he got the items back. The Friend reported that Nurse #1 went to Resident #19's house initially alone to look at buying a car. The Friend reported that the Nurse later had someone come and pick up the truck bed for her. The Friend reported he was not present when any of the items were looked at or picked up. Attempt was made to contact Adult Protective Services by phone for interview. Voice mail message left requesting a return call were not returned. Local Law Enforcement was interviewed by phone on 2/23/26 at 8:53 AM. Officer stated local law enforcement was contacted because items were taken from Resident #19's property. The Officer reported it was a 2002 Ford truck bed and other miscellaneous property. The Officer reported allegedly, Resident #19 initially told Nurse #1 she could have the truck bed and other miscellaneous items. The Officer stated later Resident #19 found out from his Friend the items could not be given away because they were up for auction. The Officer indicated it was unclear if Nurse #1 took the items before or after finding out she could not have them. The Officer stated the items were eventually returned and no charges were pressed. DON #2 was interviewed by phone on 2/17/26 at 10:06 AM. She stated Resident #19 did report he gave Nurse #1 permission to have some of his items but reported he was unaware his belongings were involved in probate. DON #2 reported there were other items on a trailer mentioned but she does not recall the details of what they were. DON #2 reported Resident #19's Friend made the facility aware there was a problem because of the probate situation. DON #2 reported Nurse #1 was suspended while an investigation was conducted, education was also provided, and then Nurse #1 was permitted to return to work once the facility had completed the investigation. DON #2 reported the situation was resolved by having the items returned and the investigation was concluded as unsubstantiated. DON #2 reported no other residents were involved and there were no other concerns regarding Nurse #1 accepting items from other residents. The Administrator was interviewed on 2/17/26 at 11:39 AM and stated allegedly Nurse #1 had received permission to have some of the items Resident #19 offered her. The Administrator reported later, Resident #19's Friend who handles his affairs, came to the facility and reported Nurse #1 could not have those items that were taken because the items were already scheduled to go to auction. The Administrator reported Nurse #1 was made aware the items needed to be returned. The Administrator reported the Friend did not press charges and referred to it as a misunderstanding. The Administrator reported disciplinary corrective action was provided including not accepting gifts from residents per policy. The Administrator reported this education was provided to Nurse #1 initially when she was hired and again after the incident. The Administrator reported Nurse #1 was still employed at the facility.

Based on record review, observation, Medical Wound Provider and staff interviews, the facility failed to assess a newly identified pressure ulcer that included the pressure ulcer stage, characteristics, and presence of pain and failed to complete pressure ulcer treatments as ordered 3 out of 5 days. This was for 1 of 5 (Resident #2) residents reviewed for pressure ulcer care.The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included recent left above the knee amputation and history of a stroke. An admission progress note dated 12/3/25, completed by Nurse #9, indicated Resident #2 had a surgical wound to the left thigh with 35 staples present. Her right foot was dry and cracked. Discoloration and scarring were present to the right leg, bruising was present to the right ankle, and her buttocks were free from any skin breakdown. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had moderately impaired cognition. She required maximum assistance with bed mobility and was dependent on staff for toileting hygiene and transfers. There was no pressure ulcers noted on the MDS but Resident #2 was coded for a surgical wound. A nursing note dated 12/27/25, written by Nurse #7, indicated Resident #2 was noted with a sacral wound, orders were received for wound care and Resident #2 would be seen by wound physician. The nurses' note read that wound care had been completed as ordered. There was no description of the sacral wound. A review of Resident #2's physician orders included an order dated 12/27/25 to cleanse wound to the sacral area with wound cleanser. Apply calcium alginate (a highly absorbent material used to create a moist healing environment) to the wound bed and cover with a dry dressing daily and as needed if soiled or dislodged. This order was discontinued on 12/31/25. A review of the December 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not contain the order for wound care to the sacral area dated 12/27/25. There was no documentation in the medical record that wound care had been provided to Resident #2's sacral wound on 12/28/25, 12/29/25 or 12/30/25. A phone interview was conducted with Nurse #7 on 2/18/26 at 11:37 AM. She stated that she began employment at the facility in the middle part of December 2025 as an as needed nurse (PRN) and recalled Resident #2 being found with skin breakdown to the sacral area. She was unable to recall which side of the sacrum the breakdown was noted on or how the area looked on 12/27/25. Nurse #7 stated that she contacted the Medical Wound Provider for wound orders and provided the care on that day. She stated she entered the wound care order into the Electronic Medical Record (EMR) system and that there was a box to activate the order onto either the MAR or TAR. She couldn't recall if that had been done but if the order didn't show up on the December 2025 MAR or TAR that would be why. Nurse #7 stated that she couldn't recall measuring the wound and felt the Medical Wound Provider would have done that when he assessed Resident #2. She stated that she only documented the new skin breakdown in the nursing note and thought she had reported it to the oncoming nurse, who she could not recall. Nurse #7 added that she didn't think there was a wound nurse at that time and that she had not been assigned to Resident #2 since 12/27/25. An interview occurred with Nurse #3 on 2/17/26 at 9:50 AM who was able to recall Resident #2. She recalled when Resident #2 was admitted to the facility on [DATE] she presented with a very thin area of pink and white tissue to her buttocks with the appearance of previously healed wounds. Nurse #3 stated when she completed skin assessments for Resident #2 on 12/6/25 and 12/21/25 the thin pink and white tissue area to her buttocks remained without any openings. Staff were providing protective skin care after each incontinent episode. Nurse #3 explained that when an order was placed in the EMR system it must be activated to show up on the MAR or TAR so staff would follow the order. An observation of wound care for Resident #2 was completed with the Wound Care Nurse on 2/17/26 at 10:13 AM. A very small area of pink and white scar tissue was present to the right buttock, with no open areas. The left buttock contained a very small, irregular shaped open area that had no depth and pink/red wound bed. There was no drainage or odor. Wound care was completed as ordered. On 2/17/26 at 4:07 PM, an interview occurred with the wound care nurse. She stated that she had worked at the facility since October 2025 as a floor nurse and had recently transitioned to the wound care nurse position in January 2026. She recalled being assigned to care for Resident #2 in December 2025 and that Resident #2 had a very thin area of pink and white tissue to the sacral area when she was first admitted to the facility. The wound care nurse had been assigned to Resident #2 on 12/29/25 and 12/30/25. She stated at that time the floor nurses were completing wound care, but she couldn't recall if she had provided any wound care to Resident #2 on 12/29/25 or 12/30/25 or if she was aware Resident #2 had skin breakdown to her sacrum as she was not the wound care nurse during this time. She added that during the end of December 2025 the Medical Wound Provider was responsible for measuring the wounds and assessing them for proper treatment, as there was not a wound care nurse. The wound care nurse reviewed the initial order for sacral wound care that was entered in the physician orders on 12/27/25 and explained that if the initial order was not activated to show up on the MAR or TAR, nursing staff would not have known to complete the wound care. She further explained that in the role of wound care nurse, she was made aware of any new skin concerns by the floor nurses and followed up to ensure the wound care orders had been entered appropriately and the resident was assessed by the Medical Wound Provider. She indicated that she provided wound care to all residents Monday through Friday and that floor nurses were responsible for any wound care that was needed after 5:00 PM and on the weekends. A phone interview was completed with the Medical Wound Provider on 2/18/26 at 10:11 AM. The Medical Wound Provider could not recall any concerns of a dressing not being present to Resident #2's pressure area on the initial visit of 12/31/25 and stated he would have noted any concerns he had on the progress note. The initial order provided on 12/27/25 was reviewed with the Medical Wound Provider and stated that he recalled providing that order until he could see Resident #2 in the next few days. He couldn't comment if not having the wound care affected the outcome of the wound but replied there were no concerns for infection. The Medical Wound Provider added that it was evident there was scar tissue in the area of her pressure injuries when he assessed her on 12/31/25 and that due to Resident #2's co-morbidities and overall change from the recent amputation, it was possible the wounds erupted very quickly. The Director of Nursing (DON) was interviewed on 2/18/26 at 2:42 PM and stated that she had recently taken over the role earlier in February 2026 and was unaware that the wound care orders dated 12/27/25, had not been populated to the December 2025 MAR or TAR for Resident #2. The DON stated that in the first part of January 2026, the facility designated a nurse for wound care. The process since January 2026 was when a skin problem was identified, the nurse was made aware. They called the provider for wound care orders, entered them into the EMR system so that it populated to the TAR and sent a communication to the wound care nurse. The wound care nurse ensured that the wound care orders had been transcribed and activated properly in the EMR. The DON added that she would expect wound care to be completed as ordered, as well as expecting Nurse #7 to have documented a description of the wound in the nursing progress note. She was unsure if the prior DON #3 had been made aware. Multiple attempts were made to contact Nurse #5, who was scheduled to care for Resident #2 on 12/27/25 from 7:00 PM to 7:00 AM. These attempts were made on 2/17/26 at 5:45 PM and 2/18/26 at 11:19 AM. Multiple attempts were made to contact the prior DON #3 on 2/17/26 at 5:00 PM and 2/18/26 at 11:17 AM regarding the process for newly identified wounds in December 2025.

Based on record review, Medical Director and staff interviews, the facility failed to hold a blood pressure medication as ordered by the physician for 1 of 6 residents whose medications were reviewed (Resident #49) for unnecessary medication.The findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included hypertension and heart failure. Review of Resident #49's physician orders included an order dated 9/6/24 for Metoprolol Tartrate (a medication for high blood pressure) 25 milligrams (mg). Give 12.5 mg by mouth every 12 hours. Hold if systolic blood pressure (SBP-the top number in the blood pressure reading) is less than 110. The January 2026 Medication Administration Record (MAR) was reviewed and revealed Resident #49 had received Metoprolol Tartrate, despite the SBP being below 110 on the following dates:1/3/26 for 9:00 PM dose, SBP was 109 administered by Nurse #5.1/9/26 for 9:00 PM dose, SBP was 109 administered by Medication Aide (MA) #1.1/10/26 for 9:00 PM dose, SBP was 99 administered by MA #1.1/12/26 for 9:00 PM dose, SBP was 106 administered by MA #1. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was cognitively intact. On 2/18/26 at 3:30 PM, an interview was conducted with MA #1, who reviewed the January 2026 MAR and verified the Metoprolol Tartrate was administered despite the SBP being below 110 when it should have been held for the 9:00 PM dose on 1/9/26, 1/10/26 and 1/12/26. She stated it was an oversight. Attempts to contact Nurse #5 were made without success on 2/17/26 at 5:45 PM and 2/18/26 at 11:19 AM. The Medical Director was interviewed on 2/18/26 at 12:01 PM and didn't feel Resident #49 would have suffered any serious harm by receiving Metoprolol Tartrate outside the parameter, however, she would expect the nursing staff to follow the orders for the Metoprolol Tartrate blood pressure parameter as written. An interview occurred with the Director of Nursing (DON) on 2/18/26 at 2:42 PM and stated she expected the nursing staff to follow physician orders including blood pressure medications with parameters to hold. The DON explained that she had recently taken over the role earlier in February 2026 and was unaware that the staff had administered the medication outside of the prescribed parameters.

Based on record review and staff interviews, the facility failed to post accurate staffing information as compared to the daily staff scheduled for licensed and unlicensed nursing staff for 22 out of 46 days (1/6/26, 1/7/26, 1/10/26, 1/13/26, 1/14/26, 1/15/26, 1/16/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/23/26, 1/24/26, 1/25/26, 1/28/26, 1/30/26, 1/31/26, 2/1/26, 2/2/26, and 2/3/26). The findings included: A review of the facility's daily posting for nursing staff for 1/1/26-2/15/26 as compared to the daily staffing schedule revealed an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 1/6/26 indicated that 6 Nurse Aides (NAs) worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 1/6/26 documented that 5 NAs worked 7:00 AM to 3:00 PM. b. The nursing schedule for 1/7/26 indicated that 6 NAs worked 3:00 PM to 11:00 PM. The daily posted nurse staffing sheet for 1/7/26 documented that 7 NAs worked from 3:00 PM to 11:00 PM. c. The nursing schedule for 1/10/26 indicated that 2 Medication Aides (MAs) worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/10/26 documented that 1 MA worked 7:00 PM to 7:00 AM. d. The nursing schedule for 1/13/26 indicated that 6 NAs worked from 7:00 AM to 3:00 PM and 6 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/13/26 documented that 7 NAs worked 7:00 AM to 3:00 PM and 5 NAs worked 11:00 PM to 7:00 AM. e. The nursing schedule for 1/14/26 indicated that 1 MA worked from 7:00 AM to 7:00 PM and 5 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/14/26 documented that 2 MAs worked 7:00 AM to 7:00 PM and 7 NAs worked 11:00 PM to 7:00 AM. f. The nursing schedule for 1/15/26 indicated that 5 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/15/26 documented that 7 NAs worked 11:00 PM to 7:00 AM. g. The nursing schedule for 1/16/26 indicated that 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN) worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/16/26 documented that no RN worked 7:00 PM to 7:00 AM and 2 LPNs worked 7:00 PM to 7:00 AM. h. The nursing schedule for 1/17/26 indicated that 1 RN, 1 MA and 1 LPN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/17/26 documented that no RN or MA worked from 7:00 PM to 7:00 AM and that 2 LPNs worked 7:00 PM to 7:00 AM. i. The nursing schedule for 1/18/26 indicated that 6 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 1/18/26 documented that 7 NAs worked 7:00 AM to 3:00 PM. j. The nursing schedule for 1/19/26 indicated that 5 NAs worked from 7:00 AM to 3:00 PM and 4 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/19/26 documented that 6 NAs worked 7:00 AM to 3:00 PM and 5 NAs worked 11:00 PM to 7:00 AM. k. The nursing schedule for 1/20/26 indicated that 4 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/20/26 documented that 3 NAs worked from 11:00 PM to 7:00 AM. l. The nursing schedule for 1/21/26 indicated that 1 RN and 2 LPNs worked from 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/21/26 documented that no RN worked 7:00 PM to 7:00 AM and 3 LPNs worked 7:00 PM to 7:00 AM. m. The nursing schedule for 1/22/26 indicated that 1 RN and 2 LPNs worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/22/26 documented that 3 LPNs worked 7:00 PM to 7:00 AM. n. The nursing schedule for 1/23/26 indicated that 2 LPNs worked 7:00 AM to 7:00 PM. The daily posted nurse staffing sheet for 1/23/26 documented that 1 LPN worked 7:00 AM to 7:00 PM. o. The nursing schedule for 1/24/26 indicated that 1 MA worked from 7:00 AM to 7:00 PM. The daily posted nurse staffing sheet for 1/24/26 documented that no MA worked 7:00 AM to 7:00 PM. p. The nursing schedule for 1/25/26 indicated that 6 NAs worked from 7:00 AM to 3:00 PM and 3 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/25/26 documented that 4 NAs worked 7:00 AM to 3:00 PM and 4 NAs worked 11:00 PM to 7:00 AM. q. The nursing schedule for 1/28/26 indicated that no MA worked 7:00 AM to 7:00 PM. The daily posted nurse staffing sheet for 1/28/26 documented that 1 MA worked from 7:00 AM to 7:00 PM. r. The nursing schedule for 1/30/26 indicated that 2 MAs worked from 7:00 AM to 7:00 PM, 1 RN worked 7:00 PM to 7:00 AM and 1 LPN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/30/26 documented that no MAs worked 7:00 AM to 7:00 PM, no RN worked 7:00 PM to 7:00 AM and 2 LPNs worked 7:00 PM to 7:00 AM. s. The nursing schedule for 1/31/26 indicated that 1 MA worked from 7:00 AM to 7:00 PM, 1 RN worked 7:00 PM to 7:00 AM and 1 LPN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 1/31/26 documented that no MA worked 7:00 AM to 7:00 PM, no RN worked 7:00 PM to 7:00 AM and 2 LPNs worked 7:00 PM to 7:00 AM. t. The nursing schedule for 2/1/26 indicated that 1 RN and 1 LPN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/1/26 documented that no RN worked from 7:00 PM to 7:00 AM and 2 LPNs worked 7:00 PM to 7:00 AM. u. The nursing schedule for 2/2/26 indicated that 1 RN and 1 LPN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/2/26 documented that no RN worked 7:00 PM to 7:00 AM and that 2 LPNs worked 7:00 PM to 7:00 AM. v. The nursing schedule for 2/3/26 indicated that 6 NAs worked 7:00 AM to 3:00 PM, 1 LPN worked 7:00 PM to 7:00 AM and 1 RN worked 7:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 2/3/26 documented that 8 NAs worked 7:00 AM to 3:00 PM, no RN worked 7:00 PM to 7:00 AM and 2 LPNs worked 7:00 PM to 7:00 AM. On 2/18/26 at 9:17 AM, an interview occurred with the Staff Scheduler. She reviewed the staffing schedule and daily postings and verified the number of staff who worked from 1/1/26 to 2/15/26 did not match. She explained that she had not counted Nurse #8 as an RN on the nursing schedule or daily posted nurse staffing sheet on 1/16/26, 1/17/26, 1/21/26, 1/22/26, 1/30/26, 1/31/26, 2/1/26, 2/2/26 and 2/3/26 because when Nurse #8 was first hired at the facility, he was an LPN waiting to take the test for his RN license. She stated she couldn't recall when he became an RN. In addition, the Staff Scheduler stated that she failed to ensure the daily posted nurse staffing sheet had been updated when a staff member didn't come to work or if a staff member came in to cover a need The Human Resources Coordinator was interviewed on 2/18/26 at 9:55 AM. She verified that Nurse #8's date of hire was 12/30/25 and that he became an RN effective 1/13/26. An interview occurred with the Administrator and Director of Nursing (DON) on 2/18/26 at 2:42 PM. The staffing schedules and daily postings were reviewed, which did not match the actual staff that worked on a certain day. The Administrator stated he recalled letting the Staffing Scheduler know of Nurse #8's transition from LPN to RN after he passed the RN boards in January 2026. In addition, the Administrator and DON stated that the daily staff schedule posting, and the staffing schedule should match the number of staff worked on any given shift.

Based on record review and staff interviews, the facility failed to maintain evidence of ongoing communication with the dialysis treatment center in the medical record for 1 of 2 residents reviewed for dialysis (Resident #65). The findings included:Resident #65 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) and dependence on dialysis (treatment to filter waste and water from the blood). Resident # 65 was discharged on 12/19/25.Resident #65 had a physician order dated 12/4/25 for hemodialysis on Tuesday, Thursday, and Saturday.A review of Resident #65's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact. Resident #65 was not coded as receiving dialysis (not coded in error).A Review of Resident #65's electronic medical record revealed no completed dialysis communication forms. The facility was unable to locate any dialysis communication forms for Resident #65.A review of Resident #65 progress notes revealed there was no documentation of communication between the facility staff and dialysis center. There was no documentation that pre-dialysis or post-dialysis assessments were completed and communicated between the facility and the dialysis center.An interview completed with Nurse #4 on 2/17/26 at 12:16 PM revealed she was Resident #65's nurse regularly on her scheduled dialysis days. Nurse #4 stated she completed the dialysis communication form prior to Resident #65's leaving the facility on her scheduled dialysis days. Nurse #4 stated the information documented on the form prior to dialysis was vital signs, weight, access site condition, and any changes in condition. Nurse #4 stated the dialysis nurse documented on the form their assessment of Resident #65's condition after dialysis was completed. Nurse #4 explained that when the resident returned from dialysis she reviewed the form for information provided by the dialysis nurse.During an interview on 2/17/26 at 3:08 PM, Nurse #3 stated the facility communicated with the dialysis center using a dialysis communication form. She explained that each resident receiving dialysis had a notebook that accompanied them to each dialysis treatment. Prior to the resident leaving the facility, the nurse completed the top portion of the dialysis communication form and placed it in the notebook. The form included pre-dialysis information such as vital signs, dialysis access assessment, and any changes in the resident's condition. After dialysis treatment, the dialysis nurse completed a post-dialysis section of the form and returned it to the resident's notebook for the facility nurse to review. Nurse #3 stated she was unsure how long the completed communication forms remained in the notebook before being removed by medical records staff.During an interview on 2/18/26 at 12:50 PM, the Medical Records Manager stated she was unable to locate any dialysis communication forms for Resident #65. She stated there was no scheduled timeframe for removing completed communication forms from the dialysis notebook and uploading them into the resident's electronic medical record. She stated she believed the communication forms completed since Resident #65's admission remained in the notebook that accompanied the resident to dialysis. She further stated it was possible that upon discharge, the resident's family took the notebook home by mistake. She had attempted to contact the family, but they had not returned her call yet.During an interview on 2/18/26 at 12:55 PM, the Director of Nursing (DON) stated the facility was responsible for completing the dialysis communication form prior to the resident leaving for dialysis and for ensuring the dialysis center completed the post-dialysis section. The DON stated the completed forms should be removed from the notebook and placed in the resident's medical record after review by the facility nurse. The DON was unable to explain why the communication forms were not in Resident #65's medical record.

Based on observations, record review, and staff interviews, the facility failed to post the most recent survey of the facility in the survey results notebook. This occurred for 2 of 4 days of the survey (2/15/26 and 2/17/26).Findings included: According to the iQIES database system, the facility's most recent survey was a complaint investigation survey completed on 11/7/25. During tours of the facility on 2/15/26 at 9:45 AM and 2/17/26 at 9:00 AM, the facility's survey results were observed in a notebook placed on a low table in the front lobby. The notebook contained survey results from a recertification survey completed on 8/16/23. The following surveys were not included in the survey results notebook:A compliant investigation survey dated 1/30/24.A focused infection control survey dated 4/8/24.A complaint investigation survey dated 8/22/24.A recertification survey dated 11/21/24.A complaint investigation survey dated 12/30/24.A complaint investigation survey dated 1/15/25.A complaint investigation survey dated 7/15/25.A complaint investigation survey dated 11/7/25. In an interview on 2/17/26 at 9:38 AM, the Administrator indicated he began employment at the facility at the end of July 2025. He stated that technical issues prevented him from printing the survey results when he first arrived at the facility. He indicated that he had the survey results in his office but had not placed them in the binder. The Administrator acknowledged that he should have placed the survey results in the notebook as soon as he was able to print them but was unable to state why this had not been done. The Administrator stated he was aware of the regulation regarding the most recent survey results from any survey should be placed in the notebook.

Based on observation, record review, and staff interviews, the facility failed to protect a resident's right to be free from resident to resident sexual abuse when Medication Aide #2 observed Resident #1, a male resident, fondle a severely cognitively impaired female resident (Resident #2) when he lifted both of Resident #2's breasts out of the neckline of her V-neck shirt and caressed them with both hands and when Medication Aide #1 observed Resident #1 holding the hand of Resident #2 and rubbing her hand over his pants in his crotch area. Resident #2 did not have the cognitive capacity to consent to this intimate sexual contact. This deficient practice affected 1 of 3 residents reviewed for resident-to-resident abuse (Resident #2).The findings included:A. Resident #1 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, diabetes mellitus, coronary artery disease, cognitive communication deficit and a history of a cerebral infarction (a condition where blood flow to the brain in interrupted leading to brain tissue damage) with residual right side hemiparesis (weakness on one side of the body). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired. Resident #1 propelled himself independently in his wheelchair.A review of Resident #1's care plan dated 7/31/2025 indicated the resident had no care plan related to sexually inappropriate behaviors as of 10/4/2025.Resident #2 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, and adult failure to thrive. A quarterly MDS assessment dated [DATE] indicated Resident #2 was severely cognitively impaired. Resident #2 was severely impaired in the area of daily decision making, she could feed herself with set up/supervision but otherwise required total assistance with all Activities of Daily Living (ADL). Resident #2 was dependent on staff for mobility and transfers to the geriatric recliner.A late entry nursing progress note dated 10/6/2025 at 1:17 AM created by the Weekend Nursing Supervisor #1 indicated on 10/4/2025 she had been told by Medication Aide #2 that Resident #1 had pulled Resident #2's breasts out of her V-neck shirt and was touching them. Staff had separated the residents. Resident #2 was laughing and Resident #1 was stating What did I do?. Emotional support was provided to Resident #2. The Administrator, Director of Nursing (DON), Medical Director, Residents' Responsible Parties, Mental Health Provider, Weekend Triage Nurse Practitioner, local law enforcement, and Adult Protective Services (APS) were notified. Resident #1 was started on Prozac, 10 milligrams (mg) capsule by mouth at bedtime for 7 days then increase Prozac to 20 mg by mouth at bedtime. (Prozac is a prescription drug used to treat a variety of mental health conditions. It works by increasing the levels of serotonin, a neurotransmitter that helps regulate mood, emotion and sleep. The side effect of decreased sexual drive is helpful in managing compulsive sexual behavior). A complete blood count (CBC) was ordered for Resident #1 with no abnormal findings. Resident #1 remained on one to one supervision until 11:00 PM on 10/4/2025 then every 15 minute checks were started. A review of the 24-hour Initial Report dated 10/4/2025 at 3:00 PM indicated that staff had notified the Administrator that a male resident (Resident #1) had been observed fondling a female resident (Resident #2). The staff immediately separated the residents. Both residents were assessed and no injuries noted. Resident #1 was placed on one to one supervision. The provider and responsible parties were notified. Local law enforcement was contacted on 10/4/2025 at 4:10 PM. The State Agency was notified on 10/4/2025 at 3:05 PM. The initial report was signed by the Administrator.A review of a local Law Enforcement Incident Report dated 10/4/2025 at 4:41 PM revealed the officer responded to a call in reference to assault with sexual motive between residents. No charges were filed or further action taken.A review of a Nurse Practitioner (NP) note dated 10/6/2025 at 6:19 PM indicated Resident #1 was seen due to inappropriate touching of another resident over the weekend. Psychiatry services were contacted and Prozac was started on 10/4/2025. Resident #1 frequently refused medication and had ongoing behaviors. Recommendations were to increase supervision, redirect inappropriate behavior, continue medications as ordered and encourage compliance and maintain regular psychiatry/psychology follow-up.A review of the 5 Day Investigation summary dated 10/10/2025 indicated staff reported on 10/4/2025 at 2:40 PM that Resident #1 was in his wheelchair and approached Resident #2 seated in a geriatric recliner at the nurses' station. Without warning Resident #1 lifted Resident #2's breasts out of her shirt and began fondling them. Staff immediately separated the residents. During the separation, Resident #1 attempted to hit and bite staff. Both residents were assessed and no injuries noted. Resident #1 was placed on one to one supervision. Local law enforcement arrived at approximately 4:40 PM. No further legal action was anticipated. APS was notified via 911 at 5:11 PM and the APS case worker returned the call at 6:11 PM. No further follow-up was required by APS. Due to the cognitive limitations of both residents, neither was able to provide a reliable account of the incident. Staff interviews were conducted. No further disruptive or inappropriate behavior was noted. The allegation was not substantiated by the facility.On 10/21/2025 at 2:10 PM a telephone interview with Nurse #1 revealed she did not witness Resident #1 touching Resident #2's breasts on 10/4/2025. By the time Nurse #1 had walked up the hallway, Medication Aide #2 and Nurse #2 had separated the residents. The Weekend Nursing Supervisor #1 had started notifying the Administrator, DON and making the necessary reports. Resident #1 was placed on one to one supervision. Nurse #1 was not sure how long Resident #1 had one to one supervision. Nurse #1 stated she had never seen Resident #1 touch anyone inappropriately though he did make inappropriate sexual comments to staff.On 10/21/2025 at 3:20 PM a telephone interview with Nurse #2 indicated she was walking up the hallway on 10/4/2025 and a Nurse Aide (NA) told her what had occurred between Resident #1 and Resident #2. Medication Aide #2 had separated the residents and Nurse #2 started to take Resident #1 back to his room. Nurse #2 stated Resident #1 planted his feet firmly on the floor and attempted to turn his wheelchair around to go back to Resident #2. When Nurse #2 stated they were returning to Resident #1's room, Resident #1 grabbed Nurse #2's arm and tried to pull it to his mouth to bite her. Nurse #2 stated she told Resident #1, No, you're not going to bite me, that's not what we're doing. We are going back to your room. Nurse #2 stated Resident #2 responded with a few curse words but otherwise complied and returned to his room without further incident. Nurse #2 stated Resident #1 had made sexual comments to staff in the past but she had never heard that he had touched anyone inappropriately until 10/4/2025.On 10/21/2025 at 4:51 PM an interview with Medication Aide #2 revealed that she had walked around the nurses' station on 10/4/2025 and saw Resident #1 in his wheelchair sitting in front of Resident #2 who was seated in a geriatric recliner. Resident #1 leaned forward and lifted both of Resident #2's breasts out the top of Resident #2's shirt and began fondling her bare breasts with both hands. Resident #2 was not wearing a bra. Medication Aide #2 immediately told Resident #1 to stop and pulled his wheelchair away from Resident #2. Resident #1 stated What did I do?. Medication Aide #2 stated Resident #2 did not seem to have any change in her behavior or baseline after the incident. Resident #2 was taken to the dining room for dinner. Nurse #2 had started to push Resident #1 back to his room and he tried to turn around to go back to Resident #2 and attempted to bite Nurse #2.On 10/21/2025 at 5:03 PM a telephone interview with the Weekend Nursing Supervisor #1 indicated she had been working in her office on 10/4/2025 when she was notified by an NA that Resident #1 had fondled Resident #2's breasts. Upon her arrival at the nurses' station, staff had already separated Resident #1 and Resident #2. One to one supervision was started for Resident #1. The Weekend Nursing Supervisor notified the Administrator, DON, local law enforcement, the Medical Director, the Mental Health Provider Weekend Triage Nurse Practitioner and APS. Resident #1 was started on Prozac. No injuries were noted on either Resident #1 or Resident #2. Emotional support was provided to both residents. Resident #2 had no change in her baseline behavior and did not display any distress after the incident.On 10/22/2025 at 10:25 AM a telephone interview with NA #1 indicated she had been charting at the nurses' station and had observed Resident #1 moving about in his wheelchair which was his normal behavior. NA #1 stated all was quiet as she was working until she heard Medication Aide #2 say Stop that, you can't do that. When she looked over the desk, she saw Resident #1 fondling Resident #2's exposed breasts. The residents were immediately separated by Medication Aide #2, NA #1 and Nurse #2 who had also arrived at the nurses' station. Resident #1 was placed on one to one supervision. On 10/5/2025, NA #1 was Resident #1's assigned NA for the 7:00 AM to 3:00 PM shift. When she arrived on 10/5/2025 at 7:00 AM to begin her shift, NA #1 was told staff was conducting every 15 minute checks for Resident #1 and he no longer had a one to one sitter.B. A review of Resident #1's revised care plan dated 10/6/2025 had a focus area regarding Resident #1 having the potential for sexually inappropriate behaviors related to cognitive loss. The goal was Resident #1 would not harm himself or others through the next review period. Interventions included assess and anticipate the resident's needs, monitor/document/report any signs or symptoms of resident posing a danger to self or others and if resident becomes agitated: intervene before agitation escalate; guide away from source of distress; engage calmly in conversation; and if response is aggressive, staff to walk calmly away and reapproach later.A nursing note dated 10/18/2025 at 9:00 PM indicated Resident #1 was observed taking Resident #2's hand and placing it on his private area and rubbing Resident #2's hand back and forth over his pants. The residents were separated immediately and the Administrator was notified.A nursing note dated 10/18/2025 at 7:00 PM created by the Weekend Nursing Supervisor #1 indicated the Mental Health Provider Triage Physician had been contacted regarding Resident #1's inappropriate sexual behavior. A new order was received to change the Prozac 20 mg daily from capsules to tablets and administer with food as Resident #1 had refused the Prozac on occasion.A review of the 24-hour Initial Report dated 10/18/2025 indicated at 4:30 PM Medication Aide #1 had observed that Resident #1 had rolled his wheelchair up to Resident #2 who was seated in a geriatric recliner. Resident #1 took Resident #2's hand and placed her hand on his genital area and rubbed her hand back and forth over his pants. The staff immediately separated the residents. Both residents were assessed for injuries and any signs of distress with none noted. Resident #1 was placed on one to one supervision. The Administrator, Provider, and the residents' responsible parties were notified. Local law enforcement was called. A facility investigation was initiated.A review of a local Law Enforcement report dated 10/18/2025 at 5:57 PM indicated the officer responded to a call regarding sexual assault between Resident #1 and Resident #2. Resident #1 had taken Resident #2's hand, placed her hand on his private area and rubbed her hand back and forth. The report indicated both residents had dementia, could not recall the incident and APS had been notified. No charges were filed.A nursing note dated 10/19/2025 at 3:25 PM created by Nurse #1 indicated that Resident #1 continued on one to one supervision and no inappropriate behavior had been observed during the shift.On 10/21/2025 at 11:25 AM an interview with Medication Aide #1 revealed she had been walking out of another resident's room when she observed that Resident #1 had rolled his wheelchair up at an angle beside Resident #2 who was in her geriatric recliner at the nurses' station. Resident #1 had taken Resident #2's hand and was rubbing it over his pants in his crotch area. Medication Aide #1 could not recall which hand Resident #1 was using or which of Resident #2's hands he was holding. Medication Aide #1 immediately called the nurse and they separated the residents. Medication Aide #1 took Resident #1 back to his room. Medication Aide #1 stated Resident #1 did not say anything and was cooperative with her. Resident #1 was placed on one to one supervision. Medication Aide #1 stated the nurse notified the Administrator.On 10/21/2025 at 2:10 PM a telephone interview with Nurse #1 indicated she was working on the medication cart on 10/18/2025 and did not witness Resident #1 touching Resident #2. Nurse #1 heard about the incident from other staff and was aware a one to one sitter had been started.On 10/21/2025 at 3:20 pm a telephone interview with Nurse #2 revealed she did not witness Resident #1 touching Resident #2 on 10/18/2025.On 10/21/2025 at 5:03 PM a telephone interview with the Weekend Nursing Supervisor #1 indicated that Medication Aide #1 had alerted her that Resident #1 was observed taking Resident #2's hand, placing Resident #2's hand on his crotch and rubbing Resident #2's hand back and forth over his pants. The residents were immediately separated and assessed for any injury with none noted. Resident #1 was placed on one to one supervision. The Weekend Supervisor #1 notified the Administrator, DON, Medical Director, Mental Health Provider Triage, local law enforcement, APS and the residents' responsible parties. The Weekend Nursing Supervisor #1 received an order from the Mental Health Provider Triage physician to change the Prozac 20 mg capsule to a 20 mg tablet as the tablet could be crushed and added to food since Resident #1 had been refusing medication.On 10/21/2025 at 11:00 AM an interview was attempted with Resident #1. Resident #1 was alert but unable to provide information and appeared to be confused. A one to one sitter was observed stationed at the doorway to his room.On 10/21/2025 at 12:45 PM a telephone voice mail was left for the Nurse Practitioner (NP) with no return call. Subsequent attempts to reach the NP were unsuccessful.On 10/21/2025 at 1:29 PM a telephone interview with the Medical Director indicated she had been notified of Resident #1's sexually inappropriate behavior on both 10/4/2025 and 10/18/2025. Resident #1 had cognitive impairment, was known to refuse medication and had behaviors with staff but the Medical Director had never known Resident #1 to touch anyone inappropriately until 10/4/2025. Resident #1 had been started on Prozac and psychiatry was involved. The Medical Director stated Resident #1 had refused medication at times. Resident #1 was currently under one to one supervision and staff was keeping Resident #1 and Resident #2 separated.On 10/21/2025 at 1:57 PM, Resident #1 was observed sitting in his wheelchair at the nurses' station without a one to one sitter.On 10/21/2025 at 2:01 PM a follow-up interview with Medication Aide #1 indicated Resident #1's one to one sitter had been pulled to the floor to provide care for other residents and staff had been told to keep an eye on Resident #1.On 10/21/2025 at 2:36 PM a telephone interview with the Psychiatric Mental Health Nurse Practitioner (PMHNP) revealed he had seen Resident #1 for three months. The PMHNP stated Resident #1 displayed compulsive and impulsive behavior. Resident #1 was forgetful. The PMHNP had been notified by the weekend triage staff that Resident #1 had acted out in a sexually inappropriate manner on 10/4/2025 and again on 10/18/2025. The PMHNP knew of no prior instances when Resident #1 had touched anyone inappropriately. The PMHNP indicated he had not seen Resident #1 since the incidents but was scheduled to see him in the next few days. The PMHNP stated he knew Resident #1 had been started on Prozac.On 10/21/2025 at 3:05 PM, Resident #1 was observed sitting in his wheelchair at the nurses' station without a one to one sitter.On 10/21/2025 at 4:00 PM an interview was attempted with Resident #2. Resident #2 was alert, sitting up in bed but answered questions in a nonsensical manner and appeared to be confused.On 10/21/2025 at 4:30 PM, Resident #1 was observed in the hallway with a one to one sitter.On 10/21/2025 at 5:08 PM an interview with the DON revealed that she had not been in the facility when Resident #1 had touched Resident #2 in a sexually inappropriate manner on 10/4/2025 and 10/18/2025. The DON was familiar with the 10/4/2025 incident through review of witness statements and nursing reports. The DON stated she was not sure why Resident #1 seemed to seek out Resident #2. The DON stated Resident #1 had remained on one-to-one supervision until cleared by psychiatry/psychology services. The DON stated Resident #1 had been seen by psychiatry after the 10/4/2025 incident. The DON stated staff was unclear about what a one-to-one supervision status meant, and she was already educating staff that the one-to-one sitter stays with the resident no matter where the resident goes. The DON stated she had been on leave and was just starting her investigation into the incident on 10/18/2025.On 10/21/2025 at 5:34 PM an interview with the Administrator indicated he had been notified immediately of both incidents involving Resident #1 and Resident #2 on 10/4/2025 and 10/18/2025. The Administrator did not know why Resident #1 had targeted Resident #2 twice. Resident #1 had not ever touched anyone inappropriately prior to 10/4/2025. The Administrator was aware that staff had not consistently provided one to one supervision on 10/21/2025 but the one-to-one sitter was back in place while the investigation continued for the incident on 10/18/2025. The Administrator stated Resident #1 had been refusing his medications but now the Prozac was able to be placed in food. The Administrator stated the previous social worker had started a search for a more appropriate setting for Resident #1 and the new Social Worker was to start 10/23/2025. The Administrator stated the staff had done their best intervening with Resident #1 and had stopped his inappropriate behavior towards Resident #2 quickly.

Based on observations, record review, and staff interviews, the facility failed to date opened vials of insulin and insulin pens stored 2 of 2 medication carts (B and C hall cart, and D and E hall cart) the facility failed to keep a medication refrigerated per manufacturer guidelines in 1 of 2 medication carts (B and C hall cart), and also failed to discard expired medications in 1 of 1 medication storage room. The findings included: a. An observation was conducted on 11/19/24 at 11:19 AM of the D and E hall cart with Nurse #1. The observation revealed 5 Lispro insulin pens were opened and undated, 2 of the 5 Lispro insulin pens were not labeled with resident names, 1 Lantus insulin pen was opened and undated, 1 Basaglar insulin pen was opened and undated. Nurse #1 verbalized that all opened medications should have been dated with the date they were opened. The medications were given to Nurse #3 to be discarded. Per the manufacturer's instructions, insulin should be discarded after 28 days of opening, b. An observation was conducted on 11/19/24 at 2:14 PM of the B and C hall cart with the Unit Manager. The observation revelaed 1 vial of Lantus insulin was opened and undated, 1 Lantus insulin pen was opened and undated, 1 Insulin Aspart pen was opened and undated, 1 Basaglar pen was opened and undated, 1 Ozempic pen was opened and undated. Per the manufacturer's instructions, insulin should be discarded after 28 days of opening, The observation also revealed 2 vials of tuberculin purified protein derivative (PPD) testing solution opened and undated, and they were stored in the same box. The vials were not refrigerated per the manufacturer's instructions that stated PPD vials should always be kept refrigerated and protected from light when not in immediate use. The Unit Manager stated all medications should have been dated when they are opened and that refrigerated medications should have been stored in the refrigerator. The medications were given to the Unit Manager to be discarded. c. An observation of the medication storage room was conducted on 11/19/24 at 3:00 PM with Nurse #1. 1 bottle of stock medication Allergy Relief tabs was unopened, and the manufacturer's stamped expiration date was 9/24. Nurse #1 stated that expired medications should be discarded. The medications were given to Nurse #1 to discard. Pharmacist #1 was interviewed on 11/19/24 at 4:25 PM. He stated he visits the facility once each month. His last visit was on November 12th. He verbalized he sample audited 10% of the carts during his visit. He stated he gave the few expired or undated medications to be disposed of by the nurse. On 11/19/24 at 3:12 PM the Director of Nursing (DON) was interviewed. She stated she expected the nurses to date all medications when they are opened and store them correctly. She stated that insulin was supposed to be discarded 28 days after opening. She revealed that the unit managers were responsible for auditing the medications carts for expired medications. The Administrator was interviewed on 11/19/24 at 3:20 PM. He stated he expected the nurses to date all medications when they were opened. He stated he expected insulin to be discarded 28 days after being opened.

Based on record reviews, observations and interviews with residents and staff, the facility failed to provide routine hair trimming as part of basic hygiene services for residents whose payor source was Medicaid. This was for 2 of 6 residents reviewed for Activities of Daily Living (ADL) (Residents #16 and #26). The findings included: 1. Resident #16 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was cognitively intact. During an interview and observation with Resident #16 on 11/17/24 at 11:45 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it. He explained he had his hair cut about six to eight weeks ago by someone he paid to come cut his hair and that he had asked staff several times about getting his hair cut. Resident #16 was unable to recall the staff that he talked to about getting his hair cut. Resident #16's hair touched his collar in the back and was long around the ears. On 11/19/24 at 3:00 PM, the Social Services Director was interviewed and stated that she had begun employment at the facility towards the end of August 2024 and has not received any concerns about Resident #16 wanting his hair cut. She added she was unsure whose role it was to cut resident's hair. Nurse #1 was interviewed on 11/20/24 at 9:42 AM and stated that nursing staff did not trim resident's hair and didn't know how residents got their haircut. An interview occurred with Nurse Aide #1 on 11/20/24 at 9:58 AM who was familiar with Resident #16. She stated Resident #16 had complained about needing his hair cut but she was unsure who to report it to. She added Nurse Aides did not cut residents hair. The Unit Manager was interviewed on 11/20/24 at 10:42 AM and stated she had heard Resident #16 was requesting a haircut, but there wasn't any staff in the building to cut his hair. She was unable to state how residents got their hair cut. The Director of Nursing was interviewed on 11/20/24 at 3:00 PM and stated that she had begun employment at the facility April 2024. She stated currently there was no staff in the facility able to cut hair, but residents could have a beautician/barber come in or their family to cut their hair. She was unaware that routine hair trimming was a covered service for residents whose payor source was Medicaid. An interview was completed with the Administrator on 11/21/24 at 8:15 AM and explained that he was unaware of Resident #16 requesting a haircut but expected residents to be able to get their hair cut as desired. He was unaware that routine hair trimming was a covered service for residents whose payor source was Medicaid. 2. Resident #26 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #26 was cognitively intact. During an interview and observation with Resident #26 on 11/17/24 at 11:30 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it and stated he couldn't recall the last time it was trimmed. He explained he had asked staff several times about getting his hair cut but was unable to recall which staff. Resident #26's hair touched his collar in the back and was long around the ears. On 11/19/24 at 3:00 PM, the Social Services Director was interviewed and stated that she had begun employment at the facility towards the end of August 2024 and has not received any concerns about Resident #26 wanting his hair cut. She added she was unsure whose role it was to cut resident's hair. Nurse #1 was interviewed on 11/20/24 at 9:42 AM and stated that nursing staff did not trim resident's hair and didn't know how residents got their haircut An interview occurred with Nurse Aide #1 on 11/20/24 at 9:58 AM who was familiar with Resident #26. She stated Resident #26 has complained about needing his hair cut but was unsure who to report it to. She added Nurse Aides did not cut residents hair. The Unit Manager was interviewed on 11/20/24 at 10:42 AM and stated she had heard Resident #16 was requesting a haircut, but there wasn't any staff in the building to cut his hair. She was unable to state how residents got their hair cut. The Director of Nursing was interviewed on 11/20/24 at 3:00 PM and stated that she had begun employment at the facility April 2024. She stated currently there was no staff in the facility able to cut hair but residents could have a beautician/barber come in or their family to cut their hair. She was unaware that routine hair trimming was a covered service for residents whose payor source was Medicaid. An interview was completed with the Administrator on 11/21/24 at 8:15 AM and explained that he was unaware of Resident #26 requesting a haircut but expected residents to be able to get their hair cut as desired. He was unaware that routine hair trimming was a covered service for residents whose payor source was Medicaid.

Based on record review, observation, and staff interviews, the facility failed to honor a resident's request for his hair to be trimmed to his preferred length by not coordinating a hair cut despite staff's knowledge of the resident's preference. This deficient practice affected 1 of 2 residents reviewed for choices (Resident #48). The findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses which included muscle weakness. Review of Resident #48's admission Minimum Dat Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Resident #48's care plan revealed the resident had an activity of daily living (ADL) self-care performance due to weakness and cognitive loss. The goal was for Resident #48 to improve the current level of function in (ADL) through the next 90 days. Interventions included Resident #48 would be able to provide personal hygiene and oral care with supervision. An observation and interview conducted with Resident #48 on 11/17/24 at 12:10 PM revealed the resident's hair was long around his ears and down his neck. Resident #48 further revealed he was frustrated because he had not had his hair trimmed since admission and disliked his hair being long. Resident #48 indicated he had reported to multiple staff but could not recall their names that he needed a haircut but staff reported there was not a beautician at the facility. Interview conducted with Nurse #1 on 11/20/24 at 9:42 AM revealed there had not been a beautician to cut hair for several months. Nurse #1 further revealed nursing staff were unable to cut or trim hair due to not being trained or licensed. Nurse #1 stated she had heard several residents complain that they would like their hair to be cut or fixed. Nurse #1 indicated Resident #48 was a clean and well-kept resident and preferred his hair shorter. Interview conducted with Nurse Aide (NA) #1 on 11/20/24 at 9:58 PM revealed she consistently cared for and assisted Resident #48 with hygiene care. NA #1 further revealed she had never been educated to trim or cut hair. NA #1 stated she had heard other residents complain about there not being a facility beautician. NA #1 indicated she had not observed anyone working in the beauty shop in several months. Interview conducted with the Director of Nursing (DON) on 11/20/24 at 11:05 AM revealed she was aware residents had complained of not receiving haircuts. The DON further revealed facility staff were not allowed to cut hair, and it would have to be done by a trained and licensed beautician. The DON indicated she was not aware Resident #48 preferred a haircut but expected residents to receive what they prefer. Interview conducted with the Administrator on 11/20/24 at 2:15 PM revealed he did not recall Resident #48 or other residents complain of not having their hair cut. It was further revealed he was aware the facility did not have anyone to cut hair for several months. The Administrator indicated he was working on getting someone hired, but expected for residents to get a hair cut if they would like.

Based on observation, record review, and staff interviews, the facility failed to disinfect a glucometer (used to check a resident's blood glucose level) after using per manufacturer's guidelines for 1 of 1 resident (Resident #29). The glucometer was individually assigned to Resident #29 and stored in the medication cart. The findings included: Review of facility policy titled Blood Glucose Monitoring and Disinfecting revised date 4/20/22 read in part; clean and disinfect the meter with disinfecting wipes (per manufacture guidelines), place meter in resident specific bag for storage. Review of the glucometer manufacturer's guidelines stated to disinfect, the meter's surface should be thoroughly wet with a Sani cloth wipe and allowed to remain wet for a full 2 minutes. Let air dry. A continuous observation was made on 11/19/24 from 1:04 PM to 1:10 PM. Nurse #1 opened the medication cart and removed the glucometer labeled for Resident #29. She then entered Resident #29's room prepared to check her blood glucose level. She cleaned Resident #29's finger on her left hand with an alcohol swab and then pricked the finger with a lancet device to obtain a blood sample. Nurse #1 then placed a drop of blood onto the testing strip that had been inserted into the glucometer. Nurse #1 then disposed of the trash. She removed her gloves and exited the room. She proceeded back to the medication cart where she performed hand hygiene. She then opened the bottom drawer of the cart, retrieved the pouch labeled with Resident #29's name and placed the used meter into the pouch and put it back into the medication cart without cleaning it and closed the drawer. Nurse #1 was immediately interviewed regarding the facility's policy for cleaning glucometers after use. She stated that it was the policy to clean the meters both before and after use. Nurse #1 then retrieved the soiled meter out of the cart and wiped it down with an alcohol pad and placed it in a plastic cup to dry. She was questioned about what product was supposed to be used to clean the meters. Nurse #1 stated that she used alcohol swabs to clean the meters, but there was something specific that was supposed to be used, but she didn't know the name of it. There were no disinfecting wipes on the cart. An interview was conducted with the Director of Nursing on 11/19/24 at 3:12 PM. She stated that nurses were supposed to clean/disinfect the glucometers after testing blood sugars of all residents using Sani wipes and that it is unacceptable to use alcohol swabs. The Administrator was interviewed on 11/19/24 at 3:20 PM. He stated that he expected the facility policy to be followed for cleaning/disinfecting glucose testing meters.

Based on observations, record reviews, Nurse Practitioner, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 29 opportunities, resulting in a medication error rate of 6.9% for 2 of 3 residents (Resident #5 and Resident #16) during the medication administration observation. The findings included: a. Resident #16 was admitted to the facility on [DATE] with a diagnosis of retention of urine. A review of Resident #16's active Physician's orders included a current order for Macrobid (antibiotic) capsules 100 milligrams initiated on 11/4/24, one capsule one time daily for long term urinary tract infection prophylaxis. On 11/19/24 at 8:25 AM, the Unit Manager, who was working as a floor nurse, was observed as she prepared 11 of 12 medications for Resident #16. It was noted the Unit Manager had pulled the card containing the ordered Macrobid out of the medication cart, but instead of dispensing the medication in the cup with the others, she laid the medication card down on top of the cart. The nurse then went into the resident's room to administer the other medication. She was asked to step out of the room to the medication cart and then asked to count the medications in the cup. She counted only 11 different medications. She was interviewed about the missing dose, and the Unit Manager stated she should have dispensed the antibiotic with the other medications being administered. She then proceeded to administer the antibiotic as well. b. Resident #5 was admitted to the facility on [DATE] with a diagnosis of dry eye. A review of Resident #5's active physician's orders included a current order for the month of November for Artificial Tears one drop in both eyes every morning and at bedtime for dry eye. On 11/19/24 at 9:08 AM, the Unit Manager was observed as she prepared 10 of the 11 medications ordered for Resident #5. It was noted that the Unit Manager took the Artificial Tears out of the medication cart and laid them on top of the cart. Once she had administered the oral medication the Unit Manager then stated she was going to wheel Resident #5 down to the cafeteria as that was the resident's preferred location to visit with others during the day. She left the area without dispensing the eye drops. On 11/19/24 at 9:22 AM the Unit Manager was interviewed and stated she should have given the eye drops but that she forgot she had not given them. On 11/19/24 at 12:10 PM the Nurse Practitioner was interviewed regarding the missed medications. She stated it was her expectation that the nurses follow her orders and give the medications as she had written. The Director of Nursing was interviewed on 11/19/24 at 3:12 PM. She stated it was her expectation that the nurses give all medications as they are ordered. The Administrator was interviewed on 11/19/24 at 3:20 PM. He stated he expected the nurses to follow the medication administration policy and administer medications from one hour before the ordered time to one hour after the ordered time.

Based on record review, observations, resident and staff interviews the facility failed to implement interventions to prevent further falls for Resident #6. This was for 1 of 3 residents reviewed for accidents (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE] with diagnosis that included unsteadiness on feet, orthostatic hypotension, osteoporosis, and dementia. Resident #6's care plan, last revised 08/20/24, indicated she was risk for falls related to cognitive loss, history of falls, weakness, incontinence, and use of psychotropic medication. Resident #6 also had poor safety awareness and required frequent cueing of safety. She had an unsteady gait and continued to transfer/ambulate without assistance due to cognitive loss. The interventions included the following: Undated intervention: Ensure that the Resident #6 was wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheel chair Fall on 3/17/24: Assist resident with toileting if will allow. Fall on 3/27/24: Re-orient resident to transfer status. Fall on 5/29/24: Educate family on appropriate footwear. Fall on 07/28/24: Encourage Resident #6 to call out for assistance with ambulation. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6's cognition was severely impaired. She was independent with bed mobility and required supervision or touching assistance with toilet transfers, and chair to bed transfers. She was also coded as requiring moderate assistance with dressing, personal hygiene, and shower transfers and required maximal assistance with toilet hygiene and shower/baths. She had no range of motion impairments. There was one fall coded during the look-back period. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6's cognition was severely impaired. She was independent with bed mobility and required supervision or touching assistance with toilet transfers, and chair to bed transfers. She was also coded as requiring moderate assistance with dressing, personal hygiene, and shower transfers and required maximal assistance with toilet hygiene and shower/baths. She had no range of motion impairments. There was one fall coded during the look-back period. Review of incident report dated 05/29/24 revealed Resident #6 was observed on the floor on her back with a laceration to the back of the head. Resident #6 stated she was looking out of the window, took a step back, and lost her balance. Predisposing situation factors included improper footwear and ambulating without assistance. Other information noted read that shoes were observed to be too big. Interdisciplinary team note read to educate family on appropriate footwear. Review of incident report dated 07/28/24 revealed Resident #6 was observed sitting on bathroom floor with a goose egg noted to the back of her head, pain to her knuckles. and a skin tear to her right forearm. Resident #6's shoes were noted to be too big. Resident #6 stated she slipped. Interdisciplinary team note read for Resident #6 encouraged to call out for assistance with ambulation. An observation and interview were conducted on 11/19/24 at 1:30 PM with Resident #6. She stated her shoes are about a half size too big. Resident was lying on her bed, fully dressed in slacks, a blouse, and tennis shoes. Her feet were crossed, and the back of her shoe/heel was visible revealing a gap approximately a inch between her heel and the inside of the heel of the shoe. She then stated her shoes do alter her balance at times resulting in her falling. An interview was conducted on 11/19/24 at 1:50 PM with Nursing Assistant #4. She stated Resident #6's shoes are little big on her however she requested to wear them. She then stated that tennis shoes and a pair of house slippers was the only shoes Resident #6 had. An interview was conducted on 11/19/24 at 1:50 PM with the Director of Nursing (DON). She stated she was aware Resident #6's shoes were too big after a fall on 05/29/24. An intervention was added to her focus for falls on 05/29/24 to educate family on appropriate footwear. She also stated she was under the impression the family had been notified to bring shoes that fit properly. She indicated she had not gone and looked at Resident #6's shoes. She explained that the intervention that was put in place after the 05/29/24 should have included preventions that the facility could do to prevent further falls due to her shoes being too big. She explained that she expected staff not to use the tennis shoes if they were too big and to use non-skid socks. The DON was aware Resident #6 had fallen again on 07/28/24 due to her shoes being too big and that she should not have fallen twice for the same reason. The DON further stated she was unaware she had not received shoes that fit better and had not followed up on the shoes. She then explained that falls were discussed every morning in the morning meeting and interventions are added to the care plans at that time. An interview was conducted on 11/21/24 at 9:36 AM with the Administrator. He stated he was not aware Resident #6's shoes were too big and possibly causing her falls. He also stated he expected the staff to make sure her shoes fit properly or to apply non-skid socks. He indicated the care plan interventions should reflect and coincide with the reason for the fall and that a root cause investigation should be completed post falls.

Based on record reviews, observation, and resident, staff, and transportation driver interviews, the facility failed to provide safe transportation for Resident #1 when she was being transported by a contracted van transport company from dialysis back to the facility on [DATE]. Resident #1's wheelchair was not secured to the floor securement system per the manufacturer's instructions. When Driver #1 accelerated the vehicle, Resident #1's wheelchair tipped backward, and the resident hit the right back side of her head. Driver #1 pulled the transportation van over to the shoulder of the road and called 911. Emergency Medical Services (EMS) arrived, assessed the resident, and determined she needed to go to the hospital for evaluation for her complaints of head pain. The accident occurred post hemodialysis and Resident #1 was prescribed and received Plavix (anticoagulant medication). There was a high likelihood of a serious adverse outcome for Resident #1 due to the resident's wheelchair not being secured to the floor of the van per the manufacturer's instructions. Resident #1 was evaluated in the emergency department and the physician noted a right parietooccipital hematoma (blood collection in the back of the head. The CT (Computed Tomography) scan of the neck and head was negative for a head injury. This was for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: The manufacturer's instructions for the 4-point Wheelchair Securement Systems manual, dated 2012, were reviewed. The illustrated manual provided directions for wheelchairs to be secured with four separate floor-mounted restraints at all times when the vehicle was moving. The restraints were to be secured to the corners of the chair, on the frame structure of the wheelchair at approximately a 45-degree angle, not on the wheels or other parts of the chair. In addition to wheelchair securement, seat belts were to be used for securing passengers at all times. The lap belt must be securely fastened around each passenger any time the vehicle was moving, and a shoulder belt be used as well. The 2023 agreement between the Transportation Company #1 and the nursing home was reviewed. The agreement indicated to immediately notify the nursing home of any accidents or incidents, involving any vehicle or clients, whether or not damage or personal injury results. Resident #1 was readmitted to the facility on [DATE]. Her diagnoses included diabetes mellitus, end stage renal disease (ESRD) with hemodialysis, and bilateral below-knee amputations The quarterly Minimum Data Set (MDS) assessment, dated 5/8/24, indicated that Resident #1 was cognitively intact. She required extensive assistance with activities of daily living (ADL), used the wheelchair for mobility, and was non-ambulatory. The resident received hemodialysis three times a week. Review of Resident 1's plan of care, dated 5/22/24, revealed her diagnoses of ESRD and hemodialysis three times a week, with goals and interventions. Review of the physician's orders for May 2024 for Resident #1 revealed hemodialysis on Tuesday, Thursday, and Saturday outside the facility. Record review of the nurses' notes revealed that on 5/25/24, the staff received a phone call from the Owner of Transportation Company #1 stating on the way from the dialysis center to the facility, Driver #1 did not secure the wheelchair with Resident #1 according to manufacturer recommendations to the van, causing the wheelchair to flip backward. The resident hit her head on the van's door. Driver #1 called EMS, and the resident was transported by EMS to the Emergency Department (ED) for hospital evaluation. Review of the EMS report, dated 5/25/24, revealed at 3:04 PM the EMS dispatch received a call from Driver #1, stating that a (redacted) female fell in the van during the transportation from dialysis center to nursing home. The EMS team arrived on the scene to Resident #1 at 3:10 PM. Upon assessment, the patient had a hematoma, 1.5 by 2 inches, over the posterior (rear) head with moderate pain in her head and no bleeding or other injuries. Driver #1 explained that he had some issues with latching mechanism and thought he had it secured well. Per Resident #1, she flipped over backwards, striking the ramp. Resident #1 was transferred to the stretcher and brought to the ED of the hospital with no changes in condition at 3:39 PM. Review of the hospital records, dated 5/25/24, revealed Resident #1 arrived at ED at 3:49 PM via EMS for her head injury. Upon arrival, the resident was not in acute distress with stable vital signs. She had notable right parietooccipital hematoma. Per resident, she was riding in her wheelchair on the wheelchair accessible van after her dialysis appointment. The wheelchair was not locked down to the van, and when the driver accelerated the vehicle forward, the resident fell backwards, hitting the back of her head on the chair lift. She was not sure if she lost consciousness. Resident #1 endorsed pain in the back of her head and reported that she took daily Plavix (anticoagulant). The resident denied all other pain. The CT (Computed Tomography) (diagnostic test) scan of the head and neck was negative for acute traumatic pathology (sudden onset injury). She received pain management, and during multiple reevaluations, reported a gradual improvement of her headache. Resident #1 was discharged to the nursing home at 10:13 PM in stable condition. On 8/20/24 at 8:05 AM, during an interview, Resident #1 indicated she remembered on one Saturday in May 2024 (could not recall the exact day), she was in her wheelchair in the van for transportation from the dialysis center to the facility. Driver #1 was new to her and secured the wheelchair to the van with straps before leaving the dialysis center parking lot. The resident did not realize the driver secured only the back part of the wheelchair and the front part of the wheelchair frame was unsecured. Driver #1 locked the wheels of the wheelchair and applied the lap and shoulder seat belts to secure the Resident #1 in the wheelchair. On the way to the facility Driver #1 accelerated the vehicle forward, the resident's wheelchair tipped backward, and the resident fell backward together with her wheelchair and hit the right back side of her head against the van's door. The driver immediately pulled the transportation van over to the shoulder of the road and called 911. When EMS arrived, they assessed the resident, who reported moderate pain in her head and took her to the hospital for evaluation. Resident #1 could not recall if there was any blood coming from her head. Resident #1 continued she received a head CT scan (diagnostic procedure), which found no issues, and pain medications. In the ED, her pain was gradually reduced, and she returned to the facility in a few hours with almost no pain in her head. Resident #1 had not used Transportation Company #1 for dialysis appointments since the incident. Instead, the facility provided their van with a driver from the facility and there had been no issues. Attempts to interview Van Driver #1 were unsuccessful. On 8/20/24 at 9:50 AM, during the phone interview, the Owner of Transportation Company #1 indicated on 5/25/24, (did not recall the exact time), he received a phone call from Driver #1, who was assigned to transfer Resident #1 from the dialysis center to the facility. Driver #1 stated he did not fully secure the wheelchair to the van, and on the way to facility, Resident #1 fell backwards and hit her head. The Owner of Transportation Company #1 directed Driver #1 to call 911and then notified the facility. The administration of Transportation Company #1 conducted an internal investigation, which revealed Driver #1 disregarded the protocol and did not secure the wheelchair to the van per manufacturer's instruction, causing the incident with Resident #1. The Owner of Transportation Company #1 confirmed that Driver #1 was terminated, and the facility halted the contract with Transportation Company #1. The Owner of Transportation Company #1 continued that Driver #1 was hired in January 2024 and completed the training related to operating the van, patients' transportation in the van, including the 4-point Wheelchair Securement Systems manual, with return demonstration. Driver #1 did not have any issues prior to 5/25/24. On 8/20/24 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated on 5/25/24, the staff received a phone call from Transportation Company #1, stating Resident #1 fell in the van on the way from the dialysis center to the facility and was sent to the hospital for evaluation via EMS. During further communication with the Owner of Transportation Company #1 via phone and email, the DON learned that Driver #1 did not follow the protocol to secure the resident's wheelchair according to the manufacturer's instruction. The resident fell backward and hit her head. Driver #1 was terminated from the transportation company, and the facility stopped the agreement with Transportation Company #1. Since the incident on 5/25/24, the facility had utilized their van and their own driver for dialysis appointments. On 8/20/24 at 11:30 AM, during an interview, the Maintenance Director explained Driver #1 did not return to the facility and the Maintenance Director did not have a chance to inspect the condition of the securement system in the van as part of the facility's investigation. The Maintenance Director indicated that for newly hired Driver #2, he provided education and training for safe resident transportation in the van, including applying a 4-point securement system, seat belts, and straps with hooks according to the manufacturer's instruction. Driver #2 utilized the facility's van for dialysis appointments, and since the incident on 5/25/24, the Maintenance Director had been checking the van daily to monitor the securement system application. On 8/21/24 at 10:10 AM, during an interview, the Medical Director indicated she was notified of the incident with Resident #1 in the van right after it happened. After the incident, the resident spent a few hours in ED and received the diagnosis of a small right parietooccipital hematoma with no acute abnormalities on imaging tests. The Medical Director understood it was a driver from the transportation company, but the facility should be responsible for providing care within the professional standard at any time. The Medical Director mentioned Resident #1 could have sustained a serious injury during a fall on the van due to her anticoagulant medications, primary diagnosis, and comorbidities. On 8/21/24 at 11:25 AM, during an interview, the Administrator indicated he became aware of the incident on 5/25/24. The Director of Nursing (DON) notified him the staff received a phone call from Transportation Company #1, stating Resident #1 fell in the van during her transfer between the dialysis center and the facility. Her fall resulted in head trauma, EMS was called to the scene, and EMS took her to the hospital for evaluation. The DON and Maintenance Director discussed the issue with the Owner of Transportation Company #1, who clarified Driver #1 did not fully secure the resident in the van per protocol, which led to the fall with injury. Driver #1 was suspended and terminated according to the owner of the transportation company. The facility halted the agreement with Transportation Company #1. The Administrator reported after the incident, the facility conducted a Quality Assurance Performance Improvement (QAPI) meeting to discuss the incident and develop a Corrective Action Plan. The Administrator explained the facility utilized its van for resident's transportation after the accident on 5/25/24. The Maintenance Director was responsible for checking the safety equipment in the van and providing education and training for drivers. The newly hired Driver #2 received education and training for safe resident transportation in the van, including applying the 4-point securement system according to the manufacturer's instructions. The Administrator was notified of immediate jeopardy on 8/21/24 at 10:00 AM. The facility implemented the following Corrective Action Plan with a completion date of 5/27/24. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Residents requiring facility assisted transportation could be affected by the deficient practice. [NAME] Administrator halted the use of the contracted transportation service on May 26th, 2024, and all drivers within their transportation company had to complete education before any further usage. The affected residents are now transported by facility van to appointments. We have contracted with a second transportation service as a backup. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice Any resident needing transportation has the potential to be affected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. [NAME] Administrator halted the use of the contracted transportation service on May 26th, 2024, and all drivers within their transportation company had to complete education before any further usage. Facility Director of Nursing and Maintenance Director completed education on properly securing residents prior to transport. The facility has contracted with a second transportation service who has provided credible evidence of safe transportation and securing residents to meet the potential appointment needs. Residents are currently being transported to their appointments by our transportation aide. Upon hire, the transportation aide received education that including, but not limited to, properly securing residents safely in the vehicle, loading and unloading and vehicle condition. On May 26th, 2024, the Executive Director reeducated the Director of Nursing and Maintenance Director as it relates to vehicle safety while transporting residents to ensure resident are properly secured during transportation. The facility maintenance director provided training on June 7th, 2024, to the transportation aide. No new transportation vendors have been added since May 25th, 2024. We are utilizing our facility van with our transportation aide as the driver. The facility made the decision to monitor/audit and bring this to QA on May 26th, 2024. 4. Include dates when corrective action will be completed. Ongoing audits began on 5/26/2024. 5. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Quality monitoring will be performed on 2 different residents weekly to ensure they are safely secured prior to transporting to appointments for 12 weeks and then monthly for 3 months by DON and transportation aide to ensure resident is properly secured in van prior to transport. The immediate jeopardy was removed on 5/27/24. The deficiency was corrected on 5/27/24. The Immediate Jeopardy was removed on 5/27/24. The Corrective Action plan was validated on 8/22/24. The facility provided documentation to support their Corrective Action Plan, including education for the Maintenance Director and Driver #2. The pre-trip inspections were completed before any van transportation by Driver #2. The Maintenance Director audited these inspections three times per week from 5/27/24 to 7/22/24. During the observation, Driver #2 and the Maintenance Director demonstrated the correct method to restrain a wheelchair with a resident in the transportation van, using the 4-point securement system. QAPI meetings were discussed with the administrator, and meeting notes were reviewed. The facility's completion date of 5/27/24 for the Corrective Action Plan was validated on 8/22/24.

Based on observations, record reviews, and interviews with resident's, staff, Nurse Practitioner #1, Physician, and wound Physician, the facility failed to complete scheduled weekly skin sweeps (a head-to-toe skin assessment), provide daily wound care treatments as ordered, and failed to thoroughly complete a comprehensive assessment on 3/5/22 for a change in wound status. All of these actions contributed to the facility failing to identify when Resident #32 developed an unstageable pressure area. In addition, the facility failed to follow wound physician recommendations (Residents #9 and #40), failed to provide wound care as ordered (Resident #9), failed to change gloves and sanitize hands when going from soiled to clean surfaces during wound care (Resident #9) and failed to set a pressure reducing mattress according to resident's weight (Residents #9 and #11). This was for 4 of 8 residents reviewed for wound care. Immediate Jeopardy began on 3/5/22 when a Change in Condition assessment did not thoroughly assess or document the change in wound status to Resident #32's right heel. In addition, staff failed to complete scheduled weekly skin sweeps and failed to provide daily wound care treatments as ordered for a resident that developed an unstageable pressure ulcer (Resident #32). Immediate Jeopardy was removed on 4/9/22 when the facility provided and implemented an acceptable credible allegation of the Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (a deficiency that constitutes a pattern with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put into place and to complete employee in-service training. The facility was also cited at a scope and severity of E for example #1b (Resident #32), example #2 (Resident #9), example #3 (Resident #11), and example #4 (Resident #40). The findings included: 1) Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 was cognitively intact and had no pressure ulcers only a surgical wound. A pressure reducing device was on the bed. Review of the Care Area Assessment (CAA) summary worksheet dated 3/9/22 indicated Resident #32 would be care planned for the risk for skin integrity issues related to limited mobility, surgical site present and incontinence of urine. The worksheet stated skin sweeps would be completed per protocol and the surgical site would be observed for complications. Resident #32's active care plan included a focus area that was initiated on 3/9/22 for potential/actual impairment to skin integrity related to right [CONDITION(S)] repair, urinary incontinence, limited mobility and [CONDITION(S)]. The interventions included to encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 1a). A review of the hospital discharge summary dated 2/24/22 did not reveal any skin breakdown to Resident #32's heels. An Admission assessment completed by Nurse #4 on 2/24/22 was reviewed. The section for skin indicated a skin sweep was completed and skin was clear except for foot problems. Surgical site present to right thigh/hip area. Skin was noted to be warm and dry. The area for description of feet concerns read Right toe(s)- toe nails long, dry and yellow. Left toe(s)- long, dry and yellow. There were no concerns marked for other foot problems, heel problems or drainage to the feet. The active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #32's medical record from 2/27/22 to 3/30/22, revealed no weekly skin sweeps were completed as ordered. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physical Exam section of the progress note read Skin: Inspection: No rashes or ulcers. A Nurse Practitioner (NP) progress note dated 3/1/22, indicated Resident #32's skin was inspected, with no skin breakdown noted other than the surgical site to her right hip. Review of a Change in Condition assessment for Resident #32, dated 3/5/22, timed 4:52 PM and completed by Nurse #5, read a pressure area was identified to the right heel. The assessment was marked unknown for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Appearance section of the Assessment was summarized as resident with pressure area to right heel. There was no description of the color or size of the area identified. The assessment noted the physician was notified and provided new orders. Multiple attempts were made to contact Nurse #5 on 3/31/22 without success. Nurse #5 was scheduled to care for Resident #32 on 3/12/22, 3/13/22, 3/26/22 and 3/27/22. Resident #32's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - An order dated 3/6/22 to apply skin prep to the right heel, pad and protect every day. This order was discontinued on 3/10/22. - An order dated 3/10/22 to apply skin prep to both heels, pad and protect every day. There was no documentation in Resident #32's medical record, from 3/5/22 to 3/22/22, explaining the impairment of her skin integrity to the right heel. The March 2022 Treatment Administration Record (TAR) was reviewed for Resident #32 and revealed the following treatments were not documented as completed: - Bilateral heel treatments were not documented as complete on 3/12/22, 3/13/22, 3/17/22, 3/21/22, 3/26/22 and 3/27/22. A late entry, nursing progress note, written by Nurse #4 and dated 3/22/22 indicated Resident #32 had eschar to the left heel when the treatment was completed on 3/20/22. A phone interview was conducted with Nurse #4 on 3/30/22 at 6:38 PM. She stated Resident #32 had eschar to the right heel when the treatment was completed on 3/20/22. Nurse #4 stated skin prep was already being utilized for the area and she left communication for the Assistant Director of Nursing (ADON) regarding her findings. Review of a wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note read an unstageable (due to necrosis- black, brown, or tan dead tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin) pressure area to the right heel of at least 23 days duration. There was no drainage or indication of pain. The area measured 3 centimeters (cm) in length and 4.2 cm in width. There was 100% of thick adherent black necrotic tissue. The dressing treatment plan was for [MEDICATION(S)] every day to the area for 30 days, float her heels when in bed and use a sponge boot. The form indicated the pertinent history was obtained with nursing staff and Resident #32. A follow-up was scheduled for 7 days with the wound physician On 4/12/22 at 3:46 PM, a phone interview occurred with the wound physician. He explained he assessed Resident #32 on the evening of 3/28/22 for a possible pressure ulcer to her right heel. When asked about the documented duration of greater than 23 days, he stated he gathered this information based on what was told to him by the resident and her daughter who was at the bedside. He was told when Resident #32 was at the hospital they were not protecting her heels and she began to develop a sore to her right heel. The wound physician stated he based the duration of the wound on her hospital discharge date of [DATE] as the area clearly didn't evolve in a week or less. The wound physician added based on the look of the area it was highly plausible the right heel pressure area was present on admission to the facility. He described the area as dry heel eschar- noninfected skin. An order was provided to use [MEDICATION(S)] daily and offload her heels. The wound physician further stated if the facility had completed the weekly skin sweeps as ordered he would have been able to clearly identify if Resident #32 was admitted with the pressure area to her right heel or when it first developed. The active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 was observed on 3/28/22 at 9:50 AM, while she was sitting up in bed. A white dressing wrap was present to her right foot, a cloth protective boot was observed, turned around with the protection on top of her foot instead of on her heel. She stated she had a sore on her heel. When asked about how long the sore was present on her heel, she stated it started either when she was at the hospital or first got the facility all my days have run together On 3/30/22 at 9:45 AM, the ADON was observed providing skin care to Resident #32. She explained Resident #32 was seen by the wound physician last evening and the area to her right heel was identified as an unstageable pressure ulcer due to eschar (tan, brown or black dead tissue that may be crusty) being present. She stated she couldn't state whether the area was present there or not before yesterday. The right heel was observed to have a dark black area to the entire heel, however there was no drainage or odor. When the ADON was asked to measure the wound, she stated only the wound physician measured wounds. The ADON cleansed the area with skin prep and then applied a [MEDICATION(S)] swab. Non-skid socks were replaced to her foot and a cloth protective boot was applied. The left heel was observed to be very dry in appearance with no red or dark colored areas present. Skin prep was applied to the left heel as ordered, by the ADON The ADON was interviewed on 3/30/22 at 10:05 AM and explained the treatment order to Resident #32's right heel was recently changed to [MEDICATION(S)] solution to the right heel every day related to an unstageable pressure ulcer per the wound physician. The ADON was unable to recall being told about the eschar to Resident #32's heel by Nurse #4. When asked about weekly skin sweeps, the ADON stated they were to be completed every week and that either she or the Director of Nursing (DON) completed them. She added, if an Nurse Aide (NA) identified an area of concern during personal care they should report it to herself, the nurses or DON. If a nurse identified an area of concern for a resident, they could report it to herself, the DON or directly to the physician or NP. The ADON was unable to state why there were no weekly skin sweeps completed for Resident #32 since her admission to the facility. She further stated she felt if they had been completed the unstageable pressure ulcer to the right heel could have been identified sooner. An interview was completed with NA #2 on 3/30/22 at 11:45 AM who was familiar with Resident #32. She stated Resident #32 had her heels wrapped in a dressing when she provided personal care and had not observed her heel area. On 3/30/22 at 3:04 PM, an interview occurred with Nurse #2 who stated weekly skin sweeps were completed by the ADON or DON since there wasn't a treatment nurse. Nurse #2 explained if the ADON was working on a medication cart, then the nurses were responsible for their own treatments. Resident #32's March 2022 TAR was reviewed with Nurse #2 and revealed she had completed wound care to Resident #32's heels last on 3/24/22. She was unable to recall any necrotic areas to Resident #32's heels when treatments were completed. NP #1 was interviewed on 3/31/22 at 11:20 AM and reported since the treatment nurse was no longer at the facility there had been errors in wound care, which she had addressed with the ADON and DON. The NP stated she had assessed Resident #32 after her admission to the facility and had not identified any pressure ulcers to her heels, only a surgical wound to her right hip. She stated she would have expected to be notified when the area was first identified so proper treatment and oversight could have occurred. The NP stated the necrosis found to Resident #32's right heel could have been prevented if weekly skin sweeps as well as the wound treatments had been completed as ordered. An interview was conducted with the Director of Nursing (DON) on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months. She stated she was unaware there were no weekly skin sweeps completed for Resident #32 or her treatments to her heels were not completed consistently as ordered. The DON stated she was unaware Resident #32 had an unstageable pressure area to her right heel until after she was seen by the wound physician on 3/28/22. She reported there had been turn-overs in staff and there wasn't a full-time treatment nurse currently. The DON added she was aware weekly skin sweeps were not occurring before she arrived at the facility and thought if she didn't complete them the ADON had. The DON stated it was her expectation for weekly skin sweeps to occur, so skin impairments were identified and treated in a timely manner. A phone interview was completed with the physician on 4/9/22 at 1:11 PM. When asked about being notified of Resident #32's pressure area to the right heel on 3/5/22, he stated he received multiple calls during the day and could not readily recall, however he would have instructed the nurse to use the facility standing orders and have the resident seen by the NP and wound physician. The physician stated he could not recall observing an area of eschar to Resident #32's right heel. The Administrator was notified of the Immediate Jeopardy on 4/8/22 at 10:05 AM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to complete scheduled skin assessments for a resident who developed an unstageable pressure injury and failed to provide wound care treatments as ordered (Resident #32). Resident #32 has been assessed by a Licensed Nurse on 4-8-22. Licensed Nurse completed chart review and skin sweep of Resident #32 on 4-8-22. Licensed Nurse notified Wound Specialist of current wound orders and protective measures. Recommendations to discontinue skin prep and pad and protection to bilateral heels. Clarification orders obtained for [MEDICATION(S)] solution daily to right heel and leave open to air after [MEDICATION(S)] is applied and float heels in bed and apply protective booties as tolerated. Medical Director assessed resident on 4-8-22 and noted the resident clinically stable. Care Plan was reviewed and updated to reflect protective booties as tolerated to promote healing. Resident #32 had interventions put into place by a Licensed Nurse and plan of care were reviewed and updated on 4-8-22. Resident #32 Kardex has been updated by the Nurse Manager and identified from the plan of care and communicated by the nurse that interventions on the Kardex for the nurse aides to review on 4-8-22. Current Facility Residents have the potential to be affected. Current Residents (47) had Braden Risk Assessments completed by a Licensed Nurse on 4-8-22 using a Braden Scale to determine those at risk for skin breakdown. a. Current residents determined to be at risk had a call placed to the Responsible Party as well as to their Physician for notification and further orders. b. These Residents had interventions put into place by a Licensed Nurse and their Plans of care were reviewed and updated on 4-8-22. c. Kardex's have been updated by the Nurse Manager for each resident identified for the plan of care for nurse aides on 4-8-22. Current Residents (47) had Skin Sweeps performed by a Licensed Nurse on 4-8-22 to ensure that skin areas that are impaired have been addressed and appropriate interventions are in place. Current residents determined to have a new skin area of impairment had a call placed to their Responsible Party as well as to their Physician for notification and further orders. a. These affected Residents had interventions put into place by a Licensed Nurse and their Plans of care were updated, accordingly on 4-8-22. b. Kardex's have been updated by the Nurse Manager on 4-8-22, accordingly. c. The Facility has a Certified Wound Physician who makes rounds weekly for consultation, assessment, and treatment orders. The Certified Wound Physician's contract is currently in place. The Certified Wound Physician is available by phone and via telehealth for consultation, assessment and treatment orders. Newly admitted or acquired wounds identified through assessment are referred to Certified wound physician) by licensed nurses. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4-8-22, the Regional Director of Clinical and or Executive Director conducted re-education with Licensed Nursing Staff to ensure the following: a. Licensed Nursing Staff and Nurse Aides - skin is assessed daily with care and weekly skin assessment is performed by a Licensed Nurse and documented in the medical record. b. Nurse Aides- inform charge nurse of any noted new skin breakdown with care. c. Licensed Nursing Staff- notify the Resident's Physician within the course of their shift or within 24 hours of any new skin breakdown for further interventions and document skin assessment, notification, and new orders in the medical record. d. Licensed Nursing Staff-Treatment orders are to be administered as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . e. The Nurse Manager educated Nursing Staff was on 4-8-22, to include contract nursing staff. Nursing Staff not re-educated on 4-8-22, will not be allowed to work their next scheduled shift prior to being re-educated. The Executive Director will monitor daily according to schedule to ensure all staff are educated prior to the scheduled shift. f. Executive Director informed Nurse Manager on 4-8-22 of newly hired staff will be educated during orientation period. Newly hired nursing staff will be educated by the Nurse Manager during the orientation period going forward. The Nurse Manager has been re-educated by the Regional Director of Clinical Services on 4-8-22 regarding conducting a weekly Wound Meeting with the Interdisciplinary Team to discuss residents who are identified to be at risk identified through skin sweeps and nurse assessment. New and or worsening skin issues will be discussed during morning meeting to ensure appropriate treatment and notification are in place. Verbal presentation of assessments and documentation presented to nurse manager on 4-8-22. The Executive Director will be responsible for implementing and following through with the plan of correction to ensure compliance. The facility alleges the removal of Immediate Jeopardy on 4-9-22. On 4/12/22 the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The 4/8/22 facility audit was reviewed and revealed 3 current residents were identified with skin integrity concerns. The Nurse Practitioner and responsible party were notified, orders obtained and initiated as well as care plans and Kardex's updated. Progress notes were documented in each resident's medical record. Review of wound care was completed as ordered since 4/8/22. Education regarding completing weekly skin sweeps and documenting in the medical record and completing treatments as ordered for licensed nursing staff was reviewed and sign in sheets were provided. Education for Nurse Aides and Medication Aides regarding assessing residents' skin daily during personal care and reporting to the charge nurse when issues were noted was reviewed and sign in sheets were provided. Review of Resident #32's medical record indicated the following had been completed on 4/8/22: - A full skin sweep was completed on 4/8/22 with the notation of an area to the right heel that was dark red and black in color. No other skin concerns were observed. - Clarification orders were received from the wound physician to discontinue skin prep, pad, and protection to bilateral heels and. Orders provided to use [MEDICATION(S)] topically to the right heel every day, leave open to air after [MEDICATION(S)] applied to dry then apply protective booties as tolerated and float the heels in bed as tolerated. - An assessment was completed by the physician and noted the resident was clinically stable. - The care plan was updated to include assess/record/monitor wound healing and update physician with any declines; pressure relief mattress; float heels in bed as tolerated; provide protective booties as tolerated; and recurring visits by the wound specialist. - The Kardex was updated to include skin protection methods put into place. A wound care observation of Resident #32 occurred with the interim Director of Nursing on 4/12/22 at 10:45 AM. Resident #32 was observed to be lying in bed watching TV. She had a pillow placed under knees and blue cloth protective booties to both feet. The right foot was observed with a black area on the heel. The area was dry in appearance with no drainage or odor noted. Wound care was provided as ordered with no concerns. Nurse #2 was interviewed on 4/12/22 at 11:30 AM and stated she had received recent education on completing weekly skin sweeps as scheduled as well as completing wound care as ordered until a treatment nurse was hired. On 4/12/22 from 11:45 AM until 12:10 PM interviews of 4 Nurse Aides was conducted which revealed they had recently received education on reporting any observed skin concerns immediately to the charge nurse or Nurse Manager. An interview occurred with the Administrator and interim Director of Nursing (DON) on 4/12/22 at 12:15 PM. The interim DON explained scheduled weekly skin sweeps were embedding into the Medication and Treatment Administration Records of the electronic medical record (EMR) system and would alert the nurse when one was due. In addition, the interim DON stated she reviewed the Dashboard feature of the EMR system multiple times during the day to ensure the scheduled skin sweep and skin treatments were completed as ordered. The interim DON stated she was covering as the wound nurse during the week and the Registered Nurse covered as the wound nurse on the weekends to ensure treatments were completed as ordered. The Administrator reported there were 2 meetings during the day (one in the morning and one in the afternoon) where wound care and concerns would be discussed. The Administrator added a wound care nurse had been hired and was due to start at the facility next week. The facility's Immediate Jeopardy removal date of 4/9/22 was validated. 1b) A nursing progress note dated 2/24/22 indicated Resident #32 was admitted to the facility. Her skin was warm and dry with redness to the sacrum. No other mention of skin concerns in the progress note. Resident #32's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - An order dated 3/9/22 to apply a thick layer of barrier cream to sacrum/buttocks twice a day for skin breakdown (at 9:00 AM and 5:00 PM). The March 2022 Treatment Administration Record (TAR) was reviewed for Resident #32 and revealed the following treatments were not documented as completed: - Sacrum/buttocks treatment at 9:00 AM on 3/12/22, 3/13/22, 3/17/22, 3/21/22, 3/26/22 and 3/27/22. - Sacrum/buttocks treatment at 5:00 PM on 3/12/22, 3/13/22, 3/15/22, 3/16/22, 3/17/22, 3/20/22, 3/21/22, 3/22/22, 3/23/22, 3/24/22, 3/25/22, 3/27/22, 3/28/22 and 3/29/22. On 3/30/22 at 9:45 AM, the Assistant Director of Nursing (ADON) was observed providing skin care to Resident #32. An observation occurred of Resident #32's buttocks which revealed no redness or skin breakdown. The ADON stated the order should have read to apply barrier cream to buttocks for protection and explained this occurred during incontinence care with the Nurse Aide's(NAs). The ADON was interviewed on 3/30/22 at 10:05 AM and explained she was assigned to do treatments when she wasn't assigned to work on a medication cart. She reported that if the treatment was not signed off on the TAR, the treatment was not provided since she nor the nurses had the chance to do them. The ADON added she used skin prep to cleanse wounds unless the order stated to use wound cleanser. On 3/30/22 at 3:04 PM, an interview occurred with Nurse #2, who worked the day shift (7:00 AM to 3:00 PM). Nurse #2 was assigned to care for Resident #32 on 3/17/22 and 3/21/22. She explained the ADON had been assisting with treatments since the facility didn't have a treatment nurse. When the ADON was assigned to work on a medication cart, the nurses were responsible for treatments. She reported if the TAR was not signed off, the treatment was not provided. Nurse #3 was interviewed on 3/30/22 at 3:07 PM and indicated she normally worked the evening shift (3:00 PM to 11:00 PM). Nurse #3 was assigned to care for Resident #32 on 3/15/22, 3/16/22, 3/17/22, 3/20/22, 3/21/22, 3/22/22, 3/23/22, 3/24/22, 3/25/22, 3/28/22 and 3/29/22. She explained evening shift nurses were responsible for completing treatments, if scheduled, and if the TAR was not signed off as completed it meant there wasn't enough time to get them completed. She was unable to state if the missed treatments were reported to the oncoming shift. Multiple attempts were made to contact Nurse #5 on 3/31/22 without success. Nurse #5 was scheduled to care for Resident #32 on 3/12/22, 3/13/22, 3/26/22 and 3/27/22. An interview was conducted with the Director of Nursing (DON) on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months. She reported there had been turn-overs in staff and administration and there wasn't a full-time treatment nurse currently. The DON added it was her expectation for the ADON to provide and document treatments completed when she was responsible for wound care and if the ADON was working on the medication cart, she would have the same expectations for the nursing staff, who responsible for their own treatments. 2a. Resident #9 was admitted to the facility 3/5/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) indicated the resident had moderate cognitive impairment, total dependent upon staff for all activities of daily living, personal hygiene, toileting, and eating. The MDS indicated Resident #9 had a stage 4 pressure injury, had positioning device for his bed and received wound care during the assessment period. Resident #9's medical record revealed the resident was seen by the wound care physician on 3/28/2022 for a stage 4 pressure injury to the left lateral shin that measured 2.5cm x 1.8cm with light serous exudate. Recommendations for wound care were as follows: Primary dressing of hydrogel with silver, secondary dressing of abdominal pad, and skin prep daily for 16 days. The resident's medical revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Clean open area to left lower lateral leg with wound cleanser, apply skin prep and cover with a dry dressing daily. The order was dated 3/28/2022. On 3/30/22 at 3:15 PM an interview was conducted with the Assistant Director of Nursing (ADON)/treatment nurse regarding wound order not matching resident's active orders. She stated she does not get the orders from the wound physician; they go to the Director of Nursing (DON) and she puts the orders in the electronic medical record. An interview was conducted with the DON on 3/31/2022 at 1:59 PM. She stated she does get the wound care physician's wound evaluation and management summary with all his recommendations. She further stated she did review the recommendations for Resident #9 dated 3/28/2022 and entered the orders in the electronic medical record. When asked to review the recommendations and the orders in the electronic medical record, she stated she was new at entering wound care orders and she did not realize the hydrogel with silver was part of the order. 2b. On 03/29/2022 at 2:45 PM during a wound care observation, the wound was observed to be open approximately 2 centimeters (cm) by 2 cm with dark exudate but free of any odor. The treatment nurse removed a visibly soiled dressing from the left lateral shin of Resident #9 and did not change gloves or perform hand hygiene prior to handing the clean wound care supplies to include the clean dressing. An interview was conducted with the treatment nurse on 3/30/2022 at 10:50 AM. She stated she does not change gloves during wound care unless the wound has a lot of exudate and Resident #9's wound only had a little exudate. On 3/31/2022 the DON was interviewed and stated she expected the treatment nurse to perform wound care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2c. [NAME] an interview on 3/28/2022 at 11:06 AM the resident stated his mattress was the most uncomfortable mattress he had ever tried to sleep on. Resident #9 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/29/2022 at 12:00 observed Resident #9 lying on a pressure reducing mattress. The mattress settings indicated the mattress was set at 250 pounds (lbs.) The medical record revealed the resident's last documented weight was on 3/11/2022 at 166.4 lbs. On 3/29/2022 at 12:02 PM an interview was conducted with Nurse #2 who was assigned to resident. She stated she was not familiar with the resident's mattress. When asked about settings, she stated she was not aware of the settings or what they should be. She observed the mattress was set at 250lbs and she was not sure of the resident's weight. She stated the mattress was set up by maintenance and he may have information on how the mattress was set up. On 3/29/2022 at 12:31 PM an interview was conducted with facilities maintenance. He stated he set the mattress up and made sure it was functioning properly, but the nurses were responsible for setting the weight and monitoring the mattress proper functioning. An interview was conducted with the DON on 3/31/2022 at 1:59 PM. She stated she expected the pressure reducing mattress to be set correctly. 3. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired, was total dependent upon staff for bed mobility and all activities of daily living, toileting, and personal hygiene. The resident had not pressure injuries during the assessment period. Resident #11's comprehensive care plan was last revised on 1/20/2022 and had a focus for skin impairment with a history of pressure injuries to bilateral heels, the sacrum, and the right hip. An interview was conducted with Resident #11 on 3/30/2022 at 9:15 AM. She stated she had wounds, but they were all healed. She further stated she was told she had a special mattress to prevent any future pressure wounds. At the time of the interview the resident was observed on a pressure reducing mattress. The mattress settings were at the firmest level, 400 pounds, (lbs.). Resident #11's medical record revealed her last documented weight was 3/11/2022at 141.4 lbs. On 3/29/2022 at 11:58 AM an interview with Nurse #2, nurse assigne [TRUNCATED]

Based on record reviews, observations, Nurse Practitioner #1, Physician, Orthopedic Surgeon, Orthopedic Nurse, Wound Physician, resident and staff interviews, the facility administration failed to provide effective oversight to ensure practitioners were notified when a change in a pressure area was identified, weekly skin sweeps were completed as ordered, and daily wound care was completed as ordered to a resident that developed an unstageable pressure area (Resident #32). In addition, the facility administration also failed to provide effective oversight to ensure wound care for pressure and non-pressure related wounds were completed as ordered (Residents #9, #40, #48, #95, #3 and #195), and residents were transported to scheduled appointments or had appointments rescheduled (Residents # 3, #17, #31 and #195). In addition, the facility administration also failed to provide effective oversight to ensure wound care for pressure and non-pressure related wounds were completed as ordered (Residents #9, #40, #48, #95, #3 and #195), residents had transportation arrangements for scheduled appointments or had appointments rescheduled (Residents #3, #17, #31 and #195), residents had podiatry care arranged (Resident #32), residents medications were administered as ordered (Residents #15, #17, #32, #195 and #196) and the facility was homelike (room [ROOM NUMBER]). Immediate Jeopardy began on 3/5/22 when the facility administration failed to implement effective systems and/or processes to ensure residents received the necessary care and services to assess for pressure ulcers, provide daily wound care as ordered and ensure physician or Nurse Practitioner notification occurred when there was a change in wound status for Resident #32. Immediate Jeopardy was removed on 4/9/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (a deficiency that constitutes a pattern with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: 1a) This citation was cross referred to F 686 K: Based on observations, record reviews, and interviews with resident's, staff, Nurse Practitioner #1, Physician, and wound Physician, the facility failed to complete scheduled weekly skin sweeps (a head-to-toe skin assessment), provide daily wound care treatments as ordered, and failed to thoroughly complete a comprehensive assessment on 3/5/22 for a change in wound status. All of these actions contributed to the facility failing to identify when Resident #32 developed an unstageable pressure area. 2) This citation was cross referred to F 580 J: Based on record review, Nurse Practitioner #1, Physician and staff interviews, the facility failed to notify the Physician or Nurse Practitioner of a change in wound condition to Resident #32's right heel on 3/20/22. This was for 1 of 8 residents reviewed for pressure ulcers. The Administrator was notified of the Immediate Jeopardy on 4/8/22 at 7:56 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The Director of Nursing/Nurse Manger failed to monitor systems to ensure weekly skin sweeps and wound treatments complete. Weekly skin sweeps and progress note/change of condition will be monitored daily in clinical meeting by reviewing of assessments in electronic chart. Completion of ordered treatments will be reviewed daily in the electronic chart by Director of Nursing/Nurse Manager. Weekly wound meetings will be held by DON/Unit Manager along with IDT team and monitored by Executive Director to ensure complete. The Executive Director will monitor daily clinical meeting and weekly wound meeting to ensure done. The facility failed to complete scheduled skin assessments for a resident who developed an unstageable pressure injury and failed to provide wound care treatments as ordered (Resident #32). Resident #32 has been assessed by a Licensed Nurse on 4-8-22. Licensed Nurse completed chart review and skin sweep of Resident #32 on 4-8-22. Licensed Nurse notified Wound Specialist of current wound orders and protective measures. Recommendations to discontinue skin prep and pad and protection to bilateral heels. Clarification orders obtained for [MEDICATION(S)] solution daily to right heel and leave open to air after [MEDICATION(S)] is applied and float heels in bed and apply protective booties as tolerated. Medical Director assessed resident on 4-8-22 and noted the resident clinically stable. Care Plan was reviewed and updated to reflect protective booties as tolerated to promote healing. Resident #32 had interventions put into place by a Licensed Nurse and plan of care were reviewed and updated on 4-8-22. Resident #32 Kardex has been updated by the Nurse Manager and identified from the plan of care and communicated by the nurse that interventions on the Kardex for the nurse aides to review on 4-8-22. On 03/05/2022 resident #32 had a change in condition completed for pressure wound to R heel. MD was notified and new orders noted for skin prep to R heel. On 3/11/2022 order noted for skin prep to bilateral heels. A late entry nursing progress note dated 3/22/22 indicated Resident #32 was observed with eschar to her heel when a treatment was completed on 3/20/22. On 3/20/22 the facility failed to notify physician of change in wound. On 3/30/2022 new order noted for [MEDICATION(S)] to right heel pressure area. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Regional Vice President of Operations (RVPO) educated the ED on 4/8/2021 in regard to implementing effective systems or processes to ensure residents received the necessary care and services to assess for pressure ulcers and provide wound care treatments as ordered. During the facility's stand up and stand down meeting on residents with pressure areas will be discussed and reviewed and chart review conducted by nursing manager and Executive Director. The Director of Nursing/Nurse Manager will report to the Executive Director daily during stand up/stand down meetings that wound dressings and skin assessments have been completed. The Executive Director educated on processes to monitor compliance of clinical meeting to include daily clinical and meeting and weekly wound meetings. The Executive Director will be responsible for implementing and following through with the plan of correction to ensure compliance. The facility alleges the removal of Immediate Jeopardy on 4-9-22. On 4/12/22 the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: Education regarding implementation of effective systems or processes to ensure residents will receive the necessary care and services to assess for pressure ulcers and provide wound care as ordered to the Administrator was reviewed and a signature sheet was provided. An interview occurred with the Administrator and interim Director of Nursing (DON) on 4/12/22 at 12:15 PM. The Administrator reported there were 2 meetings during the day (one in the morning and one in the afternoon) where the DON/Nurse Manager would report whether wound care and skin sweeps were completed. The Administrator added compliance would also be monitored in the weekly wound meetings as well. The facility's Immediate Jeopardy removal date of 4/9/22 was validated. This citation was cross referred to F 686 E for examples #1b, #2, #3 and #4: In addition, the facility failed to follow wound physician recommendations (Residents #9 and #40), failed to provide wound care as ordered (Residents #9 and #32), failed to change gloves and sanitize hands when going from soiled to clean surfaces during wound care (Resident #9) and failed to set a pressure reducing mattress according to resident's weight (Residents #9 and #11). This was for 4 of 8 residents reviewed for wound care. 3) This citation was cross referred to F584 D: Based on observations and interviews with resident and staff, the facility failed to address a peeling ceiling for 1 of 1 reviewed for environment (room [ROOM NUMBER]). 4) This citation was cross referred to F658 D: Based on record reviews, observations, and interviews with residents, staff, Nurse Practitioner #1, and Nurse Practitioner #2, the facility failed to administer medications as ordered (Residents #17 and #15) for 2 of 7 residents whose medications were reviewed. 5) This citation was cross referred to F684 G: Based on record reviews, observations, Orthopedic Surgeon, Orthopedic Nurse, Nurse Practitioner #1 (NP) and staff interviews, the facility failed to provide care to a surgical wound by not monitoring for signs and symptoms of infection and by not removing the staples as ordered (Resident #48). In addition, the facility failed to provide non-pressure related wound care as ordered (Residents #95 #3 & # 195). This was for 3 of 4 sampled residents reviewed for non-pressure wounds. Resident #48 was sent to the emergency room (ER) due to change in level of consciousness/unresponsiveness and was diagnosed with a wound infection. 6) This citation was cross referred to F687 D: Based on observation, record review, resident, staff and Nurse Practitioner #1 interviews, the facility failed to provide or arrange foot care for a resident with thick and long toenails (Resident #32) for 1 of 2 residents who were reviewed for foot care. 7) This citation was cross referred to F690 E: Based on record reviews and interviews with residents, staff, and Nurse Practitioner #1, the facility failed to follow up on urology consultations (Residents #31& #17) and failed to administer an antibiotic as ordered (Resident #196) for 3 of 17 resident records reviewed. 8) This citation was cross referred to 745 D: Based on record reviews, observations, and interviews with residents, staff, Nurse Practitioner #1, and Nurse Practitioner #2, the facility failed to ensure Resident #195 had transportation arrangements for a neurology appointment that was indicated on her hospital discharge instructions and failed to ensure Resident #3 had transportation arrangements for a scheduled prosthetic appointment, resulting in both residents missing the appointments. This was for 2 of 2 residents reviewed for medically related social services. 9) This citation was cross referred to F758 D: Based on record review, observation and interviews with staff and Nurse Practitioner #1, the facility failed to transcribe the correct frequency per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 of 7 residents whose medications were reviewed. 10) This citation was cross referred to F760 E: Based on record reviews, pharmacy technician, Nurse Practitioner #1, and staff interviews, the facility failed to administer an anticoagulant (a medication that prevents blood clots, Residents #32 and #17) and an antipsychotic medication (Residents #15 and #17) in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Director of Nursing (DON) on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months and had just started the process of looking at where deficiencies may be in the nursing department. She reported there had been turn-overs in staff. The Administrator was interviewed on 3/31/22 at 3:00 PM. She stated she was aware this had been a problem about 2 years ago with the Resident Transporter and Scheduler not following through with resident scheduled appointments and a plan had been put into place for this to not occur again. She stated he had done better for a while, but it must have fallen by the wayside when the COVID-19 pandemic hit.

Based on record review, Nurse Practitioner #1, Physician and staff interviews, the facility failed to notify the Physician or Nurse Practitioner of a change in wound condition to Resident #32's right heel on 3/20/22. This was for 1 of 8 residents reviewed for pressure ulcers. Immediate Jeopardy began on 3/20/22 when staff had failed to notify the physician or Nurse Practitioner (NP) of a change in wound status for Resident #32's right heel which progressed to an unstageable pressure ulcer. Immediate Jeopardy was removed on 4/9/22 when the facility provided and implemented an acceptable credible allegation of the Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put into place and to complete staff training. The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital discharge summary dated 2/24/22 did not reveal any skin breakdown to Resident #32's buttocks or heels. A nursing progress note dated 2/24/22 indicated Resident #32 was admitted to the facility. Her skin was warm and dry with redness to the sacrum. No other mention of skin concerns in the progress note. Review of a Change in Condition assessment for Resident #32, dated 3/5/22, timed 4:52 PM and completed by Nurse #5, read a pressure area was identified to the right heel. The assessment was marked unknown for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Appearance section of the Assessment was summarized as resident with pressure area to right heel. There was no description of the color or size of the area identified. The assessment noted the physician was notified and provided new orders. A late entry, nursing progress note, written by Nurse #4 and dated 3/22/22 indicated Resident #32 had eschar (black, brown, or tan dead tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin) to the left heel when the treatment was completed on 3/20/22. A review of Resident #32's medical record revealed there was no documentation to show the physician or NP were notified of the eschar found to Resident #32's right heel from 3/20/22 to 3/28/22. A phone interview was conducted with Nurse #4 on 3/30/22 at 6:38 PM. She stated Resident #32 had eschar to the right heel when the treatment was completed on 3/20/22. Nurse #4 stated skin prep was already being utilized for the area and she left communication for the Assistant Director of Nursing (ADON) regarding her findings since the ADON had been helping with treatments due to the wound nurse was no longer at the facility. She could not recall notifying the physician or NP of the eschar present to Resident #32's right heel. The ADON was interviewed on 3/30/22 at 10:05 AM and was unable to recall being told about the eschar to Resident #32's heel by Nurse #4. She added, if an Nurse Aide (NA) identified an area of concern during personal care they should report it to herself, the nurses, or Director of Nursing (DON). If a nurse identified an area of concern for a resident, they could report it to herself, the DON or directly to the physician/NP. On 3/30/22 at 3:04 PM, an interview occurred with Nurse #2 who stated if skin concerns were observed on any resident they would either report it to the ADON, since she had been assisting with treatments, to the DON or directly to the physician or NP. She was unable to recall if this had occurred for Resident #32. NP #1 was interviewed on 3/31/22 at 11:20 AM and reported since the treatment nurse was no longer at the facility there had been errors in wound care, which she had addressed with the ADON and DON. The NP stated she had assessed Resident #32 after her admission to the facility and had not identified any pressure ulcers to her heels, only a surgical wound to her right hip. She stated she would have expected to be notified when the area was first identified so proper treatment and oversight could have occurred. An interview was conducted with the DON on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months. She reported there had been turn-overs in staff and there wasn't a full-time treatment nurse currently. The DON added she expected the nurse who identified the open area to document what the area looks like as well as report to the either the physician or NP. A phone interview was completed with the physician on 4/9/22 at 1:11 PM. When asked about being notified of Resident #32's pressure area to the right heel on 3/5/22, he stated he received multiple calls during the day and could not readily recall, however he would have instructed the nurse to use the facility standing orders and have the resident seen by the NP and wound physician. The physician stated he could not recall observing an area of eschar to Resident #32's right heel. The Administrator was notified of the Immediate Jeopardy on 4/8/22 at 10:05 AM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. A late entry nursing progress note dated 3/22/22 indicated Resident #32 was observed with eschar to her heel when a treatment was completed on 3/20/22. On 3/20/22 the facility failed to notify physician of change in wound. On 3/30/2022 new order noted for [MEDICATION(S)] to right heel pressure area. On 04/08/2022, all residents have been assessed for change in condition to include vital signs and complete head to toe skin assessment. 47 total residents reviewed was completed by licensed nurses to identify residents with a change in condition related to pressure. On 04/08/2022 Physician/NP notification via change in condition (SBAR) was completed with any new pressure areas. On 04/08/2022, all resident's progress notes for the last 30 days have been review for change in condition to include newly identified pressure areas. Change of conditions (SBARS) were reviewed along with progress note and skin sweep completed to identify any change noted and assessment complete. Information below was reviewed and verified by licensed nurse if change was identified. 47 total residents reviewed. - Family/Responsible Party Notification - Physician Notification - Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Appropriate documentation - Interventions to prevent further changes and /or worsening of condition - Appropriate Care Plan Intervention put in place On 04/08/2022 Physician/NP notification via change in condition (SBAR) was completed with any new pressure areas. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4/08/22, the Regional Director of Clinical Services and Executive Director initiated education to the Licensed Nurses, Medication Aides and Certified Nursing Aides. After 4/08/2022, Licensed Nurses, Medication Aides and Certified Nursing Aides not educated will receive this education prior to working their next scheduled shift), regarding physician notification of a change of condition related to residents with newly identified pressure areas, recognition, and response to include the following: - Evidence of a Licensed Nurse assessment - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Treatments have been performed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Physician and responsible party notification of changes - Appropriate care plan is in place - Accurate documentation - Continued monitoring for change of condition related to On 4/08/22, the Director of Clinical Services and/or Designee initiated education with Certified Nursing Assistants/Medication Aides regarding licensed nurse notification of a change of condition observation to include the following: - Interact - Stop and Watch Tool After 4/08/2022 Certified Nursing Assistants/Medication Aides not previously educated on change of condition observation and Interact- Stop and Watch Tool will be educated prior to working their next scheduled shift. Newly Hired Certified Nursing Assistants/Medication Aides will be educated during the Orientation process going forward. The Director of Nursing has been notified of this responsibility. Newly Hired Licensed Nurses, Medication Aides and Certified Nursing Aids, will be educated during the Orientation process by the Director of Nursing, going forward. The Director of Nursing has been notified of this responsibility. Education is being provided in person and via phone. The Executive Director is tracking who has received education. Validation of understanding has been documented via post-test questionnaire. Post-test will be completed via phone by reading of multiple choice by nurse manager or Executive Director. The Director of Nursing will review electronic record who had a change in condition to the morning meeting to ensure physician notification, to include new orders for wound care and assessments complete for change of condition. Completed change of conditions are noted in point click care and discussed during morning meeting to ensure documentation and notification are complete. The facility alleges the removal of Immediate Jeopardy on 4-9-22. On 4/12/22 the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The 4/8/22 facility audit was reviewed and revealed 3 current residents were identified with skin integrity concerns during a skin sweep. Change in condition assessments were completed and the Nurse Practitioner and responsible party were notified on 4/8/22. Education to licensed nursing staff regarding provider notification of a change in condition related to newly identified pressure areas was reviewed and sign in sheets were provided. Education for Nurse Aides and Medication Aides, regarding notification to a licensed nurse when a skin impairment was observed were reviewed and sign in sheets were provided. Nurse #2 was interviewed on 4/12/22 at 11:30 AM and stated she had received recent education on notification to the physician or NP when a skin impairment was identified. In addition, a change in condition assessment would be completed and the responsible party and Nurse Manager would be made aware. On 4/12/22 from 11:45 AM until 12:10 PM interviews of 4 Nurse Aides was conducted which revealed they had recently received education on reporting any observed skin concerns immediately to the charge nurse or Nurse Manager. An interview occurred with the Administrator and interim Director of Nursing (DON) on 4/12/22 at 12:15 PM. The interim DON explained when changes in skin conditions or newly identified skin impairments were noted licensed nursing staff were to complete a change in condition assessment and notify the responsible party, physician/NP, dietician and if needed the wound physician. The Administrator stated the physician had asked for the facility staff to contact him during off hours rather than the on-call physician services as they were not familiar with the residents. The facility's Immediate Jeopardy removal date of 4/9/22 was validated.

Based on observations, record reviews, and staff interviews, the facility failed to thoroughly investigate falls and implement interventions to prevent further falls (Resident #195). Resident #195 sustained a [CONDITION(S)] requiring sutures and sustained multiple skin tears as a result of repeated falls. The facility also failed to implement a fall intervention for a resident with a history of falling (Resident #36). This was for 2 of 3 residents reviewed for accidents. The findings included: 1) Resident #195 was admitted to the facility on [DATE] with diagnoses that included a nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), repeated falls, muscle weakness, unsteadiness on feet, history of a stroke with deficits to the left side, [CONDITION(S)], and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #195 had moderately impaired cognition. She required extensive assistance for bed mobility and transfers, had limited range of motion to one upper extremity and used a wheelchair for mobility. She was coded with a history of falls prior to admission and 2 or more falls with no injury and 2 or more falls with minor injury since admission. a) A nursing progress note dated 3/4/22 and timed 3:06 PM, indicated Resident #195 fell while trying to get out of bed. She sustained a laceration to the right side of her head near the temple area, as well as skin tears to the top of her left hand, right knee, and right lower leg. The Nurse Practitioner (NP) was informed and provided an order for Resident #195 to go to the emergency room (ER) for evaluation of the [CONDITION(S)]. Resident #195's responsible party (RP) was informed as well. A different nursing progress note for 3/4/22 indicated Resident #195 returned from the ER with sutures in place to the right side of her forehead. Review of the ER progress note for 3/4/22 revealed Resident #195 was seen due to a fall while trying to get out of the bed earlier in the day resulting in skin tears to her right leg, right knee, left hand and a laceration to her right forehead. Sutures were placed and she was held for an additional 6 to 7 hours in the ER for a repeat head CT (computerized tomography) scan that revealed no acute changes. A Fall Investigation Form dated 3/4/22 and completed by the Director of Nursing (DON), indicated Resident #195 was found on the floor next to her bed with a laceration to the forehead, and skin tears to the knee and back of her hand on 3/4/22. The form indicated she attempted to get up out of bed wanting to go home. The possible reasons listed for the fall was confusion, didn't know her own limits and weakness. There was no root cause identified for the fall. An intervention of lowered bed position was put into place. A progress note dated 3/7/22 indicated an Interdisciplinary Departmental Team (IDT) meeting occurred to discuss Resident #195's fall, that occurred on 3/4/22, with new interventions in place of lowering the bed position and placing fall mats at bedside. Resident #195's active care plan revealed a focus area, initiated on 3/7/22, for having had an actual fall with injury, poor balance. The interventions included bed in low position, floor mats at bedside and resident up in general lounge area to monitor for falls. Activities and snacks provided while up out of bed. A NP progress note dated 3/8/22 read Resident #195 suffered a fall last week and was sent to the ER as she had struck her head. Sutures were applied. b) A nursing progress note dated 3/14/22 indicated Resident #195 was observed lying on the fall mat beside the bed with a pillow at approximately 1:20 PM. The bed was in the lowest position. Resident #195 had reinjured the healing skin tears to her right elbow and right shin. The facility NP and resident's RP were notified. The note indicated when Resident #195 was assisted back to bed, pillows were placed underneath the sheets to create a barrier to the edge of the bed. A Fall Investigation Form, completed by the DON and dated 3/16/22, stated Resident #195 suffered a fall on 3/14/22 at 1:20 PM, where she was found lying on a pillow on the fall mat beside her bed, which was in the lowest position. The root cause of the fall was determined to be weakness, inability to stand and self-transfer. A scoop mattress was put into place to prevent her from rolling out of the bed. The Falls Investigation Form did not include the injuries that occurred at the time of the fall. The Assistant Director of Nursing (ADON) was interviewed on 3/31/22 at 12:37 PM. She was on duty at the time of Resident #195's falls on 3/4/22 and 3/14/22 and stated they occurred because Resident #195 was getting up unassisted, wanting to go home. She felt the amount of falls that had occurred were due to Resident #195's wanting to go home, dementia, poor safety awareness and wanting someone to stay in her room and talk with her. The ADON explained falls were discussed during the morning meeting with all department heads but mostly the investigation portion was a collaboration of herself and the DON. She further stated the DON completed all the falls investigations but hadn't been to a morning meeting in a few weeks from having to work on a medication cart. c) A Falls Investigation Form, completed by the DON and dated 3/16/22, indicated Resident #195 was found on the floor of her bedroom, lying on her back, close to the door on 3/16/22 at 3:30 AM. It was noted she had gotten out of bed without assistance. The report did not include a root cause of the fall and the updated intervention listed was a scoop mattress, which was the same intervention put into place after a fall on 3/14/22. A nursing progress note could not be found related to the fall that occurred on the 11:00 PM to 7:00 AM shift on 3/16/22. d) A nursing progress note dated 3/16/22 and timed 4:23 PM, revealed Resident #195 was found on the floor in her bedroom close to the door, lying on her back. She was observed wearing non-skid socks and was fully dressed and the wheelchair was behind her. She had last been seen during shift change while sitting up in the wheelchair. A skin tear was noted to the right forearm. Physician and resident's RP were notified. A Falls Investigation Form, completed by the DON and dated 3/18/22, indicated Resident #195 was found on the floor of her bedroom, lying on her back on 3/16/22 with a skin tear present to her right forearm. The root cause was identified as confusion. The updated intervention listed a scoop mattress. The report did not thoroughly investigate how or why Resident #195 fell from the wheelchair and the intervention was the same one initiated after a fall on 3/14/22. e) A nursing progress note dated 3/17/22 and timed 12:10 AM, indicated Resident #195 was found on the floor beside her bed with her lower body resting on the floor mat. An assessment revealed no injuries. The physician and RP were notified. A NP progress note dated 3/17/22 read Resident #195 had suffered several falls since admission as she would get up unassisted. One of the falls resulted in a laceration to her right head with sutures required. A Fall Investigation Form was not found for the fall that occurred on 3/17/22. A progress note dated 3/18/22 indicated an Interdisciplinary Departmental Team (IDT) meeting occurred to discuss Resident #195's falls with new intervention of a scoop mattress placed on the bed to help with bed mobilization. This was the same intervention that was put into place after a fall on 3/14/22. f) A nursing progress note dated 3/21/22 revealed Resident #32 had a fall at 2:00 PM and sustained a laceration over her right eye and three skin tears on her hands. The physician was made aware and gave an order for the resident to be seen in the ER for evaluation of the laceration to her head. Residents RP was made aware as well. A Falls Investigation Form completed by the DON and dated 3/21/22 indicated Resident #195 had a fall on 3/21/22 at 2:00 PM and was found on the floor in her room with a laceration to eye and skin tears to her hand. She was sent to the ER for evaluation. The form listed the root cause as weakness and indicated the updated intervention was, resident placed on early get up list and low bed with mats at the side. The intervention of the low bed and fall mats at bedside was the same intervention put into place after a fall on 3/4/22. Another nursing progress note dated 3/22/22 revealed Resident #195 returned to the facility on [DATE] at 10:30 PM from the ER with sutures in place to her right forehead. A skin tear to her left forearm was identified as well. A NP progress note for 3/23/22 read Resident #195 was sent to the ER following a fall recently where she had struck her head and suffered from some skin tears. A bruise was present to her right peri-orbital (around the eye) area. Nurse #2 was interviewed on 3/30/22 at 3:20 PM. She was familiar with Resident #195 and was on duty at the time of her fall on 3/21/22 at 2:00 PM, when another laceration occurred to Resident #195's head. Nurse #2 stated staff had been trying to keep her busy during the day and would assist with placing her in bed after lunch which had seemed to help. She stated Resident #195 did try to get up unassisted and staff had to monitor closely for safety. Nurse #2 stated she was not involved with the fall's investigation process. g) A nursing progress note dated 3/23/22 and timed 2:42 AM, indicated Resident #195 was observed on the floor in her room, scooting towards the doorway. There were no injuries noted. The physician and RP were notified. A Falls Investigation Form completed by the DON and dated 3/23/22 stated Resident #195 was found on the floor in her doorway on 3/23/22 during the 11:00 PM to 7:00 AM shift. The root cause was listed as confusion, barefoot and impaired mobility. The updated intervention was non-skid socks at all times, placed on early get up list and monitor at all times. A progress note dated 3/23/22 indicated an IDT meeting occurred to discuss Resident #195's recent fall and she was placed on the early get up lift for monitoring by staff. Resident to remain in bed while sleeping and up in common area when awake. h) A Falls Investigation Form, completed by the DON and dated 3/23/22, indicated Resident #195 had a fall while trying to get up without assistance on 3/23/22 at 6:42 PM. The root cause was listed as poor Activities of Daily Living (ADL). The updated intervention was bed in low position, which had been the intervention for a fall that occurred on 3/4/22. A review of the nursing progress notes did not reveal an entry for a fall that occurred on 3/23/22 at 6:42 PM. i) A Falls Investigation Form completed by the DON and dated 3/27/22 revealed Resident #195 had an unwitnessed fall and was found on the floor on 3/25/22 at 4:30 AM. The root cause of the form read repeated falls. If resident would have had on non-skid socks. Resident has dementia. Resident is unsteady on her feet. The intervention put into place was listed as resident placed on 1:1 due to high non-compliant behavior for remainder of the shift. A review of the nursing progress notes did not reveal an entry for a fall that occurred on 3/25/22 at 4:30 AM. On 3/28/22 at 11:30 AM, Resident #195 was observed lying in the bed with a fall mat to the left side of her bed and scoop mattress present. Resident #195 was observed on 3/29/22 at 9:10 AM, sitting up in her wheelchair in her room. Scabbed areas were noted to her right forehead and a fading bruise was observed to the right eye area. Resident #32 commented the injuries had occurred because of a fall. An interview occurred with Nurse Aide (NA) #2 on 3/30/22 at 11:45 AM and was familiar with Resident #195. She stated the resident became anxious at times and did attempt to get up on her own. Staff made sure her bed was in the lowest position when they assisted her to bed and kept a close eye on her for safety. NA #2 stated rounds were made every 2 to 3 hours for Resident #195 to ensure she was safe, and she would also look into her room as she walked by in the hallway. Nurse #3 was interviewed on 3/30/22 at 3:50 PM. She was familiar with Resident #195 from the 3:00 PM to 11:00 PM shift. She stated the resident did become a little more agitated or restless in the evening hours and had been witnessed attempting to get out of her wheelchair or bed unassisted. Nurse #3 stated when she saw these behaviors, Resident #195 would either be assisted to bed or up to the wheelchair and placed where she could be monitored more closely. Nurse #3 stated Resident #195 should have rounds completed every 2 to 3 hours for incontinence care and staff would ensure she was safe at those times. On 3/30/22 at 4:32 PM, NA #1 was interviewed. She was familiar with Resident #195 on the 3:00 PM to 11:00 PM shift and stated there were times increased restlessness was observed where Resident #195 would attempt to get up unassisted. NA #1 stated when she assisted her to bed, she ensured the bed was in the low position and a fall mat was next to the bed. If she was in bed and was restless, she would then assist Resident #195 up to her wheelchair and place her in a common area with snacks where she could be monitored more closely. NA #1 stated incontinence care was provided every 2 to 3 hours and she would ensure Resident #195 was safe before leaving the room. A phone interview was completed with Nurse #4 on 3/30/22 at 6:38 PM. She was familiar with Resident #195 on the 11:00 PM to 7:00 AM shift and explained there were times when she arrived on duty and Resident #195 would be sitting up in her wheelchair. Nurse #4 stated on 3/29/22, Resident #195 didn't want to go to bed until 1:00 AM. If restlessness was observed she would attempt to find the cause, whether it was food/water needed, toileting assistance or the need to either go to bed or get up out of bed. On 3/31/22 at 2:00 PM, the DON was interviewed and explained she had been at the facility for close to 2 months. She explained falls were discussed daily in the morning meeting with all department heads. However, she began a falls investigation as soon as they occurred and would review medications, progress notes regarding the falls and then went to the room and looked at every detail. She stated that she closed the falls investigations, out so fast that sometimes she forgot to complete the whole form completely and felt her quality of standard of care was to keep all the residents safe. She reviewed all the Fall Investigation Forms, she had completed for Resident #195 and felt a better job could be done with thoroughly explaining the root causes as well putting more effective interventions in place to prevent further falls from occurring. Multiple attempts were made to contact Nurse #5 on 3/31/22 with no success. She was the nurse on duty at the time of Resident #195's falls on 3/16/22, and 3/23/22. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] following cerebral infarct (stroke). The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired, was totally dependent upon staff for all activities of daily living, toileting, and personal hygiene. The resident had impaired range on upper and lower extremity and required a wheelchair for locomotion. Resident #36 did not have any falls during the assessment period. Resident #36's comprehensive care plan, last updated 3/20/2022, had a focus for risk of falls or injury related to confusion, deconditioning, balance problems, and poor safety awareness. Interventions included keeping bed in low position and fall mat bedside. A record review revealed the resident had documented falls on the following dates: 9/2/2021 Resident #36 was found on fall mat next to bed. 10/9/2021 Resident #36 was found on fall mat next to bed. 10/18/2021 Resident #36 was found on fall mat next to bed. 1/21/2022 Resident #36 was found on fall mat next to bed. 1/26/2022 Resident #36 was found on fall mat next to bed. 3/28/2022 at 9:44 AM Resident #36 was observed lying in bed, with eyes closed. The bed was in low position but there was no fall mat next to bed. Fall mat was folded up in corner of resident's room next to her wheelchair. 3/30/2022 at 11:19 AM observed Resident#36 lying in bed. The bed was in low position but there was no fall mat observed bedside. Fall mat was folded up in corner of room. 3/31/2022 at 9:20 AM Resident #36 was observed lying in bed. The bed was in low position with no fall mat bedside. On 3/31/2022 at 9:30 AM an interview was conducted with the Nurse Assistant (NA)#2. She stated she was assigned to the resident's hall. When asked if the resident should have a fall mat next to her bed, she stated she was not sure. The NA stepped into the resident's room and observed the fall mat folded up in the corner of the room. She stated she did not work the hall often and was not familiar with the residents. An interview was conducted with Nurse #2 on 3/31/2022 at 9:30 AM. When asked if the resident should have a fall mat next to her bed, the nurse stated she should. She further stated the staff would sometimes remove the fall mat and place it in the corner of the room to prevent it from being a tripping hazard, but if the resident was in the bed, the fall mat should be bedside. An interview was conducted with the DON on 3/31/2022 at 1:59 PM. She stated it was her expectation that fall interventions be implemented by staff.

Based on record reviews, observations, Orthopedic Surgeon, Orthopedic Nurse, Facility Nurse Practitioner (NP) and staff interview, the facility failed to provide care to a surgical wound by not monitoring for signs and symptoms of infection and by not removing the staples as ordered (Resident #48). In addition, the facility failed to provide non-pressure related wound care as ordered (Residents #95 #3 & # 195). This was for 3 of 4 sampled residents reviewed for non-pressure wounds (Residents #48, #95 & #195). Resident #48 was sent to the emergency room (ER) due to change in level of consciousness/unresponsiveness and was diagnosed with wound infection. Findings included: 1. Resident #48's hospital history and physical dated 12/29/21 revealed that Resident #48 was admitted to the hospital after a mechanical fall at home. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48 was discharged to the facility of 1/5/22 for rehabilitation (rehab). The hospital note further indicated follow up visit to the orthopedic clinic on 1/13/22. Resident #48 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #48 had moderate cognitive impairment and she had a surgical wound. The nurse's notes from 1/5/22 through 1/19/22 were reviewed. There were no notes to indicate that the left hip surgical wound was assessed for any signs/symptoms of infection. The note dated 1/5/22 (admission) did not mention of the left hip surgical wound having staples (written by Nurse #1). Nurse #1 was not available for interview. Nurse #2, assigned to Resident #48 on 1/6/22, 1/7/22, 1/11/22 and on 1/12/22 was interviewed. She stated that when a resident was admitted with a surgical wound, the dressing was left in place until the follow up appointment with the surgeon. She stated that she was aware that there were staples on Resident #48's surgical wound. Nurse #2 indicated that the nurses were supposed to monitor the surgical wound for signs/symptoms of infection, but she didn't know why there were no wound assessments on the progress notes. She reported that the Appointment Scheduler was responsible for all the appointments. The nurse's note dated 1/13/22 at 10:30 AM revealed that the responsible party (RP) of Resident #48 was informed that the resident tested positive for COVID and was moved to the quarantine hall. The care plan dated 1/18/22 was reviewed. The care plan problem was the resident has fractures related to fall, left hip replacement and cast to left wrist. The goal was the resident will not develop complications and will minimize signs/symptoms of pain. The approaches included instruct resident regarding the healing process, treatment, and complications, and follow up and to monitor/document/report as needed ([CONDITION(S)], bruising/discoloration of skin, skin temperature changes, and loss of sensation). The nurse's note dated 1/18/22 at 8:05 PM (written by Nurse #5) revealed that resident had a change in mental status, not responding appropriately, on call provider was notified with an order to send the resident to the ER for evaluation and treatment. Nurse #5 was not available for interview. The ER note dated 1/18/22 revealed that Resident #48 was seen in the ER with her left hip wound clearly infected. The resident was given Ancep (an antibiotic medication) I gram intramuscular (IM) and 0.9 % Sodium Chloride bolus in ER and was prescribed 2 antibiotic medications for the wound infection. The ER note further indicated that it was strongly recommended that the facility obtain daily pictures of the wound and to track its progress. The nurse's note dated 1/19/22 at 4:56 AM revealed that Resident #48 was back from ER with 2 antibiotic medications ([MEDICATION(S)] and [MEDICATION(S)]) ordered for wound infection. The nurse's notes from 1/19/22 through 1/24/22 were reviewed. There were no wound assessments/pictures taken to track the wound progress. The MDS dated [DATE] indicated that Resident #48 was discharged to the community on 1/24/22. The ER note dated 1/25/22 revealed that Resident #48 presented in the ER with altered mental status. She was sent to the nursing facility for rehab on 1/5/22 and was discharged to home on 1/24/22. She had worsening confusion and lethargy and slept most of the day. She has had some chills but no documented fevers. She has also worsening pain to the left hip and still has the staples in place after the surgery on 12/29/21. On examination, the incision over lateral left hip from recent hemiarthroplasty with staples in place, induration surrounding [CONDITION(S)] and purulent drainage from the middle of the incision. The note further indicated that the staples should have been removed several weeks ago which may be causing some of this infection. The resident was admitted and was treated with [MEDICATION(S)] and [MEDICATION(S)] (both were antibiotic medications). The Social Worker (SW) was interviewed on 3/29/22 at 10:30 AM. The SW reported that the Appointment Scheduler was responsible for scheduling appointments and transporting residents to and from the appointments. The SW reported that she called the orthopedic clinic today (3/29/22) regarding Resident #48 and she was told that a staff member had called on 1/12/22 to cancel the appointment due to COVID positive residents and staff at the facility. The appointment was rescheduled for 1/27/22. The Appointment Scheduler was interviewed on 3/29/22 at 11:25 AM. He stated that he was not aware of Resident #48's appointment with the orthopedic on 1/13/22. When asked to see his calendar book for appointments, he responded that he did not have a calendar book for appointments in January and February 2022. He added that the Administrator just gave him a calendar in March of 2022. When the book was observed, there were no appointments listed for January and February 2022. The Scheduler denied calling the orthopedic clinic regarding Resident #48 on 1/12/22. He reported that the NP and the ADON had been helping him with the appointments by informing him of the dates of scheduled appointments. The Assistant Director of Nursing (ADON) was interviewed on 3/29/22 at 12:01 PM. The ADON stated that the Appointment Scheduler was responsible for all the appointments. The admitting nurse was supposed to give a copy of the appointment to the Scheduler, and he entered the appointment in his book. If for some reason the resident was not able to go to the scheduled appointment, the Scheduler called the clinic to inform of the reason why the appointment was cancelled. The call should have been documented on his book. The Orthopedic Surgeon was interviewed on 3/31/22 at 8:03 AM. The Surgeon reported that he performed the surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . He performed the left hip hemiarthroplasty on 12/29/21 and she was discharged to the nursing facility on 1/5/22 for rehab. On 1/6/22, she was seen in the ER. She removed the cast on her wrist and a splint was replaced. Upon her discharged , a follow up appointment was made for 1/13/22 for removal of the staples and to x-ray her wrist. The Surgeon stated that their office had a recorded communication with the facility staff. Review of the recorded communication, he stated that the facility had called on 1/12/22 and stated that the facility had number of staff and residents who were COVID positive, and the appointment was cancelled. The office staff had given an order to the facility staff to remove the staples and to change the dressing to the surgical wound daily. A follow appointment was rescheduled for 1/27/22. On 1/19/22, Resident #48 was sent to the ER due to change in condition and was found to have an infection to the incision site. The resident was sent back to the facility on 2 antibiotic medications. The Surgeon did not understand as to why the staples were not removed in the ER. The Surgeon reported that Resident #48 was again seen inER on [DATE] and the surgical site was clearly infected, and the staples were still in the wound. He indicated that he expected the staples removed in 2 weeks after surgery or else it could cause infection to the wound. The NP was interviewed on 3/31/22 at 11:12 AM. The NP stated that she had seen Resident #48 on 1/13/22 and on 1/20/22 (virtual visit). On 1/13/22 visit, she observed the surgical site with staples and there were no signs/symptoms of infection noted. On 1/20/22, she had a virtual visit and saw the surgical site, it was infected with staples in place. The wound had brownish- yellowish drainage. The resident was already on 2 antibiotic medications for the wound infection. She indicated that the staff should have called the orthopedic clinic to get an order to remove the staples at the facility if the resident was unable to go to the clinic. She also expected the nursing staff to assess/monitor the surgical wound for signs/symptoms of infection and to report to the Physician or NP. The NP reported that she had issues with appointments/consults not followed up by the staff and were missed. The facility had several turn- over in nursing and administrative staff including the Director of Nursing (DON). The Orthopedic Nurse had called and was interviewed on 4/1/22 at 3:06 PM. She stated that she was the nurse at the orthopedic clinic. She stated that their office had a recorded communication with the facility. She reported that Resident #48 had a scheduled appointment on 1/13/22 for the removal of her staples. On 1/12/22, the Scheduler had called to cancel the appointment for the resident due to COVID positive residents and staff at the facility. The Nurse gave a verbal order to the Scheduler to remove the staples at the facility and to change the dressing to the surgical site. The Scheduler had requested to fax the order for the removal of the staples and dressing change to the facility and she faxed the order on 1/13/22. The Orthopedic Nurse provided the recorded communication documentation and were reviewed. The documentation verified that the Scheduler had called the clinic and talked to the Orthopedic Nurse on 1/12/22 at 2:41 PM. The Nurse informed the Scheduler that the appointment was rescheduled to 1/27/22 and to remove the staples at the facility and to change the dressing. The Scheduler had requested to fax the order for the removal of the staples and the dressing change to the facility. A copy of the faxed letter to the facility dated 1/13/22 was reviewed and the order indicated to remove the staples on 1/13/22 and to apply [MEDICATION(S)] (used to treat wounds) and ½ inch steri-strips, may leave the wound uncovered if there is no drainage, otherwise continue dry dressing. The DON was interviewed on 3/31/22 at 1:59 PM. The DON stated that she started as DON of the facility end of February 2022 and she was not around when Resident #48 was at the facility. She reported that she reviewed Resident#48's records and did not see any documentation regarding care provided to the surgical wound. She indicated that the nursing staff should have monitored the wound for signs/symptoms of infection and to inform the physician or the NP. She also reported that there was a break in the system for the appointments/consults. The DON expected nursing to provide her and the Scheduler a copy of the appointment/consult upon admission and she would ensure the appointments were followed through. 2. Resident #95 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #95 had moderate cognitive impairment and he had diabetic ulcers and a surgical wound. Resident #95 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] & 5 PM). The care plan problem dated 3/27/22 revealed that Resident #95 had actual skin impairment, resident was admitted with surgical wound (left foot 2nd toe) and had diabetic ulcers (right foot). The approaches included monitor/document location, size, and treatment. The March 2022 Treatment Administration Records (TARs) for Resident #95 were reviewed. The TARs revealed that the treatment to the right foot and left foot was not provided at 5 PM on 3/18/22, 3/19/22, 3/20/22, 3/22/22, 3/24/22 and 3/28/22 and at 9 AM on 3/25/22, and 3/27/22. On 3/29/22 at 2:15 PM, the Assistant Director of Nursing (ADON) was observed during the dressing change on Resident #95. The diabetic ulcer on the right foot did not have slough/necrosis noted. The nurse cleaned the ulcer with a skin prep and covered the wound with a dry dressing. The left foot surgical wound did not have signs or symptoms of infection. The Nurse applied a gauze soaked with Dakin's solution and covered with dry dressing. The Nurse was not observed to clean the wound prior to applying the clean dressing. Resident #95 was interviewed on 3/29/22 at 3:20 PM. He stated that his dressings were changed mostly daily and twice a day occasionally. The ADON was interviewed on 3/30/22 at 10:05 AM. The ADON stated that she was assigned to do the treatments when she was not assigned to work on the floor. She reported that if it was not signed off on the TAR, the dressing was not provided since she or the nurses didn't get the chance to do the treatment. She also reported that she always used the skin prep to clean the wounds. Nurse #2 was interviewed on 3/30/22 at 10:10 AM. The Nurse stated that the ADON had been assigned to do the treatments since the facility did not have a treatment nurse. When the ADON was assigned to work on the floor, the nurses were responsible to provide the treatments. She reported that when the TAR was not signed off, the treatment was not provided, it was possible that the nurse did not have the time to do it. The Director of Nursing (DON) was interviewed on 3/31/22 at 1:59 PM. The DON stated that she started as DON of the facility end of February 2022. She reported that the facility had a big turn - over in nursing and administrative staff. She did not have a full-time treatment nurse. She expected nursing to provide the treatment as ordered. 3) Resident #3 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact and had no pressure ulcers or other skin impairments. Resident #3's active care plan, last reviewed on 12/30/21, included a focus area for potential impairment to skin integrity related to problems with mobility, incontinence, history of stroke, PVD with right and left above the knee amputations, [CONDITION(S)] and protein calorie malnutrition. History of stage 3 pressure ulcer to the left buttock area. The interventions included: - Administer treatments as ordered and monitor for effectiveness. - Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Notify nurse of any new areas of skin breakdown, redness, blisters, bruises, and discoloration noted during bath or daily care. A review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing progress notes were reviewed from 6/1/2021 to 3/28/22 and revealed a note on 6/30/21 that Resident #3 had developed an open area on the top of his scalp with new orders received from the physician for an antibiotic and wound care. This area was resolved on 7/26/21. There were no progress notes regarding skin integrity concerns for Resident #3's buttocks. A Review of the Weekly Skin Integrity Review reports dated 12/16/21, 2/3/22, 3/10/22 and 3/24/22, revealed no skin integrity issues were noted. A Nurse Practitioner (NP) progress note, dated 3/29/22, indicated Resident #3 was seen at the request of nursing staff to assess a potential area of breakdown to his buttocks. The note read that Resident #3 was assessed while in bed and was noted to have scar tissue to his buttocks where a previous wound had been with no open areas found. The note continued to state the site could certainly become compromised given the previous injury to his skin integrity and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview occurred with Resident #3 on 3/28/22 at 12:00 PM, who stated he had skin breakdown to his left buttock area that had been present since his admission. He stated, they just put a pad on it when I ask. Resident #3 stated the area was tender, but his routine pain medication helped to alleviate the discomfort. On 3/29/22 at 11:03 AM, an observation was made of Resident #3 and Nurse Aide (NA) #4 during personal care. Resident rolled to his left side, where a dark colored protective dressing was observed in place to his left inner buttock region. Resident #3 stated the NA's changed the dressing when asked which was every 2 to 3 days and denied having a nurse changing the dressing since the former treatment nurse had left. He further stated that either he or the NA's will go and get more protective dressings and keep them in the bedside table. NA #4 opened the bedside table to reveal 4 to 5 packages of the protective dressing. She confirmed replacing the dressing when asked by Resident #3 and stated she never questioned it because the nurses provided the dressing and thought they were aware of what was under the dressing. NA #4 added the area underneath had the appearance of pink, raw skin. On 3/29/22 at 11:08 AM, an observation was made of Resident #3's left inner buttock that was covered by the protective dressing with the Assistant Director of Nursing (ADON). She commented being unaware of any breakdown or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing was removed with a dark moist substance present on the dressing. There was no odor or drainage, but the area was the size of a 50-cent piece and was bright pink in color. The ADON stated the protective dressing that was in place was not the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON was unable to state if the area was open, a shear or a pressure area, but would report to the facility NP for her to assess the area further. Nurse #2 was interviewed on 3/29/22 at 11:32 AM and stated she had been employed at the facility for close to two and half years and was familiar with Resident #3. She explained the former treatment nurse would provide the protective dressings to either Resident #3 or the NA's so they could apply to the left inner buttock area for his piece of mind and protection. Nurse #2 went on to say, she had provided the protective dressings to the NA's when asked and was aware they were kept in his bedside table but was unaware of what was under the dressing as she had never completed a treatment or skin assessment on Resident #3. Nurse #2 explained that currently the ADON or Director of Nursing (DON) were completing the skin assessments. An interview was conducted with NA #3 on 3/30/22 at 11:50 AM. She stated when she has rendered personal care to Resident #3 over the past few years, there would be a protective dressing to his left inner buttock area and other times the dressing wouldn't be there. She recalled the area was pink in color when the dressing wasn't present and had reported this to the nurses and former treatment nurse. On 3/30/22 at 4:32 PM, an interview occurred with NA #1 who stated she had observed the protective dressing on Resident #3's buttock area when providing personal care assistance but hadn't' questioned it as she thought nursing was taking care of the area. The DON was interviewed on 3/29/22 at 1:10 PM and stated she had completed Resident #3's skin review on 3/10/22 and 3/24/22. She explained she did not notice a protective dressing in place or skin breakdown/concerns to his buttocks area. The DON further stated she was unaware a protective dressing was being provided to Resident #3 and utilized without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Practitioner (NP) #1 was interviewed on 3/31/22 at 11:20 AM and stated she was unaware Resident #3 was using a protective dressing on his buttocks area. She further stated she would have expected the nursing staff to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated she assessed the area on the evening of 3/29/22, felt it was scar tissue from previous breakdown and provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 4) Resident #195 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #195 had moderately impaired cognition and was coded with skin tears and moisture associated skin damage (MASD). Resident #195's active care plan revealed a focus area, initiated on 3/13/22, for potential/actual impairment to skin integrity related to resident had multiple skin tears on her face and extremities related to falls, had a contracture of the left arm/hand and limited mobility. The interventions included to monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #195's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - An order dated 3/15/22 to clean skin tear to the right elbow with wound cleanser, apply triple antibiotic ointment and cover with a dry dressing every day until healed. - An order dated 3/15/22 to clean skin tear to the right shin with wound cleanser, apply triple antibiotic ointment and cover with a dry dressing every day until healed. - An order dated 3/25/22 to apply [MEDICATION(S)] (an antifungal) powder mixed with barrier cream to buttocks twice a day on the day and evening shifts for rash. The March 2022 Treatment Administration Record (TAR) for Resident #195 was reviewed and revealed the treatment to the right elbow and right shin skin tears was not provided on 3/15/22, 3/17/22, 3/21/22, 3/23/22, 3/25/22, 3/26/22 and 3/27/22. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/29/22 at 3:49 PM, the Assistant Director of Nursing (ADON) was observed providing wound and skin care to Resident #195. A skin tear was located on the left forearm, not the right elbow, and was approximated in a C shape. The area was scabbed with a very small open area in the middle of the wound. The ADON cleansed the area with wound cleanser and applied triple antibiotic ointment to the skin tear, covered with Vaseline gauze and a dry dressing. There were no open areas or skin tears observed to Resident #195's legs. An observation occurred of her buttocks which revealed a red, spotty rash to the entire buttock area and inner legs. The ADON applied the [MEDICATION(S)] powder mixed with barrier cream to the area. The ADON was interviewed on 3/29/22 at 4:00 PM. When asked about the treatment order for the right elbow she stated the right and left must have gotten mixed up when the order was put in and that she liked to use Vaseline gauze, so the dressing didn't stick to the wound when it was removed and was aware it was not part of the treatment order. The ADON was unaware when the areas were healed to Resident #195's legs and stated the order should have been resolved. Another interview occurred with the ADON on 3/30/22 at 10:05 AM, and stated she was assigned to do treatments when she wasn't assigned to work on a medication cart. She reported that if the treatment was not signed off on the TAR, the dressing was not provided since she or the nurses didn't get the chance to do the treatments. On 3/30/22 at 3:04 PM, an interview occurred with Nurse #2, who worked the day shift (7:00 AM to 3:00 PM). Nurse #2 was assigned to Resident #195 on 3/17/22, 3/21 and 3/27/22. She explained the ADON had been assisting with treatments since the facility didn't have a treatment nurse. When the ADON was assigned to work on a medication cart, the nurses were responsible for treatments. She reported if the TAR was not signed off, the treatment was not provided. Nurse #3 was interviewed on 3/30/22 at 3:07 PM and indicated she normally worked the evening shift (3:00 PM to 11:00 PM) but would also work some on the day shift. Nurse #3 was assigned to Resident #195 on 3/23/22, 3/25/22, 3/26/22, 3/28/22 and 3/29/22. She explained evening shift nurses were responsible for completing treatments, if scheduled, and if the TAR was not signed off as completed it meant there wasn't enough time to get them completed. An interview was conducted with the Director of Nursing (DON) on 3/31/22 at 2:00 PM and indicated she had been employed at the facility for close to 2 months. She reported there had been turn-overs in staff and administration and there wasn't a full-time treatment nurse currently. The DON added it was her expectation for nursing to provide the treatments as ordered.

Based on record review, observations, staff interview, resident and family interview, wound care Nurse Practitioner interview, and Nurse Practitioner interview, the facility failed to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation, and communication with the outside podiatrist who was also treating, resulting in worsening, increase in size and infection of the pressure ulcer (Resident #36); failed to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation (Resident #1); and failed to provide daily pressure ulcer wound care as ordered and weekly wound measurement/assessment and documentation (Resident #44) for 3 of 4 sampled residents reviewed for wound care. Immediate Jeopardy began on 11/6/18 when staff failed to provide pressure ulcer care with resulting infection for Resident #36. Immediate Jeopardy was removed on 3/6/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level to ensure monitoring of systems are put in place and to complete employee in-service training. The facility was also cited at a scope and severity of E (a deficiency that constitutes a pattern with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) for example #2 (Resident #1) and example #3 (Resident #44). Findings included: 1. Resident #36 was admitted on [DATE] with the [DIAGNOSES REDACTED]. A review of the resident ' s care plan dated 10/1/18 revealed goals and interventions for pressure ulcer prevention and status. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had an intact cognition. The resident required extensive assistance of 2 persons for transfer, bathing and incontinence care. The resident had one unstageable pressure ulcer on the side of the right heel. A review of the resident ' s physician progress notes [REDACTED]. A review of the physician order [REDACTED]. A review of the resident ' s (MONTH) (YEAR) treatment administration record (TAR) for dressing change of the right heel pressure ulcer revealed there was no documentation for wound care dates 10/6-8, 10/13-14, 10/17-18, 10/20-21, and 10/27-28. A review of the resident ' s wound culture lab dated 11/2/18 revealed an infection of [MEDICAL CONDITION] (MRSA) of the side of right heel. A review of the residents (MONTH) (YEAR) TAR for dressing change of the right heel pressure ulcer revealed there was no documentation for wound care dates 11/15-16, 11/23-25, and 11/20. A review of the resident ' s physician progress notes [REDACTED]. There was an order for [REDACTED].>A review of the resident ' s physician progress notes [REDACTED]. The resident was his own responsible party. A review of the physician ' s progress note dated 11/27/18 revealed the resident was treated for [REDACTED]. The resident finished his antibiotic medication and contact precautions were no longer needed (healed). A review of the resident ' s (MONTH) (YEAR) TAR for dressing change of the right heel pressure ulcer revealed there was no documentation for wound care dates 12/1-2, 12/5, 12/7, 12/15-17, 12/21-23, 12/25, and 12/28-31. physician progress notes [REDACTED]. The resident was followed by wound care (Foot and Ankle Center outside the facility) for the side of the right heel pressure ulcer. On 1/7/19 at 10:45 am an interview was conducted with the resident who stated his right heel wound dressing was not always changed every day. On 1/8/19 at 1:57 pm an interview was conducted with Nurse #9 who stated that the resident had a pressure ulcer to right side of heel that was present on admission and the dressing change was completed by the treatment nurse. On 1/8/19 at 3:00 pm an observation was done of the resident ' s right heel pressure ulcer wound care by the treatment nurse (TN). The dressing of the right heel was dated 1/4/18 and was soaked through with yellow purulent drainage and the wound was macerated (wet, white, and peeling) around the edges. A review of the (MONTH) 2019 TAR for dressing change of the right heel pressure ulcer revealed the dressing was documented as being done on 1/1, 1/4 and 1/8. On 1/8/19 at 10:25 am an interview was conducted with the TN who stated that she was responsible for all resident treatments but was frequently being re-assigned to nursing assistant due to staff shortage. The TN stated when she was not in the role of treatment nurse the assigned floor nurse was responsible to provide wound care for their residents. The TN stated that she had been reassigned for the past four months and residents had not received their daily wound care. On 1/8/19 at 3:10 pm an interview was conducted with the treatment nurse (TN) who stated the resident ' s right heel pressure ulcer dressing had the date she placed on the gauze from last week, dated 1/4/18. The TN stated she referred back to the treatment administration record (TAR) and was the last nurse to document/change the resident's right heel dressing on 1/4/18. The TN commented that if the TAR was not signed/documented the dressing was not changed which included this resident ' s care back to (MONTH) (YEAR). 1/8/19 at 10:30 am an interview was conducted with the Administrator who stated that there had been several staff resignations as well as terminations. To temporarily resolve the nursing assistance shortage, licensed nurses have been assigned to the nursing assistant role since (MONTH) of (YEAR). On 1/8/19 at 1:57 pm an interview was conducted with Nurse #9 who stated that the resident had a pressure ulcer to his right heel that was present on admission and the dressing change was completed by the treatment nurse. Nurse #9 also stated that she was not responsible to change the dressing. Nurse #9 stated that she was assigned to the resident on 1/7-9/19, she had not changed the resident ' s right heel dressing and later learned that the resident had not received his dressing change by the treatment nurse. If there was no documentation in the resident ' s record the wound care was not done which included prior months back to his admission of 10/1/18. On 1/8/19 at 2:21 pm an interview was conducted with the TN who stated the resident acquired an infection of the right heel pressure ulcer. Not changing the resident ' s pressure ulcer dressing placed him at risk for an infection. The treatment nurse stated that the right heel wound had worsened by becoming larger with increased drainage and the drainage that was scant serous was now moderate creamy yellow. The TN further commented that the family took the resident to a podiatrist for the right heel wound because they were aware the dressing was not being changed by the date on the dressing and by what the resident stated. On the weeks the resident saw the podiatrist the wound care Nurse Practitioner could not treat the resident. The resident ' s wound was not followed by the facility because there was no weekly measurement done at the facility nor did the facility obtain the podiatry notes, the resident ' s dressing was not changed, and when the wound had gotten larger with increased drainage the facility ' s medical nurse practitioner or wound care nurse practitioner had not assessed the wound. On 1/8/19 at 3:30 pm an interview was conducted with the Director of Nursing (DON) who stated that she expected staff to complete all treatments as ordered. On 1/10/19 at 9:00 am an interview was conducted with the wound care Nurse Practitioner who stated she rounded on the residents for wound assessment each week with the facility's treatment nurse. Due to staff shortage, the TN was not available to assist each week to measure the wounds and Resident #36 was being seen periodically by the podiatrist. The wound care Nurse Practitioner stated she observed Resident #36 ' s right heel pressure ulcer during nursing wound care today and assessed that the wound was larger and had increased drainage than last month (she had not measured the wound) but was not infected. She was aware that the resident had acquired [MEDICAL CONDITION] infection of the right heel wound last month but was not aware that the dressing was not changed as ordered until now. The failure to change the dressing placed the resident at high-risk to acquire a wound infection and would have contributed to his [MEDICAL CONDITION] infection.[MEDICAL CONDITION] was in the environment and a wound that was not cared for by dressing change was high-risk cause [MEDICAL CONDITION] to infect an open wound with accumulating wound drainage in the dressing. The wound care Nurse Practitioner went on to state that she asked the DON for the resident ' s podiatry notes and they were not provided to her nor available in the resident ' s medical record. She also stated that she was aware of the nursing staff shortage, made aware that wound care and measurements were not completed, and had brought her concerns to the DON in the past couple of months. The wound care Nurse Practitioner stated that she could not evaluate, treat and measure the resident ' s wound on a regular basis because he was being seen outside the facility by a podiatrist (duplication of services). On 1/10/19 at 9:30 am an interview was conducted with the facility medical Nurse Practitioner who stated that the resident ' s right heel pressure ulcer wound was macerated around the edges and changed the wound care order due to the failure to change the dressing and wound status change and decline. The facility Nurse Practitioner stated she had not usually followed the right heel pressure ulcer wound because he was seen by an outside podiatrist and it was considered a duplication of services. On 1/10/19 at 2:00 pm an interview was conducted with the DON who stated there were no podiatry notes in the facility record for the resident. The DON stated she would attempt to obtain a copy from the podiatry office. On 1/10/19 at 10:10 am an interview was conducted with the TN who stated she was informed by the DON that she would be assigned as NA for 1/7, 1/8, and 1/9 and would not be responsible for facility treatments. The facility treatments would be assigned to the nurse on each hall responsible for their residents that required a treatment which included all wounds. On 1/10/19 at 10:12 am an interview was conducted with the DON with Nurse #7 and TN present. DON stated that she was aware that treatments were not completed for Resident #36 on 1/7, 1/8, and 1/9 and expected the TN nurse to complete the treatments on all the facility residents in the afternoon after her NA day shift duties. On 1/9/18 the DON allowed the TN to accompany the surveyor to observe resident ' s right heel dressing change. The DON stated she was made aware that the dressing was dated 1/4/19 and that the dressing had not been changed for 4 days. The TN nurse stated that she was not aware that she was responsible to complete treatments including wound care after her NA day shift on the three days. Nurse #7 stated that she was not responsible for treatments and had not completed the resident ' s wound care on 1/7, 1/8, and 1/9. The DON stated she agreed there was a breakdown in communication as to who was responsible to complete the resident's treatments. The DON also stated that the resident was seen by an outside podiatrist and would obtain the records. At the end of the survey on 1/10/19 at 5:00 pm there were no podiatry records for the resident provided by the facility. The Administrator and DON were notified of the Immediate Jeopardy on 3/4/19 at 1:00 pm. On 3/5/19 the facility provided the following credible allegation of Immediate Jeopardy removal: The center Executive Director alleges abatement of immediate jeopardy on 03/05/19. 1. The corrective action for the alleged deficient practice was accomplished by: On 1/8/2019 resident #36 had wound care provided by a licensed nurse. Resident #36 had a pressure reducing mattress and pad on bed and wheelchair 10/1/18. Resident #36 ' s heels were floated, and he was provided an off loading boot for therapy 10/11/18. Wound care was provided to Resident #36 ' s heel daily starting 1/10/19 as ordered by the physician, and his wound was assessed weekly for signs of improvement by the licensed nurse starting 1/23/19. Resident #36 was followed by his physician starting on admission to facility on 10/1/2018, and his care plan was updated on 1/29/19 by the MDS nurse. Resident #36 ' s wound resolved on 2/8/2019 and he was discharged [DATE]. Daily wound care was provided starting 1/10/19 following doctor ' s orders. Corporate Human Resources and Regional staff worked with the Interim Executive Director to implement staff recruitment practices to ensure the center was appropriately staffed (center achieved appropriate staffing on 02/08/19). On 01/22/19 a root cause analysis was completed by the Regional Vice President of Operations, Regional Director of Clinical Services, the Director of Nursing and the Divisional Executive Director (acting administrator) and determined that the Executive Director failed to provide consistent staffing to ensure treatments were completed as ordered. Residents with the potential to be affected by alleged deficient practice: On 2/15/2019 the Director of Nursing completed a quality review of all current resident treatment sheets, compared them to the treatment orders and observed treatments to ensure that residents were provided wound care as ordered. There are three current residents with pressure sores. Current residents with wounds are followed by wound physician associated with the medical director ' s practice or a Vascular Surgeon. Residents with wound care had their care plans reviewed on 2/27/19-2/28/19 to ensure that the facility addressed the pressure sores comprehensively to prevent worsening and promote healing of the pressure sores. Residents with pressure ulcers had their care plans reviewed on 2/28/19 by the divisional MDS nurse. Resident ' s wounds are observed weekly starting 1/23/19 and measured by the treatment nurse. The facility ' s treatment nurse coordinates outside services as needed and/or as ordered with collaboration with the physician. Current residents with wounds are followed by the wound physician associated with the Medical Directors practice, or a Vascular Surgeon. The physician notes are sent to the facility via secure server email for the Director of Nursing ' s review and then they are filed in the medical record. On 2/15/19 the Director of Nursing began observing treatments on 3 pressure wounds and 2 non-pressure related wounds (3 residents per day, 3 days per week) 2. Systemic Changes: The Director of Nursing and or Consulate Healthcare Executive Director and Director of Nursing provided re-education to facility licensed staff, including all shifts, part-time and prn, on providing treatments as ordered by the physician and recording the treatment on a TAR by 2/8/2019. The Divisional Quality Educator provided education to the Director of Nursing and Treatment Nurse on treatment procedures beginning on 02/28/19 and on an on-going basis. The Divisional Quality Educator provided additional one on one training and completed a clean dressing change competency evaluation with the Treatment Nurse on 02/28/19. Licensed nurses were reeducated by the DON and Regional Director of Clinical Services on assessing status of wounds on a weekly basis and with treatments and providing wound care to improve wounds and promote healing by 3/3/2019. Licensed nurses notify the physician if there is a change to a wound, in collaboration with the physician a referral may be made to the wound doctor. Certified Nurse Assistants will be reeducated on reporting changes in resident skin integrity, preventative measures for preventing wounds, following care plan related to devices and relieving pressure by Director of Nursing, Regional Director of Clinical Services and Divisional Executive Director by 3/3/19. Staff will not be allowed to return to work until education complete. New hires will be provided the same training on hire prior to getting an assignment. The facility employees a full-time treatment nurse. If the treatment nurse is unavailable it will be communicated to the licensed nurses by the Director of Nursing to provide treatments as ordered by the physician. Licensed staff have the capacity to complete their assignments, including treatments within the parameters of their work schedule. If the licensed nurse cannot complete the treatment within the parameter of their work schedule, the licensed nurse will report the issue to the Director of Nursing. The Director of Nursing will grant overtime to the licensed nurse to complete the task, delegate the responsibility to another nurse or assist with the task. The Director of Nursing and/or Minimum Data Set Nurse will complete the assessment and measurements if the treatment nurse is unavailable. The Director of Nursing will observe licensed nurses providing treatments, 3 times per week, to ensure competency and documentation are completed. The Director of Nursing will provide additional education on clean dressing and competency skills checklist beginning on 03/01/19. Licensed staff will not return to work until education is completed. Corporate Human Resources and Regional staff worked with the Interim Executive Director to implement staff recruitment practices to ensure the center was appropriately staffed (center achieved appropriate staffing on 02/08/19). The Divisional Quality Educator provided education to the Director of Nursing and Treatment Nurse in regard to treatment procedures beginning on 02/28/19 and on an on-going basis. The Divisional Quality Educator provided additional one on one training and completed a competency evaluation with the Treatment Nurse on 02/28/19. The Regional Vice President of Operations and the Regional Director of Clinical will monitor staffing levels to ensure adequate staffing is maintained. On 2/7/19 the Regional Vice President of Operations and Regional Director of Clinical Services began monitoring daily staffing of direct care per resident per day using morning meeting and internal labor portal. If a staffing challenge presents itself and the treatment nurse is put on a cart, the Director of Clinical Services will complete that day ' s treatments that are ordered. Regional Director of Clinical Services and or Director of Nursing will conduct quality monitoring (audit) including observation of resident treatments and documentation for 3 residents (rotating residents), 3 times per week for 4 weeks, then weekly for 3 months. The Director of Nursing will report on the results of the quality monitoring (audit) and report to the QAPI committee. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated as indicated. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting by the Director of Nursing for review of ongoing wound care monthly. The Executive Director will provide data on staffing to the QAPI committee for review of any staffing challenges. Quality Improvement monitoring schedule will be modified based on findings of monitoring. The center Executive Director conveyed an ADH[NAME] Quality Assurance Performance Improvement meeting 02/22/19, including the Interim Executive Director, Director of Nursing, the SDC, Director of Rehab, MDS Nurse, Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records, Central Supply Clerk, Admissions Director, Dietary Manager, Activity Director and the Environmental Services Director regarding the plan of removal of immediacy. The Medical Director was made aware of the of immediacy plan via telephone with the Executive Director and the Director of Nursing on 3/1/19. The credible allegation of Immediate Jeopardy removal was validated on 3/6/19 at 12:30 PM which included: The 2/15/19 facility audit was reviewed and confirmed 3 current residents with wounds were being followed by the wound physician associated with the medical director ' s practice or a Vascular Surgeon. Progress notes were documented in each resident ' s medical record. Care plans were reviewed and had been updated for each resident. Documentation revealed there were weekly observations, measurements beginning 1/23/19 for each resident, and wound care was completed as ordered. Education regarding the responsibility for wound care treatments in-service documentation was reviewed and sign in sheets for nursing was provided. A review of Resident #36 ' s discharge from the facility to home dated 2/20/19 revealed he was discharged to home with family, was scheduled to follow up with his physician, home care services were started, and medical supply was contacted. The first visit scheduled was for 2/25/19. A review of Resident #36 ' s treatment administration record for (MONTH) and (MONTH) 2019 revealed documentation that he received his daily wound care since the last survey. The resident was discharged to home and not available for observation and interview. On 3/6/19 at 11:55 am an interview was conducted with the Director of Clinical Services/Director of Nursing (DON) who stated that Resident #36 ' s right heel wound was healed on 1/30/19, and he received a preventative dressing to prevent further pressure. The resident was discharged to home with family and home care services. To ensure wound care was completed daily the treatment nurse was dedicated to wound care and if unavailable the assigned staff nurse was required to complete the wound care, and if unable the assigned staff nurse was to inform the DON to complete care or reassign. On 3/6/19 at 2:30 pm an interview was conducted with the Treatment Nurse (TN) who stated she was required to participate in recent education regarding abuse, neglect, and exploitation and how a failure to provide care was related. The TN stated that if she was unavailable to complete any care she was to inform the DON and the assigned staff nurse would be assigned and the scheduler notified. Nurses also received education on how to complete the treatments, wound measurement, and communication of new wounds. There has not been floating of nurses to the nursing assistant role. The care and timeliness to provide care for the residents has improved now that there is enough staff. Wounds are now healing because treatments are done as ordered. On 3/6/19 at 4:30 pm interviews of 5 random staff members were conducted which revealed that several newly employed nursing assistants had started over the past 2 months and the facility was fully staffed. The rate of grievances filed by residents and/or their family had dropped by half. The last resident council meeting in (MONTH) 2019 identified that call lights and incontinence care were addressed timely to the satisfaction of the residents. All interviewed staff stated that they recently received training for abuse, neglect, exploitation and how not providing care (including wound care) to meet the resident ' s needs is related to neglect. On 3/6/19 at 5:30 pm an interview was conducted with the Corporate Vice President of Operations who stated he conferenced with the Divisional Human Resources Director and implemented staffing plans including wage increases and recruitment and retention plans to ensure sufficient staffing. On 2/7/19 sufficient staff had been hired and received orientation prior to accepting an assignment. Daily staffing meetings have occurred to ensure sufficient staffing patterns. 2. Resident #1 was admitted to the facility 10/3/18 with cumulative [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed that the Cognitive Pattern assessment (Section C) and the Mood (Section D) assessment was not completed. She was coded total staff assistance with bed mobility, toileting and personal hygiene. Resident #1 was coded as non-ambulatory and incontinent of bladder and bowel. She was coded for one stage 2 pressure ulcer and one Suspected Deep Tissue Injury (SDTI) both present on admission. Interventions included a pressure reducing mattress to her bed and pressure ulcer care. Resident #1 was coded for a prognosis of less than 6 months and for Hospice Services. Review of Resident #1's Care Area assessment dated [DATE] for pressure ulcers read she was a Hospice resident and she was admitted with a SDTI and she was dependent of the staff for her activities of daily living. Review of Resident #1's skin/wound care plan dated initiated 10/17/18 read she had a SDTI to her left heel on 10/17/18. The goal was for Resident #1's wound was to show signs of healing. Interventions included the facility was to provide treatments as ordered. Review of a Hospice nursing note dated 10/8/18 read Resident #1 had a blister to her left heel measuring approximately 10 centimeter (cm). New orders were written to apply Skin Prep to the blister daily and float her heels. Review of a Hospice note dated 10/11/18 read no changes in Resident #1's left heel blister. Review of an as needed (PRN) Hospice note read Resident #1 was seen on 10/12/18 because her left heel blister had ruptured. There were new orders dated 10/12/18 which read her left heel was to be cleansed with Normal Saline (NS), the area patted dry and the application of [MEDICATION NAME] (two-sided wound contact layer dressing), cover with area with padding and wrap with a gauze dressing. The dressing was ordered to be changed every Monday and Thursday by the Hospice nurse. Review of the Hospice notes from 10/12/18 through 10/22/18 revealed the Hospice Nurse provided Resident #1's left heel wound care every Monday and Thursday as ordered. Review of a Hospice note dated 10/22/18 read Resident #1's left heel [MEDICATION NAME] dressing was hanging off her heel but not on the wound. New orders were written to clean her left heel wound with NS, pat dry then apply a Vaseline gauze, cover with a non-adherent dressing, pad the heel and secure with a gauze wrap. The dressing change was to be done every Monday and Thursday and the Hospice Nurse would be completing Resident #1's wound care. Review of the Hospice notes from 10/22/18 through 10/31/18 revealed the Hospice Nurse provided Resident #1's left heel wound care every Monday and Thursday as ordered. Review of the weekly Skin Evaluation Report dated 10/12/18, read her Resident #1 an open area to her left heel. Review of a Hospice note dated 10/31/18 read there was new orders for paint Resident #1's left heel wound with [MEDICATION NAME], cover the wound with a nonadherent dressing and wrap with a gauze dressing daily. The note indicated the new wound care orders were discussed with the Treatment Nurse at the facility. Review of the facility (MONTH) (YEAR) Treatment Administration Record (TAR) revealed no documented evidence of Resident #1's daily treatment to her left heel on 11/2/18, 11/3/18,11/4/18, 11/10/18, 11/13/18, 11/16/18, 11/21/18, 11/22/18 11/24/18 and 11/26/18. There was no evidence of a facility weekly Skin Evaluation Report for the week of 11/09/18, the week of 11/16/18, 11/23/18, 12/7/18 and 12/26/18. Review of the facility (MONTH) (YEAR) TAR revealed no documented evidence of Resident #1's daily treatment to her left heel on 12/2/18, 12/7/18, 12/11/18 12/19/18, 12/25/18, 12/28/18 and 12/29/18. Review of Resident #1's skin/wound care plan dated revised 1/3/19 read her area to the left heel was described as unstageable. The goal was for Resident #1's wound was to show signs of healing. Interventions included the facility was to provide treatments as ordered Review of the facility (MONTH) 2019 TAR revealed no documented evidence of Resident #1's daily treatment to her left heel on 1/1/19, 1/2/19, 1/4/19 and 1/8/19. During an interview on 1/8/19 at 10:14 AM, the Treatment Nurse stated that she had been the Treatment Nurse at the facility since (MONTH) (YEAR). She revealed that prior to sometime around (MONTH) of (MONTH) (YEAR), the facility began having difficulty obtaining and maintaining Nursing Assistants (NA). She further explained at that time due to the lack of NAs on staff, she was normally assigned as an NA and the floor nurses were supposed to complete the treatments. Review of a Nurse Practitioner (NP) note dated 1/10/19 read Resident #1 was seen for wound follow up to her left heel. The NP assessed Resident #1's left heel pressure ulcer was described as unstageable with 90% eschar with 10% granulation, no odor with a small amount of serous drainage. New orders were given for Thera-honey (dressing impregnated with medical grade honey) daily to any granulated areas and continue to apply [MEDICATION NAME] daily to the dark eschar. During another interview on 1/10/19 at 8:40 AM, the Treatment Nurse revealed she had concerns that treatments were not being provided as ordered to Resident #1 by the floor nurses for over a month. Review of the facility Weekly Wound Report revealed Resident #1 did not appear on the report for pressure ulcers until the week of 1/23/19. Review of Resident #1's skin/wound care plan dated revised 1/30/19 read her left heel wound was described as a stage 3 pressure ulcer. The goal was for Resident #1's wound was to show signs of healing. Interventions included the facility was to provide treatments as ordered. During a wound care observation on 3/6/19 at 10:00 AM, the Treatment Nurse provided Resident #1' pressure ulcer treatment to her left heel. There were no observed concerns with her technique or infection control. Resident #1's left heel appeared pale pink in color with white wound edges. There was no odor and evidence of bloody drainage after cleaning the wound with NS. The area was padded dry and Santyl was applied to the wound bed which measured approximately 3 cm by 2 cm by 0.5 cm. The area was covered with a nonadherent dressing and wrapped with gauze. Resident #1's voiced no pain. She was lying on a properly functioning air mattress and her heels were floated above the mattress surface. During an interview on 3/6/19 at 12:20 PM, the Administrator stated he assumed the role of Administrator of the facility shortly after the recertification survey exit date of 1/10/19. He stated it was at that time he became aware of the residents not receiving all their ordered treatments due to issues with staffing. He stated it was his expectation that all the residents with pressure ulcers receive their treatments as ordered. During an interview on 3/6/19 at 1:38 PM, the Director of Nursing (DON) validated she worked with Resident #1 on 11/3/18 and 12/7/18 where there was no documented evidence of pressure ulcer care to Resident #1's left heel. She stated she was unable to recall if she did treatments on 11/3/18 and 12/7/18 but if she didn't document, she likely didn't do. The DON stated if she did not complete Resident #1's treatments on 11/3/18 and 12/7/18 it would have been because she didn't have time to do it due to li (TRUNCATED)

Based on record review, observations, staff interview, resident and family interview, and wound care Nurse Practitioner interview, the facility's Administrator failed to provide oversight of processes and policies and effective leadership to ensure residents were free from neglect as evidenced by not providing wound care for 3 of 4 residents with wounds (Resident # 1, #36, and #44); not providing catheter care for 1 of 1 residents reviewed (Resident #44); and by not answering a call light related to a request for incontinence care for 1 of 1 resident reviewed (Resident #49). The facility's administrator also failed to provide sufficient nursing staff to honor resident preferences, treat residents with dignity and respect, resolve individual and resident council grievances, and ensure Nursing Assistant involvement in the development of the comprehensive care plan. This affected 14 of 24 sampled residents (Residents #1, #30, #32, #36, #44, #47, #49, #50, and 6 members of the resident council). The repeated failure to provide sufficient staffing for pressure ulcer care to Resident #36 resulted in his pressure ulcer worsening and the development [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus) infection. Immediate Jeopardy began on 11/6/18 when due to insufficient staffing and failed oversight, staff neglected to provide pressure ulcer care resulting in increase in size and infection of Resident #36's wound. Immediate Jeopardy was removed on 3/6/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of G (actual harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Findings included: This tag is cross referenced to: 1a. Tag F-600: Based on record review, observations, staff interview, resident interview, family interview, wound care Nurse Practitioner interview, Nurse Practitioner interview, and Department of Social Services interview, the facility neglected to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation, and communication with the outside podiatrist who was also treating resulting in a worsening pressure ulcer and infection (Resident #36); neglected to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation (Resident #1); and neglected to provide daily pressure ulcer wound care as ordered and weekly wound measurement/assessment and documentation (Resident #44) for 3 of 4 residents reviewed; the facility neglected to provide catheter care (Resident #44) for 1 of 1 resident reviewed; and the facility also neglected to answer a call light related to a request for incontinence care (Resident #49) for 1 of 1 resident reviewed. b. Tag F-686: Based on record review, observations, staff interview, resident and family interview, wound care Nurse Practitioner interview, and Nurse Practitioner interview, the facility failed to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation, and communication with the outside podiatrist who was also treating resulting in a worsening pressure ulcer and infection (Resident #36); failed to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation (Resident #1); and failed to provide daily pressure ulcer wound care as ordered and weekly wound measurement/assessment and documentation (Resident #44) for 3 of 4 sampled residents reviewed for wound care. c. Tag F-725: Based on observation, record review, and interviews with resident, family, staff, Department of Social Services, and Nurse Practitioners, the facility failed to provide sufficient nursing staff to ensure residents received pressure ulcer wound care, urinary catheter care, assistance with Activities of Daily Living (ADLs), and respond to call bells. The facility also failed to provide sufficient nursing staff to honor resident preferences, treat residents with dignity and respect, resolve individual and resident council grievances, and ensure Nursing Assistant involvement in the development of the comprehensive care plan. This affected 13 of 24 sampled residents (Residents #1, #30, #32, #36, #44, #49, #50, and 6 members of the resident council). The repeated failure to provide sufficient staffing for pressure ulcer care to Resident #36 resulted in his pressure ulcer worsening and the development [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus) infection. The Administrator and DON were notified of the Immediate Jeopardy on 3/6/19 11:29 am. On 3/6/19 the facility provided the following credible allegation of Immediate Jeopardy removal: The center Executive Director alleges abatement of immediate jeopardy on 03/06/19. Deficient Practice The facility Administrator failed to provide oversight of processes and policies and effective leadership to ensure residents were free from neglect, received pressure ulcer care as ordered and maintained sufficient nursing staffing to provide necessary care and services. A Root Cause Analysis of 01/22/19 was completed by the Divisional Executive Director, Regional Vice President of Operations, Regional Director of Clinical Services, Regional Director of Human Resources and the Senior Vice President of Human Resources. The preliminary investigative information to determine root cause was the center wage scale and a competitive wage analysis. The competitive wage analysis revealed that the center needed to increase the lower end of the wage scale for new hires as compared to other centers in the market. 1. The corrective action for the alleged deficient practice was accomplished by: On 1/18/19 effective leadership (an interim administrator Divisional Executive Director) was installed by Regional Vice President of Operations to ensure proper Administration of the center including the oversight of processes and policies and to ensure resident were free from neglect, received pressure ulcer care as ordered and maintained sufficient nursing staffing to provide necessary care and service for all residents of the center. Corporate Human Resources and Regional staff worked with the Interim Executive Director to implement staff recruitment practices to ensure the center was appropriately staffed (center achieved appropriate staffing on 02/07/19). The Divisional Executive Director, Regional Vice President of Operations, Regional Director of Clinical Services, Regional Director of Human Resources and the Senior Vice President of Human Resources conferred on 01/22/19 to discuss Root Cause Analysis and develop an action plan. The action plan included the following: · Recruit, with incentives, Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN) and Registered Nurse (RN) staff from sister center in Triad market, · Referral Bonus for existing staff with immediate pay out, · Recruit and hire Personal Care Assistants, · Retrain staff scheduler and ensure schedule is accurate, · Sign on bonus for CNA position, and · That sufficient staff is provided to ensure that pressure sores care and treatment is done per physician orders [REDACTED]. On 01/22/19 a root cause analysis was completed by the Regional Vice President of Operations, Regional Director of Clinical Services, the Director of Nursing and the Divisional Executive Director (acting administrator) and determined that the former Executive Director failed to provide consistent staffing to ensure treatments were completed as ordered, and failed to provide oversight to make sure that care and services were delivered per physician order. By 02/07/19 sufficient staff was provided to ensure residents receiving pressure ulcer treatment. 2. Residents with the potential to be affected by alleged deficient practice: On 01/22/2019 the Executive Director, Regional Vice President of Operations, Divisional Human Resources conferenced and implemented staffing plans including wage increases, recruitment and retention plans to ensure sufficient staffing. On 02/07/19 sufficient staff were hired and have completed orientation. The Executive Director will provide oversight of the delivery of care and services of wounds to prevent neglect through daily routine rounds, daily communication with Director of Nursing and daily review of staffing levels. 3. Systemic Changes: On 01/18/19 the Regional Vice President of Operations and the Regional Director of Human Resources began recruiting and interviewing qualified Administrators to fill the Executive Director position at the center. The Executive Director worked with the facility and corporate Human Resources staff to fulfill staffing needs through appropriate recruitment and retention programs. The facility achieved sufficient staffing on 02/07/19. The Director of Nursing will monitor daily staffing levels at morning and evening meetings, review of open positions and validation of staffing levels daily to ensure wound care will be completed. If the treatment nurse is unavailable it will be communicated to the licensed nurses by the Director of Nursing to provide treatments as ordered by the physician. Licensed staff have the capacity to complete their assignments, including treatments within the parameters of their work schedule. If the licensed nurse cannot complete the treatment within the parameter of their work schedule, the licensed nurse will report the issue to the Director of Nursing. The Director of Nursing will grant overtime to the licensed nurse to complete the task, delegate the responsibility to another nurse or assist with the task. The Director of Nursing and/or Minimum Data Set Nurse will complete the assessment and measurements if the treatment nurse is unavailable and report to the Executive Director. Executive Director will monitor staff openings, scheduling of staff and delivery of care through review of daily staffing levels at morning and evening meetings, review of open positions with scheduler and validation of staffing levels daily through rounds and staff interviews. Executive Director will monitor staffing and the delivery of wound care 5 times a week then 3 times a week for 4 weeks then 1 time a week for 8 weeks to ensure all resources are utilized. The Executive Director and Director of Nursing will report on the results of the quality monitoring (audit) and report to the QAPI committee. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated as indicated. The Regional Vice President of Operations and the Regional Director of Clinical Services will monitor staffing levels and the delivery of wound care through internal portal, communication with Executive Director/Director of Nursing and weekly visits to ensure adequate staffing is maintained. The center Executive Director conveyed an ADH[NAME] Quality Assurance Performance Improvement meeting 03/06/19, including the Interim Executive Director, Director of Nursing, Director of Rehab, MDS Nurse, Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records, Central Supply Clerk, Admissions Director, Dietary Manager, Activity Director, the Environmental Services Director, the Regional Vice President of Operations and Regional Director of Clinical Services regarding the plan of removal of immediacy. The Medical Director was made aware of the of immediacy plan via telephone with the Executive Director and the Director of Nursing on 3/6/19. The credible allegation of Immediate Jeopardy removal was validated on 3/6/19 at 5:30 PM which included: Human resources record review indicated there were 17 new employees documented as starting employment as nursing assistant and licensed nurse between 1/12/19 and 2/27/19. On 3/6/19 at 4:30 pm interviews of 5 random staff members were conducted which revealed that several newly employed nursing assistants had started over the past 2 months and the facility was fully staffed. The rate of grievances filed by residents and/or their family had dropped by half. The last resident council meeting held (MONTH) 2019 identified that call lights and incontinence care were addressed timely to the satisfaction of the residents. On 3/6/19 at 5:10 pm an interview was conducted with the Corporate Vice President of Operations who stated he conferenced with the Divisional Human Resources Director and implemented staffing plans including wage increases and recruitment and retention plans to ensure sufficient staffing. On 2/7/19 sufficient staff had been hired and had received orientation prior to accepting an assignment. Daily staffing meetings have occurred to ensure sufficient staffing patterns. The Corporate Vice President further commented that he was not aware of staffing to the significance level it had reached. He had communication from the facility Administrator who discussed recruitment of nursing assistants and that current nursing staff were covering shifts but not that care was not completed. The nursing assistant wage scale was higher for experience and the Administrator was informed to offer the higher wage scale to all staff. The Administrator did not follow the direction well. There was a lack of oversight and understanding the urgency. The Administrator was new in training under the direction of a seasoned Administrator. Feedback provided during training indicated that the Administrator was doing well. Corporate staff visits were made to the facility and the Administrator did not follow directions and things fell apart quickly. Staffing was tied in to every citation on the annual survey. The Administrator did not communicate to facility Human Resources that the salary scale offered to nursing assistants was higher. The Administrator was unable to state why staffing deteriorated and was not adequately addressed. There is now a heightened oversite in the process of staffing.

Based on record review, observations, staff interview, resident interview, family interview, wound care Nurse Practitioner interview, Nurse Practitioner interview, and Department of Social Services interview, the facility neglected to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation, and communication with the outside podiatrist who was also treating, resulting in worsening, increase in size and infection of the pressure ulcer (Resident #36); neglected to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation (Resident #1); and neglected to provide daily pressure ulcer wound care as ordered and weekly wound measurement/assessment and documentation (Resident #44) for 3 of 4 residents reviewed; the facility neglected to provide catheter care (Resident #44) for 1 of 1 resident reviewed; and the facility also neglected to answer a call light related to a request for incontinence care (Resident #49) for 1 of 1 resident reviewed. Immediate Jeopardy began on 11/6/18 when staff neglected to provide pressure ulcer care with resulting infection for Resident #36. Immediate Jeopardy was removed on 3/6/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level to ensure monitoring of systems are put in place and to complete employee in-service training. The facility was cited at a scope and severity of G (an isolated deficiency of actual harm that is not Immediate Jeopardy) for Example #3 (Resident #49). The facility was also cited at a scope and severity of E (a deficiency that constitutes a pattern of no actual harm with a potential for minimal harm that is not Immediate Jeopardy) for Example #2 (Resident #1) and Example #4 (Resident #44). Findings included: 1. Resident #36 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of the resident ' s care plan dated 10/1/18 revealed goals and interventions for pressure ulcer prevention and status. A review of the physician order [REDACTED]. A review of the resident ' s physician progress notes [REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had an intact cognition. The resident required extensive assistance of 2 persons for transfer, bathing and incontinence care. The resident had one unstageable pressure ulcer on the side of the right heel. A review of the resident ' s (MONTH) (YEAR) treatment administration record (TAR) for dressing change of the right heel pressure ulcer revealed there was no documentation for wound care on 10/6-8, 10/13-14, 10/17-18, 10/20-21, and 10/27-28. A review of the resident ' s (MONTH) (YEAR) TAR for dressing change of the right heel pressure ulcer revealed there was no documentation for wound care on 11/15-16, 11/23-25, and 11/20. A review of the resident ' s wound culture lab results dated 11/2/18 revealed an infection of [MEDICAL CONDITION] (MRSA) of the side of right heel. A review of the resident ' s physician progress notes [REDACTED]. There was an order for [REDACTED]. A review of the resident ' s physician progress notes [REDACTED]. The resident was his own responsible party. A review of the physician ' s progress note dated 11/27/18 revealed the resident was treated for [REDACTED]. The resident finished his antibiotic (11/8/18) medication and contact precautions were no longer needed (healed). A review of the resident ' s (MONTH) (YEAR) TAR for dressing change of the right heel pressure ulcer revealed there was no documentation for wound care on 12/1-2, 12/5, 12/7, 12/15-17, 12/21-23, 12/25, and 12/28-31. physician progress notes [REDACTED]. The resident was followed by wound care (Foot and Ankle Center outside the facility) for the side of the right heel pressure ulcer. On 1/7/19 at 10:45 am an interview was conducted with the resident who stated his right heel wound dressing was not always changed every day. On 1/7/19 at 2:00 pm an interview was conducted with the resident ' s family member who stated the right foot wound dressing was not being changed each day as ordered and that she had taken the resident to the podiatrist to follow up. The family member commented that the resident informed her the dressing was not always being changed and the family member looked at the date on the dressing and could see the date had passed by a couple of days. On 1/8/19 at 3:00 pm an observation was done of the resident ' s right heel pressure ulcer wound care provided by the treatment nurse (TN). The dressing of the right heel was dated 1/4/19 and was soaked through with yellow purulent drainage and the wound was macerated (wet, white, and peeling) around the edges. A review of the (MONTH) 2019 TAR for dressing change of the right heel pressure ulcer revealed the dressing was documented as being done on 1/1, 1/4 and 1/8. On 1/8/19 at 10:25 am an interview was conducted with the TN who stated that she was responsible for all resident treatments but was frequently being re-assigned to work as a nursing assistant due to staff shortage. The TN stated when she was not in the role of treatment nurse the assigned floor nurse was responsible to provide wound care for their residents. The treatment nurse stated that she was responsible to measure all the resident's wounds once a week and when she was assigned as a nursing assistant the wounds were not measured or reassigned. The treatment nurse stated she assisted the wound care Nurse Practitioner once a week during weekly rounds except when she was assigned as a nursing assistant. 1/8/19 at 10:30 am an interview was conducted with the Administrator who stated that there had been several staff resignations as well as terminations. To temporarily resolve the nursing assistant shortage, licensed nurses have been assigned to the nursing assistant role. The staff informed the Administrator that they were exhausted. On 1/8/19 at 1:57 pm an interview was conducted with Nurse #9 who stated that the resident had a pressure ulcer to his right heel that was present on admission and the dressing change was completed by the treatment nurse. Nurse #9 also stated that she was not responsible to change the dressing. Nurse #9 stated that she was assigned to the resident on 1/7-9/19, she had not changed the resident ' s right heel dressing and later learned that the resident had not received his dressing change by the treatment nurse. If there was no documentation in the resident ' s record the wound care was not done. On 1/8/19 at 2:21 pm an interview was conducted with the TN who stated the resident acquired an infection of the right heel pressure ulcer during his stay at the facility. Not changing the resident ' s pressure ulcer dressing placed him at risk for an infection. The treatment nurse stated that the right heel wound had worsened after he completed his antibiotic and the dressing was not changed daily by becoming larger with increased drainage and the drainage that was scant serous was now moderate creamy yellow. The TN further commented that the family took the resident to a podiatrist for the right heel wound because they were aware the dressing was not being changed by the date on the dressing and by what the resident stated. On the weeks the resident saw the podiatrist the wound care Nurse Practitioner could not treat the resident. The resident ' s wound was not followed by the facility because there was no weekly measurement done at the facility nor did the facility obtain the podiatry notes, the resident ' s dressing was not changed, and when the wound had gotten larger with increased drainage the facility ' s medical nurse practitioner or wound care nurse practitioner had not assessed the wound. On 1/8/19 at 3:10 pm an interview was conducted with the treatment nurse (TN) who stated the resident ' s right heel pressure ulcer dressing had the date she placed on the gauze from last week, dated 1/4/19. The TN stated she referred back to the treatment administration record (TAR) and was the last nurse to document/change the resident's right heel dressing on 1/4/18. The TN commented that if the TAR was not signed/documented the dressing was not changed. The TN nurse stated that other than the nurse practitioner notes there were not facility documented wound measurements. On 1/8/19 at 3:30 pm an interview was conducted with the Director of Nursing (DON) who stated that she expected staff to complete all treatments as ordered. On 1/10/19 at 9:00 am an interview was conducted with the wound care Nurse Practitioner who stated she rounded on the residents for wound assessment each week with the facility's treatment nurse. Due to staff shortage, the TN was not available to assist each week to measure the wounds and Resident #36 was being seen periodically by the podiatrist. The wound care Nurse Practitioner stated she observed Resident #36 ' s right heel pressure ulcer during nursing wound care today and assessed that the wound was larger and had increased drainage than last month (she had not measured the wound) but was not infected. She was aware that the resident had acquired [MEDICAL CONDITION] infection of the right heel wound last month but was not aware that the dressing was not changed as ordered until now. The failure to change the dressing placed the resident at high-risk to acquire a wound infection and would have contributed to his [MEDICAL CONDITION] infection.[MEDICAL CONDITION] was in the environment and a wound that was not cared for by dressing change was high-risk cause [MEDICAL CONDITION] to infect an open wound with accumulating wound drainage in the dressing. The wound care Nurse Practitioner went on to state that she asked the DON for the resident ' s podiatry notes and they were not provided to her nor available in the resident ' s medical record. She also stated that she was aware of the nursing staff shortage, made aware that wound care and measurements were not completed, and had brought her concerns to the DON in the past couple of months. The wound care Nurse Practitioner stated that she could not evaluate, treat and measure the resident ' s wound on a regular basis because he was being seen outside the facility by a podiatrist (duplication of services). On 1/10/19 at 9:30 am an interview was conducted with the facility medical Nurse Practitioner who stated that the resident ' s right heel pressure ulcer wound was macerated around the edges and changed the wound care order due to the failure to change the dressing and wound status change and decline. The facility Nurse Practitioner stated she had not usually followed the right heel pressure ulcer wound because he was seen by an outside podiatrist and it was considered a duplication of services. On 1/10/19 at 2:00 pm an interview was conducted with the DON who stated there were no podiatry notes in the facility record for the resident. The DON stated she would attempt to obtain a copy from the podiatry office. On 1/10/19 at 10:10 am an interview was conducted with the TN who stated she was informed by the DON that she would be assigned as NA for 1/7, 1/8, and 1/9 and would not be responsible for facility treatments. The facility treatments would be assigned to the nurse on each hall responsible for their residents that required a treatment which included all wounds. On 1/10/19 at 10:12 am an interview was conducted with the DON with Nurse #7 and TN present. DON stated that she was aware that treatments were not completed for Resident #36 on 1/7, 1/8, and 1/9 and expected the TN nurse to complete the treatments on all the facility residents in the afternoon after her NA day shift duties. On 1/9/18 3:10 pm the DON and the TN to accompany the surveyor to observe resident ' s right heel dressing change. The DON stated she was made aware that the dressing was dated 1/4/19 and that the dressing had not been changed for 4 days. The TN nurse stated that she was not aware that she was responsible to complete treatments including wound care after her NA day shift on the three days. Nurse #7 stated that she was not responsible for treatments and had not completed the resident ' s wound care on 1/7, 1/8, and 1/9. The DON stated she agreed there was a breakdown in communication as to who was responsible to complete the resident's treatments. The DON also stated that the resident was seen by an outside podiatrist and would obtain the records. The Administrator and Director of Nursing were notified of Immediate Jeopardy on 3/4/19 at 1:00 pm. On 3/5/19 the facility provided the following credible allegation of Immediate Jeopardy removal: The center Executive Director alleges abatement of immediate jeopardy on 03/05/19. 1. The corrective action for the alleged deficient practice was accomplished by: On 1/8/2019 resident #36 had wound care provided by a licensed nurse. Resident #36 had a pressure reducing mattress and pad on bed and wheelchair 10/1/18. Resident #36 ' s heels were floated and he was provided an off loading boot for therapy 10/11/18. Wound care was provided to Resident #36 ' s heel daily starting 1/10/19 as ordered by the physician, and his wound was assessed weekly for signs of improvement by the licensed nurse starting 1/23/19. Resident #36 was followed by his physician starting on admission to facility on 10/1/2018, and his care plan was updated on 1/29/19 by the MDS nurse. Resident #36 ' s wound resolved on 2/8/2019 and he was discharged [DATE]. Daily wound care was provided starting 1/10/19 following physician's order [REDACTED]. Corporate Human Resources and Regional staff worked with the Interim Executive Director to implement staff recruitment practices to ensure the center was appropriately staffed (center achieved appropriate staffing on 02/08/19). On 01/22/19 a root cause analysis was completed by the Regional Vice President of Operations, Regional Director of Clinical Services, the Director of Nursing and the Divisional Executive Director (acting administrator) and determined that the Executive Director failed to provide consistent staffing to ensure treatments were completed as ordered. 2. Residents with the potential to be affected by alleged deficient practice: On 2/15/2019 the Director of Nursing completed a quality review of all current resident treatment sheets, compared them to the treatment orders and observed treatments to ensure that residents were provided wound care as ordered. There are 3 current residents with pressure sores. Current residents with wounds are followed by wound physician associated with the medical director ' s practice or a Vascular Surgeon. Residents with wound care had their care plans reviewed on 2/27/19-2/28/19 to ensure that the facility addressed the pressure sores comprehensively to prevent worsening and promote healing of the pressure sores. Residents with pressure ulcers had their care plans reviewed on 2/28/19 by the Divisional MDS nurse. Resident ' s wounds are observed and measured weekly by the treatment nurse, beginning 1/23/19. The facility ' s treatment nurse coordinates outside services as needed and/or as ordered in collaboration with the physician. Current residents with wounds are followed by the wound physician associated with the Medical Directors practice, or a Vascular Surgeon. The physician notes are sent to the facility via secure server email for the Director of Nursing ' s review and then they are filed in the medical record. Alert and oriented residents were interviewed 3/4/2019 if they have ever felt neglected. No negative responses were noted. 3. Systemic Changes: Director of Nursing, Divisional Executive Director, and Regional Director of Clinical Services provided education to all staff on abuse and neglect with emphasis that not providing care to the resident is neglect on 2/3/19, 2/5/19, 2/11/19, 2/19/19 and re-educated on 3/3/19 and 3/4/19. New hires will be provided training on neglect to include not providing care to the resident is neglect. Newly hired licensed nursing staff will be provided training and education on neglect including not providing care to the resident as well as not providing wound care and treatment as being neglect. The facility employees a full time treatment nurse. If the treatment nurse is unavailable, it will be communicated to the licensed nurses by the Director of Nursing to provide treatments as ordered by the physician. The licensed nurses have the capacity to complete their assignments, including treatments within the parameters of their work schedule. If the licensed nurse cannot complete the treatment within the parameter of their work schedule, the licensed nurse will report the issue to the Director of Nursing. The Director of Nursing will grant overtime to the licensed nurse to complete the task, delegate the responsibility to another nurse or assist with the task. The DON or MDS nurse will complete the assessment and measurements if the treatment nurse is unavailable. Corporate Human Resources and Regional staff worked with the Interim Executive Director to implement staff recruitment practices to ensure the center was appropriately staffed (center achieved appropriate staffing on 02/08/19). The Regional Vice President of Operations and the Regional Director of Clinical Services will monitor staffing levels to ensure adequate staffing is maintained. On 2/7/19 the Regional Vice President of Operations and Regional Director of Clinical Services began monitoring daily staffing of direct care per resident per day using morning meeting and internal labor portal. Facility leadership, including the Executive Director, Director of Nursing and Interdisciplinary team provide direct oversight through rounding, observation and resident/family communication to ensure neglect is not present and the residents receive the care and services they need. Interdisciplinary team to include Social Worker, Activities Director, Medical Records Director, Dietary Manager, Housekeeping Manager, Rehab Director, Business Office Manager, MDS Coordinator and Human Resources Director. Issues identified will be presented to the Executive Director and will follow the Abuse and Neglect process for investigation, resolution and/or reporting. Regional Director of Clinical Services and or Director of Nursing will conduct quality monitoring (audit) for neglect including observation and interview of resident treatments and documentation for 3 residents (rotating residents), 3 times per week for 4 weeks, then weekly for 3 months. The Director of Nursing will report on the results of the quality monitoring (audit) and report to the QAPI committee. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated as indicated. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting by the Director of Nursing for review of on going wound care monthly. The Executive Director will provide data on staffing to the QAPI committee for review of any staffing challenges. Quality Improvement monitoring schedule will be modified based on findings of monitoring. The center Executive Director conveyed an ADH[NAME] Quality Assurance Performance Improvement meeting 02/22/19, including the Interim Executive Director, Director of Nursing, the SDC, Director of Rehab, MDS Nurse, Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records, Central Supply Clerk, Admissions Director, Dietary Manager, Activity Director and the Environmental Services Director regarding the plan of removal of immediacy. The Medical Director was made aware of the of immediacy plan via telephone with the Executive Director and the Director of Nursing on 3/1/19. The credible allegation of Immediate Jeopardy removal was validated on 3/6/19 at 12:30 PM which included: Human resources record review indicated there were 17 new employees documented as starting employment as nursing assistant and licensed nurse between 1/12/19 and 2/27/19. A review of Resident #36 ' s discharge from the facility to home dated 2/20/19 revealed he was discharged to home with family, was scheduled to follow up with his physician, home care services were started, and medical supply was contacted. The first home visit scheduled was for 2/25/19. A review of Resident #36 ' s treatment administration record for (MONTH) and (MONTH) 2019 revealed documentation that he received his daily wound care since the last survey. A review of the facility audit documentation dated 2/15/19 and 3 current residents were confirmed that their wounds followed by the wound physician associated with the medical director ' s practice or a Vascular Surgeon and wound care as ordered as evidenced by notes in their medical record. Wound care documentation was reviewed, and weekly observations and measurements were identified beginning 1/23/19. Education in-service, sign-in sheets for wound care and abuse/neglect/exploitation were reviewed. Signatures totaled the current employment count. Documentation of resident interviews dated 3/4/2019 was reviewed and resident responses indicated that they had ever felt neglected. No negative responses were noted. Resident #36 was discharged to home and not available for observation and interview. On 3/6/19 at 11:55 am an interview was conducted with the Director of Clinical Services/Director of Nursing (DON) who stated the facility was now fully staffed since mid-February 2019 and the new Administrator provided across the board raises for all staff. All facility staff were required to participate in education for abuse, neglect, and exploitation. Staff morale has improved and there are fewer reported grievances. Staffing was the root cause of the failures to provide care (neglect), call light answer, low morale, and failure to meet resident preferences. Resident council is now held every 2 weeks to address concerns. The increased staff has been sustained. Surplus applicants not hired contact information has been retained. On 3/6/19 at 4:30 pm interviews of 5 random staff members were conducted which revealed that all staff were required to participate in abuse/neglect/exploitation in-service. The staff commented that several newly employed nursing assistants had started over the past 2 months and the facility was fully staffed. The rate of grievances filed by residents and/or their family had dropped by half. The last resident council meeting in (MONTH) 2019 identified that call lights and incontinence care were addressed timely to the satisfaction of the residents. An interview was conducted with the Treatment Nurse (TN) who stated that she was no longer required to float to the nursing assistant position and was available every day for treatments. On the weekends the nurse assigned to the resident completed the treatments. In the TN ' s absence the nurse assigned completed the treatments and a schedule book for who is responsible was kept at the nurses ' station and managed by the Scheduling Coordinator and Director of Nursing. On 3/6/19 at 5:30 pm an interview was conducted with the Corporate Vice President of Operations who stated he conferenced with the Divisional Human Resources Director and implemented staffing plans including wage increases and recruitment and retention plans to ensure sufficient staffing. On 2/7/19 sufficient staff had been hired and received orientation prior to accepting an assignment. Daily staffing meetings have occurred to ensure sufficient staffing patterns. 2. Resident #1 was admitted to the facility 10/3/18 with cumulative [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed that the Cognitive Pattern assessment (Section C) and the Mood (Section D) assessment was not completed. She was coded total staff assistance with bed mobility, toileting and personal hygiene. Resident #1 was coded as non-ambulatory and incontinent of bladder and bowel. She was coded for one stage 2 pressure ulcer and one Suspected Deep Tissue Injury (SDTI) both present on admission. Interventions included a pressure reducing mattress to her bed and pressure ulcer care. Resident #1 was coded for a prognosis of less than 6 months and for Hospice Services. Review of Resident #1's Care Area assessment dated [DATE] for pressure ulcers read she was a Hospice resident and she was admitted with a SDTI and she was dependent of the staff for her activities of daily living. Review of Resident #1's skin/wound care plan dated initiated 10/17/18 read she had a SDTI to her left heel on 10/17/18. The goal was for Resident #1's wound was to show signs of healing. Interventions included the facility was to provide treatments as ordered Review of a Hospice nursing note dated 10/8/18 read Resident #1 had a blister to her left heel measuring approximately 10 centimeter (cm). New orders were written to apply Skin Prep to the blister daily and float her heels. Review of an as needed (PRN) Hospice note read Resident #1 was seen on 10/12/18 because her left heel blister had ruptured. There were new orders dated 10/12/18 which read her left heel was to be cleansed with Normal Saline (NS), the area patted dry and the application of [MEDICATION NAME] (two-sided wound contact layer dressing), cover with area with padding and wrap with a gauze dressing. The dressing was ordered to be changed every Monday and Thursday by the Hospice nurse. Review of a Hospice note dated 10/22/18 read Resident #1's left heel [MEDICATION NAME] dressing was hanging off her heel but not on the wound. New orders were written to clean her left heel wound with NS, pat dry then apply a Vaseline gauze, cover with a non-adherent dressing, pad the heel and secure with a gauze wrap. The dressing change was to be done every Monday and Thursday and the Hospice Nurse would be completing Resident #1's wound care. Review of a Hospice note dated 10/31/18 read there was new orders for paint Resident #1's left heel wound with [MEDICATION NAME], cover the wound with a nonadherent dressing and wrap with a gauze dressing daily. The note indicated the new wound care orders were discussed with the Treatment Nurse at the facility. Review of the facility (MONTH) (YEAR) Treatment Administration Record (TAR) revealed no documented evidence of Resident #1's daily treatment to her left heel on 11/2/18, 11/3/18,11/4/18, 11/10/18, 11/13/18, 11/16/18, 11/21/18, 11/22/18 11/24/18 and 11/26/18. Review of the facility (MONTH) (YEAR) TAR revealed no documented evidence of Resident #1's daily treatment to her left heel on 12/2/18, 12/7/18, 12/11/18 12/19/18, 12/25/18, 12/28/18 and 12/29/18. Review of Resident #1's skin/wound care plan dated revised 1/3/19 read her area to the left heel was described as unstageable. The goal was for Resident #1's wound was to show signs of healing. Interventions included the facility was to provide treatments as ordered Review of the facility (MONTH) 2019 TAR revealed no documented evidence of Resident #1's daily treatment to her left heel on 1/1/19, 1/2/19, 1/4/19 and 1/8/19. During an interview on 1/8/19 at 10:14 AM, the Treatment Nurse stated that she had been the Treatment Nurse at the facility since (MONTH) (YEAR). She revealed that prior to sometime around (MONTH) of (MONTH) (YEAR), the facility began having difficulty obtaining and maintaining Nursing Assistants (NA). She further explained at that time due to the lack of NAs on staff, she was normally assigned as an NA and the floor nurses were supposed to complete the treatments. Review of a Nurse Practitioner (NP) note dated 1/10/19 read Resident #1 was seen for wound follow up to her left heel. The NP assessed Resident #1's left heel pressure ulcer was described as unstageable with 90% eschar with 10% granulation, no odor with a small amount of serous drainage. New orders were given for Thera-honey (dressing impregnated with medical grade honey) daily to any granulated areas and continue to apply [MEDICATION NAME] daily to the dark eschar. During another interview on 1/10/19 at 8:40 AM, the Treatment Nurse revealed she had concerns that treatments were not being provided as ordered to Resident #1 by the floor nurses for over a month. During an interview with the Director of Nursing (DON) on 1/10/19 at 2:31 PM, she indicated she expected the necessary care and services to be provided to residents as indicated in their comprehensive care plan and as ordered by the physician. She acknowledged that Resident #1's care plan interventions and physician's orders [REDACTED]. During an interview with the Administrator on 1/10/19 at 2:31 PM, he indicated he expected the necessary care and services to be provided to residents as indicated in their comprehensive care plan and as ordered by the physician. Review of the facility Weekly Wound Report revealed Resident #1 did not appear on the report for pressure ulcers until the week of 1/23/19. Review of Resident #1's skin/wound care plan dated revised 1/30/19 read her left heel wound was described as a stage 3 pressure ulcer. The goal was for Resident #1's wound was to show signs of healing. Interventions included the facility was to provide treatments as ordered. During a wound care observation on 3/6/19 at 10:00 AM, the Treatment Nurse provided Resident #1' pressure ulcer treatment to her left heel. There were no observed concerns with her technique or infection control. Resident #1's left heel appeared pale pink in color with white wound edges. There was no odor and evidence of bloody drainage after cleaning the wound with NS. The area was padded dry and Santyl was applied to the wound bed which measured approximately 3 cm by 2 cm by 0.5 cm. The area was covered with a nonadherent dressing and wrapped with gauze. Resident #1's voiced no pain. She was lying on a properly functioning air mattress and her heels were floated above the mattress surface. During an interview on 3/6/19 at 1:38 PM, the DON validated she worked with Resident #1 on 11/3/18 and 12/7/18 where there was no documented evidence of pressure ulcer care to Resident #1's left heel. She stated she was unable to recall if she did treatments on 11/3/18 and 12/7/18 but if she didn't document, she likely didn't do. The DON stated if she did not complete Resident #1's treatments on 11/3/18 and 12/7/18 it would have been because she didn't have time to do it due to limited staff. When asked who was responsible for monitoring the TARs to ensure that treatments were administered as ordered, the DON stated she had been monitoring the Medication Administration Records (MARs), but no one had been monitoring the TARs. During an interview on 3/6/19 at 1:48 PM, Nurse #9 verified she worked with Resident #1 on 11/4/18, 11/10/18 and 12/2/18. Nurse #9 stated she was unable to recall if she completed Resident #1's treatment to her left heel on the days in question but stated during (MONTH) (YEAR) and (MONTH) 20 (TRUNCATED)

Based on observation, record review, and interviews with resident, family, staff, Department of Social Services, and Nurse Practitioners, the facility failed to provide sufficient nursing staff to ensure residents received pressure ulcer wound care, urinary catheter care, assistance with Activities of Daily Living (ADLs), and respond to call bells. The facility also failed to provide sufficient nursing staff to honor resident preferences, treat residents with dignity and respect, resolve individual and resident council grievances, and ensure Nursing Assistant involvement in the development of the comprehensive care plan. This affected 14 of 24 sampled residents (Residents #1, #30, #32, #36, #44, #47, #49, #50, and 6 members of the resident council). The repeated failure to provide sufficient staffing for pressure ulcer care to Resident #36 resulted in his pressure ulcer worsening and the development [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus) infection. Immediate Jeopardy began on 11/6/18 when Resident #36 developed [MEDICAL CONDITION] infection in a pressure ulcer that had worsened as a result of the facility's repeated failure to follow physician orders [REDACTED]. Immediate Jeopardy was removed on 3/6/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of G (actual harm that is not immediate jeopardy) for Examples #1a and #1b. Examples #2, #3, and #4 were cited at a scope and severity of G, examples #5 and #6 were cited at scope and severity of E, and examples #7 and #8 were cited at a scope and severity of D. The findings included: This tag is cross-referred to: 1a. F600: Based on record review, observations, staff interview, resident interview, family interview, wound care Nurse Practitioner interview, Nurse Practitioner interview, and Department of Social Services interview, the facility neglected to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation, and communication with the outside podiatrist who was also treating, resulting in a worsening pressure ulcer and infection (Resident #36); neglected to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation (Resident #1); and neglected to provide daily pressure ulcer wound care as ordered and weekly wound measurement/assessment and documentation (Resident #44) for 3 of 4 residents reviewed; the facility neglected to provide catheter care (Resident #44) for 1 of 1 resident reviewed; and the facility also neglected to answer a call light related to a request for incontinence care (Resident #49) for 1 of 1 resident reviewed. 1b. F686: Based on record review, observations, staff interview, resident and family interview, wound care Nurse Practitioner interview, and Nurse Practitioner interview, the facility failed to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation, and communication with the outside podiatrist who was also treating resulting in a worsening pressure ulcer and infection (Resident #36); failed to provide daily pressure ulcer wound care as ordered, weekly wound measurement/assessment and documentation (Resident #1); and failed to provide daily pressure ulcer wound care as ordered and weekly wound measurement/assessment and documentation (Resident #44) for 3 of 4 sampled residents reviewed for wound care. During an interview with the Administrator on 1/8/19 at 10:30 AM he stated he started as the Administrator in (MONTH) of (YEAR). He revealed that the facility had been having difficulty obtaining and maintaining enough NAs to staff all three shifts since that time. He reported that nurses had been assigned to work as Nursing Assistants (NAs) to fill in the gaps on the schedule. The Administrator stated that the Treatment Nurse was one of the nurses who frequently had been assigned as an NA. A follow up interview was conducted with the Administrator on 1/10/19 at 2:31 PM. He stated that sufficient staffing meant having enough staff both in terms of quality and quantity to meet the needs of the residents. He acknowledged his awareness that sufficient staffing was an issue at the facility. He stated that the facility was currently working with the corporate office to develop employment incentives to obtain and maintain additional staff to meet the needs of the residents. An interview was conducted with the Treatment Nurse on 3/6/19 at 12:04 PM. She indicated the facility was insufficiently staffed to meet the needs of the residents. She revealed this insufficient staffing resulted in a failure to provide pressure ulcer care as ordered by the physician. An interview was conducted with the Director of Nursing (DON) on 3/6/19 at 11:50 AM. She revealed the facility was insufficiently staffed to meet the needs of the residents. She stated this insufficient staffing resulted in a failure to provide pressure ulcer care as ordered by the physician. An interview was conducted with the Interim Administrator on 3/6/19 at 12:20 PM. He reported he began working at the facility as an Interim Administrator on 1/18/19. He revealed the Regional Vice President of Operations (RVPO), the Corporate Human Resources Director, and himself identified insufficient staffing as the root cause of the facility's failure to meet the needs of the residents. He further revealed this insufficient staffing resulted in a failure to provide pressure ulcer care as ordered by the physician. An interview was conducted with the RVPO on 3/6/19 at 1:34 PM. He confirmed the Treatment Nurse's, DON's, and Interim Administrator's interviews that indicated the facility had been insufficiently staffed to meet the needs of the residents. He verified that this insufficient staffing resulted in a failure to provide pressure ulcer care as ordered by the physician. The RVPO stated the previous Administrator made him aware of some difficulties with the facility obtaining staff, but he had not described the extent of these difficulties. He revealed he had been unaware that residents' needs were unable to be met because the facility was insufficiently staffed. The RVPO stated that the root cause of the facility's failures was two-fold: 1. A lack of oversight 2. Insufficient staff The RVPO explained that the facility's previous Administrator failed to provide oversight of processes and policies and effective leadership to ensure residents were free from neglect, received pressure ulcer care as ordered by the physician, and maintained sufficient nursing staffing to provide necessary care and services. The Interim Administrator, DON, and RVPO were notified of the Immediate Jeopardy on 3/6/19 at 11:29 AM. On 3/6/19 at 5:17 PM the facility provided the following credible allegation of Immediate Jeopardy removal: The center Executive Director alleges abatement of immediate jeopardy on 03/06/19. Deficient Practice: The facility failed to provide sufficient staff to ensure residents received pressure ulcer treatment. A Root Cause Analysis was completed 01/22/2019 by the Divisional Executive Director, Regional Vice President of Operations, Regional Director of Clinical Services, Regional Director of Human Resources and the Senior Vice President of Human Resources. The preliminary investigative information to determine root cause was the center wage scale and a competitive wage analysis. The competitive wage analysis revealed that the center needed to increase the lower end of the wage scale for new hires as compared to other centers in the market. The contributing factors identified the following issues: - The Executive Director's failure to follow guidance for keeping recruitment software up to date. The recruitment software provides real-time open positions to online job websites (Indeed, Monster, etc.); additionally, the software pulls resumes and applications to ensure a flow of applicants to the center for interview. - The Executive Director's failure to hire staff at an approved higher wage rate, and - The Executive Director's failure to report staffing issues to regional and corporate Human Resources staff. 1. The corrective action for the alleged deficient practice was accomplished by: Corporate Human Resources and Regional staff worked with the Interim Executive Director to implement staff recruitment practices to ensure the center was appropriately staffed (center achieved appropriate staffing on 02/07/19). Recruitment practices include: a. Update ICISMs software (recruitment software mentioned above) for Certified Nursing Assistants (CNAs) and Personal Care Assistants, b. Incentives for staffs from sister centers to work PRN (as needed) or full-time schedules, c. Referral bonuses for current staff to refer new qualified applicants, d. Sign on bonuses for new CNAs. The Divisional Executive Director, Regional Vice President of Operations, Regional Director of Clinical Services, Regional Director of Human Resources and the Senior Vice President of Human Resources conferred on 01/22/19 to discuss Root Cause Analysis and develop an action plan. The action plan included the following: - Recruit, with incentives, CNA, Licensed Practice Nursing (LPN) and Registered Nurse (RN) staff from sister center in Triad market, - Referral Bonus for existing staff with immediate pay out, - Recruit and hire Personal Care Assistants, - Retrain staff scheduler and ensure schedule is accurate, - Sign on bonus for CNA position. By 02/07/19 sufficient staff was provided to ensure residents are receiving pressure ulcer treatment. 2. Residents with the potential to be affected by alleged deficient practice: On 01/22/2019 the ED, Regional Vice President of Operations, Divisional Human Resources Director of Human Resources conferenced and implemented staffing plans including wage increases, recruitment and retention plans to ensure sufficient staffing. On 02/07/19 sufficient staff have been hired and have or are completing orientation. Sufficient staffing is measured as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. 3. Systemic Changes: The Executive Director will work with facility and corporate Human Resources staff to fulfill staffing needs through appropriate recruitment and retention programs. Sufficient staffing was achieved on 02/07/19. Executive Director will monitor staff openings, recruitment, training and scheduling of staff through review of daily staffing levels at morning and evening meetings, review of open positions and validation of staffing levels daily. The Director of Nursing will monitor daily staffing levels at morning and evening meetings, review of open positions and validation of staffing levels daily to ensure wound care will be completed. If the treatment nurse is unavailable it will be communicated to the licensed nurses by the Director of Nursing to provide treatments as ordered by the physician. Licensed staff have the capacity to complete their assignments, including treatments within the parameters of their work schedule. If the licensed nurse cannot complete the treatment within the parameter of their work schedule, the licensed nurse will report the issue to the Director of Nursing. The Director of Nursing will grant overtime to the licensed nurse to complete the task, delegate the responsibility to another nurse or assist with the task. The Director of Nursing and/or Minimum Data Set Nurse will complete the assessment and measurements if the treatment nurse is unavailable. The schedulers, when there is a call out, is instructed to message all staff through OnShift (scheduling software that texts staff) and inform the Director of Nursing. The Director of Nursing will assist the scheduler in making calls and if unable to fill a certain shift, the scheduler or Director of Nursing will fill the open shift themselves. Executive Director will monitor staff openings, recruitment, training and scheduling of staff through review of daily staffing levels at morning and evening meetings, review of open positions with scheduler and validation of staffing levels daily through rounds and staff interviews. Executive Director will monitor staffing 5 times a week then 3 times a week for 4 weeks then 1 time a week for 8 weeks to ensure all resources are utilized. The ED will report on the results of the quality monitoring (audit) and report to the Quality Assurance and Performance Improvement (QAPI) committee. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated as indicated. The Regional Vice President of Operations and the Regional Director of Clinical Services will monitor staffing levels through internal portal and weekly visits to ensure adequate staffing is maintained. Sufficient staffing is measured as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. The staff scheduler will inform the Executive Director and Director of Nursing when there are open positions. The Executive Director will inform the Human Resource Director of open positions and to update ICISMs (recruitment software). The Director of Nursing will work with the staff scheduler to fill open positions to ensure care is delivered. The center Executive Director conveyed an ADH[NAME] Quality Assurance Performance Improvement meeting 03/06/19, including the Interim Executive Director, Director of Nursing, Director of Rehab, MDS Nurse, Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records, Central Supply Clerk, Admissions Director, Dietary Manager, Activity Director, the Environmental Services Director, the Regional Vice President of Operations and Regional Director of Clinical Services regarding the plan of removal of immediacy. The Medical Director was made aware of the of immediacy plan via telephone with the Executive Director and the Director of Nursing on 3/6/19. The Executive Director will be responsible for the execution of the plan and communicating progress to the region team. The region team will monitor the facility weekly through observation and communication to ensure the center is sufficiently staffed. The credible allegation of Immediate Jeopardy removal was validated on 3/6/19 at 5:18 PM. Record review confirmed multiple new staff had been hired, including a new scheduler, Personal Care Assistants, NAs, and Nurses. Staff interviews verified recruitment incentives were implemented and multiple new staff had been hired. These staff interviews revealed the staff now felt equipped to meet the residents' needs. An interview with the Treatment Nurse confirmed she was now able to provide pressure ulcer care as ordered by the physician due to the increase in staff. Interviews with the scheduler, DON, Interim Administrator, and RVPO indicated they all felt the residents' needs were being met and the facility was sufficiently staffed as of 2/7/19. An interview with the Medical Director confirmed he had been made aware of the facility's credible allegation action plan for F725 on 3/6/19. 2. F550: Based on record review, observation, resident interview, Department of Social Services (DSS) interview, and staff interview, the facility failed to treat residents in a dignified manner as evidenced by inappropriate staff to resident verbal statements (Resident #32 and #49) and by not answering a call light related to a request for incontinence care (Resident #49). This failure caused Resident #49 to cry and to feel humiliated and helpless. The facility also failed to cover Resident #47 ' s urinary catheter drainage bag to promote dignity for 3 of 5 sampled residents reviewed for dignity and respect. 3. F561: Based on record review, resident interview, observation, Nurse Practitioner interview, and staff interview, the facility failed to consistently honor a resident's choice of getting out of bed at his preferred time in the morning for a resident who required extensive assistance with transfers (Resident #32) and failed to trim, clean and file resident's nails (Resident #30) for 2 of 2 residents reviewed for choices. Resident #30's nails were long, jagged, dirty and the left thumb nail was painful and cracked down past the nail bed. 4. F677: Based on record review, observation, and interviews with resident, family, Department of Social Services, and staff, the facility failed to provide incontinence care, showers, and/or bathing for 3 of 4 dependent residents reviewed for the provision of activity of daily living (ADL) care (Residents #36, #49 and #44). Resident # 49 was upset and teary for staying soaked with urine before the facility staff responded to the call bell to provide incontinence care. 5. F565: Based on record review, and interviews with residents and staff, the facility failed to resolve the repeat concern reported during Resident Council meetings for 4 of 4 consecutive months regarding call lights not being answered timely. 6. F690: Based on record review and interviews with the resident, staff, and Nurse Practitioner, the facility failed to provide urinary catheter care as ordered for 1 of 1 sampled residents (Resident #44) reviewed for urinary catheter care. 7. F585: Based on record review, staff interview, resident and family interview, and Department of Social Services (DSS) staff interview, the facility failed to provide a written summary for grievances reported (Resident #36) and failed to write and investigate a grievance that was reported verbally to staff (Resident #49) for 2 of 2 residents reviewed for grievances. 8. F657: Based on record review, resident interview, and staff interview, the facility failed to incorporate a Nursing Assistant in the care planning process for 1 of 4 residents reviewed for the care planning process (Resident #50). During an interview with the Administrator on 1/8/19 at 10:30 AM he stated he started as the Administrator in (MONTH) of (YEAR). He revealed that the facility had been having difficulty obtaining and maintaining enough NAs to staff all three shifts since that time. He reported that nurses had been assigned to work as Nursing Assistants (NAs) to fill in the gaps on the schedule. The Administrator stated that the Treatment Nurse was one of the nurses who frequently had been assigned as an NA. During an interview with NA #1 on 1/9/19 at 3:58 PM he stated that he was hired to work the third shift, but he frequently worked other shifts as well due to the facility's difficulty obtaining and maintaining NA staff. He revealed there were several times in the past few months that he had been asked to work a double shift to fill in a gap in the NA schedule. NA #1 spoke specifically about the third shift NA staffing and stated that when only 2 NAs were working on the third shift he had difficulty answering resident call bells timely, providing timely incontinence care, and honoring a resident's choice to get out of bed early in the morning. During an interview with NA #2 on 1/10/19 at 6:20 AM she stated she normally worked the third shift. NA #2 revealed that over the past several months third shift was staffed with 2 NAs. She indicated that when only 2 NAs were working on the third shift she had difficulty answering resident call bells timely, providing timely incontinence care, and honoring a resident's choice to get out of bed early in the morning. During an interview with NA #3 on 1/10/19 at 6:25 AM she stated that she normally worked the third shift. NA #3 indicated that when only 2 NAs were working on the third shift she had difficulty answering resident call bells timely, providing timely incontinence care, and honoring a resident's choice to get out of bed early in the morning. During an interview with the Director of Nursing (DON) on 1/9/19 at 3:31 PM she stated she began working as the DON at the facility in (MONTH) of (YEAR). She confirmed the Administrator's report related to the facility having difficulty obtaining and maintaining enough NAs to staff all three shifts. The DON stated that staff members had been asked to work additional shifts and/or to work double shifts. She revealed that this had been going on for several months and had caused some of the staff to be exhausted. She acknowledged her awareness that essential care needs had been missed because of insufficient staffing. A follow up interview was conducted with the Administrator on 1/10/19 at 2:31 PM. He stated that sufficient staffing meant having enough staff both in terms of quality and quantity to meet the needs of the residents. He acknowledged his awareness that sufficient staffing was an issue at the facility. He stated that the facility was currently working with the corporate office to develop employment incentives to obtain and maintain additional staff to meet the needs of the residents. An interview was conducted with the Interim Administrator on 3/6/19 at 12:20 PM. He reported he began working at the facility as an Interim Administrator on 1/18/19. He revealed the Regional Vice President of Operations (RVPO), the Corporate Human Resources Director, and himself identified insufficient staffing as the root cause of the facility's failure to meet the needs of the residents. An interview was conducted with the RVPO on 3/6/19 at 1:34 PM. He confirmed the Interim Administrator's interview that indicated the facility had been insufficiently staffed to meet the needs of the residents. The RVPO stated the previous Administrator made him aware of some difficulties with the facility obtaining staff, but he had not described the extent of these difficulties. He revealed he had been unaware that residents' needs were unable to be met because the facility was insufficiently staffed. The RVPO stated that the root cause of the facility's failures was two-fold: 1. A lack of oversight 2. Insufficient staff The RVPO explained that the facility's previous Administrator failed to provide oversight of processes and policies and effective leadership to ensure the facility had sufficient nursing staff to meet the needs of the residents.

Based on record review, resident interview, observation, Nurse Practitioner interview, and staff interview, the facility failed to consistently honor a resident's choice of getting out of bed at his preferred time in the morning for a resident who required extensive assistance with transfers (Resident #32) and failed to trim, clean and file resident's nails (Resident #30) for 2 of 2 residents reviewed for choices. Resident #30's nails were long, jagged, dirty and the left thumb nail was painful and cracked down past the nail bed. The findings included: 1. Resident #30 was admitted [DATE] with [MEDICAL CONDITION] and Dysphagia. Resident #30's quarterly Minimum (MDS) data set [DATE] indicated he was cognitively intact and exhibited no behaviors. He was coded for impaired vision and limited assistance with personal hygiene. Review of Resident #30's activities of daily living (ADL) care plan dated last revised 11/13/18 indicated he required staff assistance with bathing, eating and locomotion. There was no indicated staff assistance noted with his personal hygiene. Review of Resident #30's undated Nurse Tech Information Kardex indicated he required staff assistance with brushing his teeth, combing his hair, perineum care and shaving. Assistance with nail care was not checked for assistance. In an observation on 1/7/19 at 3:30 PM, Resident #30 was sitting on the side of his bed watching television. His finger nails were observed. They appeared approximately ¾ of an inch long, jagged and dirty. He stated the staff had not offered to assist him with nail care and he did not have a pair of nail clippers in his possession. Resident #30 stated he preferred his nails to be trimmed and they were too long for his liking. He stated he had not requested staff assistance in trimming his nails. In an observation on 1/8/19 at 11:10 AM, Resident #30 was observed lying in bed. His nails still appeared long, dirty and jagged. In an interview on 1/9/19 at 8:05 AM, Nursing Assistant (NA) #9 confirmed she was assigned Resident #30. She stated he did not refuse any assistance with his ADLs, but that he was very independent. In an interview and observation on 1/9/19 at 11:45 AM, Resident #30 was sitting on the side of his bed. His nails appeared long, clean and jagged. He stated his left thumb nail was painful. His left thumb nail was observed cracked down past the nail bed. He stated even if he had clippers, he would have difficulty seeing how to cut his nails. Resident #30 stated he could not remember the last time he received nail care. In an interview on 1/9/19 at 11:55 AM, NA #9 stated she was under the impression that Resident #30 was able to cut his own nails, but she would assist him immediately. In an observation on 1/19/19 at 12:40 PM, Resident #30 was eating his lunch. His nails were trimmed and filed. He stated the nurse recently trimmed his finger nails and they felt better. In an interview on 1/10/19 at 9:30 AM, the Nurse Practitioner stated even if Resident #30 had clippers in his possession, his vision would be a concern and it was her expectation that the staff assist Resident #30 routinely with his nail care. In an interview on 1/10/19 at 2:30 PM, the Administrator and Director of Nursing stated it was their expectation that Resident #30 receive nail care as needed or requested. 2. Resident #32 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32's cognition was fully intact, and he had no behaviors or rejection of care. He required the extensive assistance of 1 for bed mobility, transfers, personal hygiene, dressing, and toileting. Resident #32 had functional impairment with range of motion on 1 side of his upper and lower extremities. An interview was conducted with Resident #32 on 1/7/19 at 4:40 PM. He indicated that he was an early riser and preferred to get out of bed between 4:00 AM and 5:00 AM. He stated he required staff assistance to get out of bed. Resident #32 reported that staff were aware of this preference as he had been a resident at the facility for several years. He revealed that although staff was aware, they had not consistently been getting him out of bed at his preferred time. He stated that on average there were 2 to 3 times per week that he was not assisted out of bed until closer to 7:00 AM. Resident #32 indicated he thought that there were not enough staff on the third shift which caused them to get him up later than he preferred. An observation and interview were conducted of Resident #32 on 1/10/19 at 6:00 AM. Resident #32 was seated in his wheelchair. He stated that his Nursing Assistant (NA) had gotten him out of bed about an hour ago and he was satisfied with this timing. An interview was conducted with Nursing Assistant (NA) #1 on 1/9/19 at 3:58 PM. He stated that he was hired to work the third shift, but that he frequently worked other shifts as well. He reported he was very familiar with Resident #32 and was aware he liked to get up between 4:00 AM and 5:00 AM. NA #1 stated that third shift normally had 2 or 3 NAs for around 60-65 residents total depending on the census that day. He indicated that recently the NA staffing for the third shift had been 2 NAs. He explained that he had difficulty meeting residents' needs timely when there were only 2 NAs working on the third shift. He further explained that tasks were prioritized and that sometimes getting Resident #32 out of bed at his preferred time was not able to be accomplish because more critical tasks were prioritized before him. An interview was conducted with NA #2 on 1/10/19 at 6:20 AM. She stated that she had worked at the facility for over 8 months and normally worked the third shift. She reported she was familiar with Resident #32 and was aware he liked to get up between 4:00 AM and 5:00 AM. NA #2 stated that third shift normally had 2 or 3 NAs for around 60-65 residents total depending on the census that day. She indicated that recently the NA staffing for the third shift had been 2 NAs. She explained that she had difficulty meeting residents' needs timely when there were only 2 NAs working on the third shift. She further explained that she had to prioritize her tasks to make sure the more important tasks were completed first. NA #2 revealed that this prioritization caused other non-critical tasks such as getting Resident #32 up at his preferred time to be pushed back and completed later in the morning. An interview was conducted with NA #3 on 1/10/19 at 6:25 AM. She stated that she began working in the facility 2 months ago and normally worked on the third shift. She reported she was familiar with Resident #32 and was aware he liked to get up very early in the morning. NA #3 stated that third shift normally had 2 or 3 NAs for around 60-65 residents total depending on the census that day. She indicated that recently the NA staffing for the third shift had been 2 NAs. She revealed she had difficulty meeting residents' needs timely when there were only 2 NAs working on the third shift. She stated that tasks had to be prioritized to make sure the most important tasks were completely first. NA #3 revealed that this prioritization caused other non-critical tasks such as getting Resident #32 up at his preferred time to be pushed back and completed later in the morning. During an interview with the Administrator on 1/8/19 at 10:30 AM he stated he began working as the Administrator at this facility in (MONTH) of (YEAR). He revealed that the facility had difficulty obtaining and maintaining enough NAs to staff all three shifts since he began as the Administrator. When asked what his definition of sufficient staffing was he stated that sufficient staffing was enough staff both in terms of quality and quantity to meet the needs of the residents. During an interview with the Director of Nursing (DON) on 1/9/19 at 3:31 PM she stated she began working as the DON at the facility in (MONTH) of (YEAR). She confirmed the Administrator's interview related to the facility having difficulty obtaining and maintaining enough NAs to staff all three shifts. She stated that third shift was normally staffed with 2 or 3 NAs. She revealed that one day recently she had to come in to work as an NA on the 3rd shift because 1 of the 2 NAs who were on the schedule called off and she was unable to find anyone else to fill in. A follow up interview with the Administrator and Director of Nursing on 1/10/19 at 2:31 PM they both indicated their expectation was for the choices of residents to be honored. They additionally indicated their expectation was to provide sufficient staffing to meet the residents' needs.

Based on record review, observation, resident interview, Department of Social Services (DSS) interview, and staff interview, the facility failed to treat residents in a dignified manner as evidenced by inappropriate staff to resident verbal statements (Resident #32 and #49) and by not answering a call light related to a request for incontinence care (Resident #49). This failure caused Resident #49 to cry and to feel humiliated and helpless. The facility also failed to cover Resident #47 ' s urinary catheter drainage bag to promote dignity for 3 of 5 sampled residents reviewed for dignity and respect. The findings included: 1. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Social Work (SW) note dated [DATE] indicated Resident #49 was admitted from an acute hospital after being taken to the Emergency Department by Adult Protective Services (APS) following the death of her spouse who was her primary caregiver at home. A Psychiatric Nurse Practitioner (PNP) Note dated [DATE] indicated Resident #49 was going through the normal grieving process related to the death of her spouse. She was noted with new [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 ' s cognition was fully intact. She had no behaviors and no rejection of care. Resident #49 required the extensive assistance of 1 for bed mobility and toileting and 2 or more for transfers. She was frequently incontinent of bladder and always incontinent of bowel. She was administered antianxiety medication and antidepressant medication during the MDS review period. The Care Area Assessment (CAA) related to urinary incontinence for Resident #49 ' s [DATE] admission MDS indicated she was alert, oriented, and able to make decisions and communicate needs. Resident #49 indicated she had a history of [REDACTED]. A SW note dated [DATE] indicated Resident #49 was on antidepressant medication and antianxiety medication. She was noted to become tearful when speaking about her spouse who recently passed away. The active care plan for Resident #49 included, in part, the following areas: - Resident #49 had an Activities of Daily Living (ADL) self-care performance deficit related to mobility, [MEDICAL CONDITIONS] and impaired balance. The interventions included, in part, assistance with tasks of washing hands, adjusting clothes, and cleaning self in relation to toilet use. - Resident #49 had altered bladder elimination related [MEDICAL CONDITION] right sided [MEDICAL CONDITION] and contractures of the right hand and wrist. Resident #49 was noted to report difficulty holding her urine. The interventions included, in part, bed pan, mechanical lift for transfers, and encourage communication of needs for assistance with toileting. - Resident #49 utilized antianxiety medication and antidepressant medication. She was noted to be grieving the loss of her husband, she had a [DIAGNOSES REDACTED]. The interventions included behavior monitoring and side effect monitoring. An interview was conducted with Resident #49 on [DATE] at 3:00 PM. Resident #49 was alert and oriented with no impaired cognition noted. When asked if she had any concerns with her care she stated that several weeks ago during the second shift (3:00 PM to 11:00 PM) she rang her call bell and requested for staff to adjust her bed pan, so she could urinate. She explained that she preferred to urinate in her bed pan. She reported 2 staff members came into her room and 1 of them said the bed pan was too small for her. Resident #49 stated that this staff member then said to her, do it in your pants .haven ' t you ever gone in your pants? She reported she told the staff she hadn ' t gone in her pants since she was a baby. Resident #49 indicated the staff had taken the bed pan with them out of her room and she had to urinate in her brief. She was unable to recall the names of either staff member and was unable to recall how long it took for incontinent care to be provided to her after this incident. She stated she felt humiliated and she recalled crying after the incident occurred. She reported that she had lost her husband, she lost her home, and she lost her independence. She indicated that she felt like the staff were speaking to her as if she were a child. Resident #49 stated that she had reported this incident to one of the nurses (unable to recall the name of the nurse) and she believed the Director of Nursing (DON) was also aware. She indicated she had not seen either of the 2 staff members again after she reported this incident to the nurse. Resident #49 expressed concern and fear of reprisal with this incident being investigated as she had not wanted to make anyone angry. A complaint/grievance report dated [DATE] communicated by Resident #49 to the Human Resources Coordinator (HRC) indicated that the resident was concerned about how long she waited for her call light to be answered. This form had been reviewed by the SW and was assigned to the DON for investigation. A follow up interview was conducted with Resident #49 on [DATE] at 11:30 AM. Resident #49 stated that she changed her mind and wanted the incident she reported during the [DATE] interview to be investigated. She stated she located her personal calendar that she kept handwritten notes in. The calendar was observed to have a handwritten note on the date [DATE] that read, 2 (staff) came in my room and upset me about the bed pan. Told me to do it in my pants. They took the bed pan with them. During this interview the grievance dated [DATE] written by the HRC that discussed the resident ' s concern with how long it took for her call light to be answered was reviewed with Resident #49. She stated that in the early morning on [DATE] she pressed her call bell because she had to urinate. She indicated it took over 2 hours for her call bell to be answered. She stated she urinated in her brief during that time as she had difficulty holding her urine. She revealed she sat in her brief that was soaked with urine until her call bell was answered by the HRC. Resident #49 indicated this incident made her feel helpless. She stated the DON then provided her with incontinent care. A phone interview was conducted with Department of Social Services (DSS) staff by phone on [DATE] at 8:09 AM. She stated that Resident #49 reported to her several weeks ago that she had requested staff to adjust her bed pan and they said something to her about the size of the bed pan and told her that if she had not wanted to use the bed pan that she would pee on herself. She stated that Resident #49 was tearful and upset when she provided this information. DSS staff stated that she spoke with Resident #49 again yesterday, [DATE], and the resident told her she sat in a urine-soaked brief for over 2 hours after pressing her call light for assistance. An interview was conducted with the HRC on [DATE] at 2:40 PM. The complaint/grievance report dated [DATE] related to Resident #49 was reviewed with the HRC. She stated she was walking the halls on [DATE] when she saw Resident #49 ' s call light on, so she entered the room and asked the resident if there was something she could help with. Resident #49 informed her she had been waiting awhile and needed cleaned up. She stated that Resident #49 reported that she turned her call light on at 4:45 AM. The HRC estimated it to be around 7:10 AM when she entered the room to answer the call light. She stated there was no obvious odor of urine in the room. She indicated that Resident #49 was visibly upset and was crying when she spoke with her. She said that after speaking to Resident #49 she went to the DON and Administrator to report the information. An interview was conducted with the SW on [DATE] at 12:00 PM. She indicated she spoke with Resident #49 on [DATE] after the grievance was reported by the HRC. She revealed that Resident #49 was visibly upset and tearful at the time she spoke with her. She stated that she had not asked Resident #49 how the incident made her feel, but instead focused on trying to find out who the staff members were that were assigned to her during the [DATE] incident. She stated the investigation was ongoing. The SW denied knowledge of any previous incidents related to incontinent care for Resident #49. An interview was conducted with the DON on [DATE] at 2:30 PM. She reported she had provided incontinent care to Resident #49 on [DATE] after the HRC reported she answered the resident ' s call light and the resident said her light had been on for over 2 hours. The DON stated that Resident #49 had urinated in her brief. She reported Resident #49 was visibly upset and was tearful when she provided care. The DON indicated she expected call bells to be answered timely. This interview with the DON continued. She revealed she had previously heard one of the staff say something about Resident #49 reporting that a staff member told her to use her brief to urinate because they were unable to change her at that time. She confirmed that this was prior to the [DATE] grievance and was a separate incident. The DON stated she was unable to recall what staff member she heard this from and she was also unable to recall when this occurred. She revealed there was no grievance written related to this incident and no investigation was conducted. The DON reported it was a dignity issue for a resident to be told to urinate in their brief. She indicated she expected residents to be treated with dignity and respect. Based on review of the nursing schedule and DON confirmation on [DATE] at 2:45 PM, Nursing Assistant (NA) #5 was assigned to Resident #49 on [DATE] during the second shift and Nurse #2 and NA #1 were assigned to the resident for the third shift on [DATE] beginning at 11:00 PM and ending on [DATE] at 7:00 AM. An interview was conducted with NA #5 on [DATE] at 2:52 PM. She stated she was not frequently assigned to Resident #49 but acknowledged that she had worked with her in the past. She denied telling Resident #49 to urinate in her brief and additionally denied making any statement related to the size of the resident ' s bed pan. A phone interview was conducted with Nurse #2 on [DATE] at 3:00 PM. He confirmed he was assigned to Resident #49 during the third shift beginning [DATE] and ending [DATE]. He indicated that 2 NAs were working the third shift for the entire building and that NA #1 was assigned to Resident #49. Nurse #2 revealed he recalled Resident #49 ' s call light being on for an extended period of time during the early morning on [DATE]. He was not surprised that it took over 2 hours for Resident #49 ' s call light to be answered. He explained that when there were only 2 NAs working it was difficult for them to answer call lights timely which caused a delay in meeting the residents ' needs. An interview was conducted with NA #1 on [DATE] at 3:15 PM. He confirmed he was assigned to Resident #49 during the third shift beginning [DATE] and ending [DATE]. He stated he was working a double that day beginning on the second shift [DATE] and working through the third shift ending [DATE]. He reported that he was 1 of 2 NAs working the third shift that day and they each had about 30 residents. NA #1 indicated he had not recalled Resident #49 ' s call light being on for an extended period of time during the early morning on [DATE], but revealed it was not a surprise to him. He explained that he had difficulty meeting residents ' needs timely when there were only 2 NAs working on the third shift. He stated he was unaware a complaint/grievance form had been filed related to Resident #49 ' s concern about how long she waited for her call light to be answered during the early morning hours of [DATE]. An interview was conducted with the Administrator on [DATE] at 10:20 AM. He indicated he spoke with Resident #49 on [DATE] after the grievance was reported by the HRC. He stated that Resident #49 reported to him that she had to wait a long time for her call bell to be answered. He additionally stated that Resident #49 reported a staff member told her that she could just go in her brief if she had not wanted to wait. The Administrator indicated the investigation into these reports was just beginning. He stated he had not previously been made aware of incidents related to incontinent care or dignity for Resident #49. The Administrator stated it was unacceptable for a resident to be told to urinate in their brief. He additionally stated it was unacceptable for a resident to wait over 2 hours for a call bell to be answered. 2. Resident #32 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32' s cognition was fully intact. He had no behaviors and no rejection of care. Resident #32 was assessed with [REDACTED]. The investigation report dated [DATE] for a Facility Reported Incident (FRI) of staff to resident abuse that occurred on [DATE] at 10:30 AM involving Resident #32 and Cook #1 was reviewed. The allegation details indicated that Resident #32 overheard Cook #1 state I ' ll give him a muffin but if the (m .fer) chokes then its not on us. The summary of the facility ' s investigation indicated that Cook #1 was overheard by staff and residents being rude. Cook #1 was immediately sent out of the facility and was terminated the same day ([DATE]). The investigation was conducted by the Administrator and the allegation of staff to resident abuse was substantiated by the facility. A written statement dated [DATE] that was unsigned was provided by the Administrator. On [DATE] at 10:15 AM he stated this written statement was completed by NA #4. The statement indicated Resident #32 had asked for a muffin in the dining room. NA #4 requested the muffin from dietary staff and Cook #1 told her the resident was unable to have the muffin because it wasn ' t on his meal ticket. NA #4 wrote that she spoke with Nurse #1 and Nurse #4 and they stated that Resident #32 was able to have a muffin. NA #4 indicated she and Nurse #1 returned to the kitchen and informed Cook #1 that Resident #32 was able to have a muffin. NA #4 wrote that Cook #1 stated, If he (m .fing) choke then it was on (nursing staff). A phone interview was conducted with NA #4 on [DATE] at 8:17 AM. NA #4 confirmed she had completed the written statement dated [DATE]. She reported that Resident #32 was in the dining room and he asked her if he could have a muffin. She stated she went into the kitchen and asked Cook #1 for a muffin for Resident #32. NA #4 reported that Cook #1 said she wouldn ' t give Resident #32 a muffin because it wasn ' t on his meal ticket. She stated she went to speak with Nurse #1 and Nurse #4 and asked if Resident #32 was able to have a muffin. Nurse #1 and Nurse #4 reported that if Resident #32 wanted a muffin he could be given a muffin. NA #4 indicated she went back to the kitchen and informed Cook #1 that Nurse #1 and Nurse #4 said Resident #32 could have a muffin. She stated that Cook #1 stated, if he (m .fing) chokes it ' s on you. NA #4 explained that Cook #1 meant that it was not the dietary staff ' s fault if Resident #32 choked on the muffin. She stated that she was holding the kitchen door open at the time Cook #1 made this statement and that multiple residents were within hearing distance. She reported Resident #32 had overheard the statement. She indicated she spoke with Resident #32 after the incident and he was upset. NA #4 stated she recalled him say something like, ' I don ' t understand why she doesn ' t like me ' and that he ' never did nothing to her ' . A written statement dated [DATE] completed by Nurse #1 indicated NA #4 informed her that Resident #32 wanted a muffin from the kitchen and Cook #1 refused to give him the muffin. She reported that she went to the kitchen and told Cook #1 to give Resident #32 a muffin. Nurse #1 wrote that Cook #1 replied, if the MF choke its gonna be on (nursing staff). Nurse #1 indicated she informed Nurse #4 about Cook #1 ' s statement regarding Resident #32. She additionally indicated that Resident #32 had overheard Cook #1 ' s statement. A phone interview was conducted with Nurse #1 on [DATE] at 10:42 AM. She stated that she recalled the [DATE] incident related to the muffin that involved Resident #32 and Cook #1. She additionally confirmed she had completed the written statement dated [DATE]. Nurse #1 reported that she was unable to recall all of the specifics of the incident, but that remembered one of the kitchen staff had used profanity directed at Resident #32. Nurse #1 indicated she spoke with Resident #32 after the incident and he shared with her that the incident had upset him. A phone interview was conducted with Nurse #4 on [DATE] at 5:58 PM. She stated that she recalled the [DATE] incident related to the muffin that involved Resident #32 and Cook #1. She confirmed the information provided by NA #4 and Nurse #1. She added that Resident #32 had not been given a muffin because his meal ticket indicated that he was to have toast based on his diet and his swallowing issues. Nurse #4 stated Resident #32 was alert and oriented and that he understood the risks of eating a muffin related to his swallowing issues. She additionally stated that it was Resident #32 ' s right to receive the muffin as long as he understood the risks. Nurse #4 reported she was not present when NA #4 and Nurse #1 returned to the kitchen to instruct Cook #1 to give Resident #32 a muffin. A phone interview was conducted with Cook #1 on [DATE] at 3:36 PM. Cook #1 stated that she was terminated on [DATE] for the incident involving the muffin and Resident #32. She reported that she was in the kitchen with Dietary Aide (DA) #1 and DA #2 when NA #4 came to the kitchen and said that Resident #32 wanted a muffin. Cook #1 stated she told NA #4 that the muffin was not on his meal ticket as he had some choking issues and he was provided with toast instead of the muffin. She reported that she told NA #4 she was not giving Resident #32 a muffin. Cook #1 said that NA #4 then brought one of the nurses over and they told her to give Resident #32 a muffin. She stated she told the nurse and NA #4 that if Resident #32 choked on the muffin and died that it was not on her or the dietary staff, but that it was on the nursing staff. She indicated that NA #4 was holding the kitchen door open when this exchange of words occurred. She stated she was unsure if any residents had overheard the conversation. Cook #1 denied using profanity when speaking about Resident #32. A phone interview was conducted with DA #2 on [DATE] at 11:03 AM. She stated that she recalled the [DATE] incident related to the muffin that involved Resident #32 and Cook #1. She reported that she was in the kitchen with DA #1 and Cook #1 on [DATE] at the time of the incident. DA #2 stated that Cook #1 said to NA #4, if the (m .fer) chokes, don ' t bring it back here on the kitchen leave it out there. She explained that Cook #1 wanted to make sure dietary staff were not to blame if Resident #32 choked on the muffin. A phone interview was conducted with DA #1 on [DATE] at 2:05 PM. She stated that she recalled the [DATE] incident related to the muffin that involved Resident #32 and Cook #1. She reported that she was in the kitchen with DA #2 and Cook #1 on [DATE] at the time of the incident. DA #1 reported that Cook #1 told NA #4 that it was not on the kitchen staff if Resident #32 choked on the muffin. She stated that NA #4 was holding the kitchen door open and that residents were in the dining room during this incident. She indicated she was unsure if any residents overheard the conversation. An interview was conducted with Resident #32 on [DATE] at 4:40 PM. He was alert and oriented with no signs of cognitive impairment. He stated he recalled the incident on [DATE] that involved Cook #1 and the muffin. He reported that Cook #1 said something rude to him and she was fired by the Administrator. He indicated he was content with this resolution. Resident #32 indicated that this incident no longer bothered him, and he had no additional concerns with staff treating him with dignity and respect. An interview was conducted with the Administrator on [DATE] at 10:20 AM. He stated he completed the investigation related to an allegation of staff to resident verbal abuse on [DATE]. He stated this incident occurred over a weekend and he was not present at the actual time it happened. He stated one of the staff phoned him to report the incident. He indicated he had Cook #1 leave the facility grounds immediately upon receipt of the report. He stated he came into the facility that same day to begin his investigation. The Administrator stated he interviewed Resident #32 on [DATE] and the resident reported that he heard someone in the kitchen say that they hope he chokes on the (m .fing) muffin. Resident #32 told the Administrator he had not seen who made the statement. He indicated the resident said this bothered him and made him angry. The Administrator reported that based on Resident #32 ' s interview and corroborating interviews with nursing staff he substantiated the allegation and terminated Cook #1. He stated that this behavior from staff was unacceptable and that he expected residents to be treated with dignity and respect at all times. 3. Resident #47 was admitted [DATE] and readmitted [DATE] with cumulative [DIAGNOSES REDACTED]. Review of Resident #47 quarterly Minimum (MDS) data set [DATE] indicated he was cognitively intact and exhibited no behaviors. He was coded for an indwelling urinary catheter. Review of Resident #47 care plan dated last revised [DATE] indicated he had indwelling urinary catheter. Interventions included the application of a leg strap to anchor his catheter. The care plan did not include the intervention of a privacy bag for dignity. In an interview and observation on [DATE] at 1:40 PM, Resident #47 was sitting up in his room in a wheelchair. His urinary catheter drainage bag was observed covered in a privacy bag for dignity. Resident #47 stated he was paralyzed and unable to move his lower extremities. In an observation on [DATE] at 4:20 PM, Resident #47 was observed lying in bed with his urinary drainage bag facing toward the hall with his door open. There was no observed privacy bag covering his urinary drainage bag. In an observation on [DATE] at 8:30 AM, Resident #47 was observed lying in bed with his urinary drainage bag facing toward the hall with his door open. There was no observed privacy bag covering his urinary drainage bag. In an observation on [DATE] at 9:00 AM, Resident #47 was observed lying in bed with his urinary drainage bag facing toward the hall with his door open. There was no observed privacy bag covering his urinary drainage bag. In an interview and observation on [DATE] at 9:45 AM, Resident #47 was observed lying in bed with his urinary drainage bag facing toward the hall with his door open. He stated he had a privacy bag for his urinary drainage bag that was attached to his wheelchair. He stated he was not aware that his urinary drainage bag was uncovered at present while lying in bed. He stated he preferred his urinary drainage bag to be covered but expressed no psychological ill affect from it being exposed at present. Resident #47 requested that staff come and address it. In an interview on [DATE] at 9:45 AM, Nurse #3 was shown the uncovered urinary drainage bag from the hall into Resident #47's room. She stated it should be covered always for dignity. Nurse #3 stated whoever put Resident #47 back to bed must have forgotten to move the privacy bag on his wheelchair to his bed. Nurse #3 stated Nursing Assistant (NA) 9 was assigned Resident #47. In an interview on [DATE] at 11:15 AM, the Director of Nursing (DON) stated NA #9 had to leave work due to a family emergency and was unavailable for interview. She stated it was her expectation that Resident #47's urinary collection bag be covered at all times for dignity.

Based on record review, observation, and interviews with resident, family, Department of Social Services, and staff, the facility failed to provide incontinence care, showers, and/or bathing for 3 of 4 dependent residents reviewed for the provision of activity of daily living (ADL) care (Residents #36, #49 and #44). Resident # 49 was upset and teary for staying soaked with urine before the facility staff responded to the call bell to provide incontinence care. Findings included: 1. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 ' s cognition was fully intact. She had no behaviors and no rejection of care. Resident #49 required the extensive assistance of 1 for bed mobility and toileting and 2 or more for transfers. She was frequently incontinent of bladder and always incontinent of bowel. The Care Area Assessment (CAA) related to urinary incontinence for Resident #49 ' s 12/13/18 admission MDS indicated she was alert, oriented, and able to make decisions and communicate needs. Resident #49 indicated she had a history of [REDACTED]. The active care plan for Resident #49 included, in part, the following areas: - Resident #49 had an Activities of Daily Living (ADL) self-care performance deficit related to mobility, [MEDICAL CONDITIONS] and impaired balance. The interventions included, in part, assistance with tasks of washing hands, adjusting clothes, and cleaning self in relation to toilet use. - Resident #49 had altered bladder elimination related [MEDICAL CONDITION] contractures of the right hand and wrist. Resident #49 was noted to report difficulty holding her urine. The interventions included, in part, bed pan, mechanical lift for transfers, and encourage communication of needs for assistance with toileting. A complaint/grievance report dated 1/8/19 communicated by Resident #49 to the Human Resources Coordinator (HRC) indicated that the resident was concerned about how long she waited for her call light to be answered. This form had been reviewed by the SW and was assigned to the DON for investigation. An interview was conducted with Resident #49 on 1/9/19 at 11:30 AM. The grievance dated 1/8/19 written by the HRC that discussed the resident ' s concern with how long it took for her call light to be answered was reviewed with Resident #49. She stated that in the early morning on 1/8/19 she pressed her call bell because she had to urinate. She indicated it took over 2 hours for her call bell to be answered. She stated she urinated in her brief during that time as she had difficulty holding her urine. She revealed she sat in her brief that was soaked with urine until her call bell was answered by the HRC. She stated the DON then provided her with incontinent care. A phone interview was conducted with Department of Social Services (DSS) staff by phone on 1/9/19 at 8:09 AM. DSS staff stated she spoke with Resident #49 yesterday, 1/8/19, and the resident told her she sat in a urine-soaked brief for over 2 hours after pressing her call light for assistance. An interview was conducted with the HRC on 1/9/19 at 2:40 PM. The complaint/grievance report dated 1/8/19 related to Resident #49 was reviewed with the HRC. She stated she was walking the halls on 1/8/19 when she saw Resident #49 ' s call light on, so she entered the room and asked the resident if there was something she could help with. Resident #49 informed her she had been waiting awhile and needed cleaned up. She stated that Resident #49 reported that she turned her call light on at 4:45 AM. The HRC estimated it to be around 7:10 AM when she entered the room to answer the call light. She stated there was no obvious odor of urine in the room. She indicated that Resident #49 was visibly upset and was crying when she spoke with her. She said that after speaking to Resident #49 she went to the DON and Administrator to report the information. An interview was conducted with the DON on 1/9/19 at 2:30 PM. She reported she had provided incontinent care to Resident #49 on 1/8/19 after the HRC reported she answered the resident ' s call light and the resident said her light had been on for over 2 hours. The DON stated that Resident #49 had urinated in her brief. She reported Resident #49 was visibly upset and was tearful when she provided care. The DON indicated she expected call bells to be answered timely. Based on review of the nursing schedule and DON confirmation on 1/9/19 at 2:45 PM, Nurse #2 and NA #1 were assigned to Resident #49 for the third shift on 1/7/19 beginning at 11:00 PM and ending on 1/8/19 at 7:00 AM. A phone interview was conducted with Nurse #2 on 1/9/19 at 3:00 PM. He confirmed he was assigned to Resident #49 during the third shift beginning 1/7/19 and ending 1/8/19. He indicated that 2 NAs were working the third shift for the entire building and that NA #1 was assigned to Resident #49. Nurse #2 revealed he recalled Resident #49 ' s call light being on for an extended period of time during the early morning on 1/8/19. He was not surprised that it took over 2 hours for Resident #49 ' s call light to be answered. He explained that when there were only 2 NAs working it was difficult for them to answer call lights timely which caused a delay in meeting the residents ' needs. An interview was conducted with NA #1 on 1/9/19 at 3:15 PM. He confirmed he was assigned to Resident #49 during the third shift beginning 1/7/19 and ending 1/8/19. He stated he was working a double that day beginning on the second shift 1/7/19 and working through the third shift ending 1/8/19. He reported that he was 1 of 2 NAs working the third shift that day and they each had about 30 residents. NA #1 indicated he had not recalled Resident #49 ' s call light being on for an extended period of time during the early morning on 1/8/19, but revealed it was not a surprise to him. He explained that he had difficulty meeting residents ' needs timely when there were only 2 NAs working on the third shift. NA #1 reported that he had informed the DON in the past that it was difficult for him to meet the residents ' needs timely when only 2 NAs were working on the third shift. He stated that this had been going on for months and it had not improved. During an interview with the Administrator on 1/8/19 at 10:30 AM he stated he began working as the Administrator at this facility in (MONTH) of (YEAR). He revealed that the facility had difficulty obtaining and maintaining enough NAs to staff all three shifts since he began as the Administrator. When asked what his definition of sufficient staffing was he stated that sufficient staffing was enough staff both in terms of quality and quantity to meet the needs of the residents. During an interview with the Director of Nursing (DON) on 1/9/19 at 3:31 PM she stated she began working as the DON at the facility in (MONTH) of (YEAR). She confirmed the Administrator ' s interview related to the facility having difficulty obtaining and maintaining enough NAs to staff all three shifts. She stated that third shift was normally staffed with 2 or 3 NAs. She revealed that one day recently she had to come in to work as an NA on the 3rd shift because 1 of the 2 NAs who were on the schedule called off and she was unable to find anyone else to fill in. An interview was conducted with the Administrator on 1/9/19 at 10:20 AM. He indicated he spoke with Resident #49 on 1/8/19 after the grievance was reported by the HRC. He stated that Resident #49 reported to him that she had to wait a long time for her call bell to be answered. The Administrator indicated the investigation into this grievance was just beginning. He stated it was unacceptable for a resident to wait over 2 hours for a call bell to be answered. 2. Resident #44 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #44 ' s cognition was fully intact. She had no behaviors and no rejection of care. Resident #44 required the extensive assistance of 1 staff for bed mobility, dressing, toileting, and personal hygiene. She was dependent on 1 for bathing. The medical record indicated Resident #44 had a hospital stay from 12/12/18 through 12/18/18. A review of the shower/bathing schedule indicated Resident #44 ' s shower/bath days were Wednesdays and Saturdays. A review of the hard copy shower/bath documentation from 12/1/18 through 1/7/19 for Resident #44 was conducted and revealed the following: - Saturday 12/1/18: Resident #44 ' s shower/bath sheet was blank. - Wednesday 12/5/18: Resident #44 ' s shower/bath sheet was blank. - Saturday 12/8/18: Resident #44 had no shower/bath sheet for 12/8/18. - Wednesday 12/12/18: Resident #44 was discharged to the hospital on [DATE]. - Saturday 12/15/18: Resident #44 remained in the hospital on [DATE]. - Wednesday 12/19/18: Resident #44 was readmitted on [DATE] and the 12/19/18 shower/bath sheet was blank. - Saturday 12/22/18: Resident #44 had no shower/bath sheet for 12/22/18. - Wednesday 12/26/18: Resident #44 ' s hair was documented as washed on the shower/bath sheet. - Saturday 12/29/18: Resident #44 had no shower/bath sheet for 12/29/18. - Wednesday 1/2/19: Resident #44 ' s shower/bath sheet was blank. - Saturday 1/5/19: Resident #44 had no shower/bath sheet for 1/5/19. The active care plan for Resident #44 indicated the focus area of an Activities of Daily Living (ADL) self-care deficit. The interventions indicated Resident #44 was dependent on 1 staff for bathing and grooming. An interview and observation were conducted with Resident #44 on 1/7/19 at 12:00 PM. Resident #44 ' s hair appeared uncombed and greasy. She stated that she preferred to get bed baths over showers and that staff complied with this preference. She revealed that she had a concern with getting her hair washed. She stated that her hair was supposed to be washed on her shower/bath days which were scheduled twice per week. She indicated her shower/bath days were Wednesdays and Saturdays. She reported her hair was not always washed twice per week. Resident #44 indicated her hair got oily and her scalp was itchy when her hair wasn ' t washed twice per week. She stated that she was in the hospital in the middle of (MONTH) for about a week and that she only had her hair washed once since she returned from the hospital. An interview was conducted with Nursing Assistant (NA) #1 on 1/9/19 at 3:58 PM. He stated that he was originally hired to work the third shift, but that he frequently worked first and second shift as well. He reported he was familiar with Resident #44 and he stated that she was dependent on staff for her bathing and grooming needs. He indicated Resident #44 rarely got out of bed and she preferred to receive bed baths. He stated that hair washing was supposed to be provided for dependent residents twice per week on their shower/bath day. NA #1 revealed that the facility had difficulty obtaining and maintaining NA staff to fill all three shifts and that sometimes tasks such as hair washing were pushed to another shift or another day if the assigned NA was not able to get all of their tasks completed. He explained that the more critical tasks had to be prioritized first and that hair washing was not on the top of the priority list. During an interview with the Administrator on 1/8/19 at 10:30 AM he stated he began working as the Administrator at this facility in (MONTH) of (YEAR). He revealed that the facility had difficulty obtaining and maintaining enough NAs to staff all three shifts since he began as the Administrator. When asked what his definition of sufficient staffing was he stated that sufficient staffing was enough staff both in terms of quality and quantity to meet the needs of the residents. During an interview with the Director of Nursing (DON) on 1/9/19 at 3:31 PM she stated she began working as the DON at the facility in (MONTH) of (YEAR). She confirmed the Administrator ' s interview related to the facility having difficulty obtaining and maintaining enough NAs to staff all three shifts. She indicated that staff members were asked to work additional shifts and/or to work double shifts. The DON indicated that this had been going on for several months and had caused some of the staff to be exhausted. She acknowledged her awareness that essential care needs had been missed. A follow up interview with the Administrator and Director of Nursing on 1/10/19 at 2:31 PM. They both indicated that they expected residents ' ADL care needs to be met. They additionally indicated their expectation was to provide sufficient staffing to meet the residents ' needs. 3. Resident #36 was admitted on [DATE] with the [DIAGNOSES REDACTED]. A review of the residents care plan dated 10/1/18 revealed goals and interventions for activities of daily living self-care deficit. Goals was for the resident to receive personal care and to participate as able. Interventions were for bathing, grooming and incontinence care. The care plan included that the resident would also call out or [MEDICATION NAME] when assistance was needed in addition to using the call light. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had an intact cognition. The resident required extensive assistance of 2 persons for transfer, bathing and incontinence care. 3a. A review of Resident #36 ' s documented shower sheets from admission 10/1/8 to 1/10/19 revealed the resident did not receive his scheduled two showers per week. The resident was documented as having had a shower on (MONTH) 30, (YEAR) on second shift, (MONTH) 18, (YEAR) on second shift, and (MONTH) 4, 2019. On 1/7/19 at 10:30 am an interview was conducted with Resident #36 who stated he had not received his two showers per week as scheduled. The resident stated that he only had one shower last week and none the week before. On 1/7/19 at 11:00 am an interview was conducted with a family member of Resident #36 who stated she was informed by the resident that he had not received a shower during the last week in (MONTH) (YEAR). The family member observed that the resident ' s hygiene was currently dirty, including his hair. The family member commented that she assisted her father to have a bath herself. On 1/8/19 at 10:25 am an interview was conducted with the treatment nurse (TN) who stated that she was frequently being re-assigned for an entire shift as a nursing assistant due to staff shortages. It was not uncommon for an assignment to include 17 residents on day shift which included showers. The TN commented that if there was not enough time showers would be rescheduled. The treatment nurse stated if the resident ' s shower sheets were not documented then the shower was not done. The TN was aware that some residents had not received their showers, including Resident #36. On 1/8/19 at 1:15 pm an interview was conducted with Nursing Assistant (NA) #8, who regularly cared for Resident #36. NA #8 stated that there was currently a nursing assistant shortage at the facility. NA #8 stated she had 17 residents assigned to her on two different halls. The NA felt she could handle the load by putting off showers until the afternoon. The NA also stated that not all NAs could handle the load, could not complete their assignment and required help. NA #8 stated that Resident #36 had not refused his shower for her. The resident was able to make his needs known. NA #8 stated that staff was required to document when the resident received a bath or shower on the resident ' s shower sheets and if refused to let the nurse know. The NA also commented that if the shower sheets were not completed the shower was considered not to be done. On 1/8/19 at 1:57 pm an interview was conducted with Nurse #9, who regularly cared for Resident #36. Nurse #9 stated there was a shortage of nursing assistants so she assisted them during her shift and was reassigned as a nursing assistant for an entire shift more than one day a week. Nurse #9 was not aware that Resident #36 had not received his scheduled showers each week and stated he had not refused his shower. 1/8/19 at 10:30 am an interview was conducted with the Administrator who stated that there had been several staff resignations and terminations. To temporarily resolve the nursing assistance shortage, licensed nurses have been assigned to the nursing assistant role, but not taken from a nursing assignment. The shortage had been over the past 3 months. The Administrator expected residents to receive showers as scheduled and if delayed to complete the shower on the next shift or next day. On 1/10/19 at 2:00 pm an interview was conducted with the Director of Nursing (DON) who stated that she expected nursing assistants to provide showers to the residents twice a week and if there was a refusal to report this to the nurse for intervention. The DON further stated that there was a nursing assistant staff shortage and nurses where reassigned to assist. The DON stated that there were times when lesser important tasks such as showers were postponed due to the shortage. The DON commented that if the shower sheets were not completed/documented then the shower was not provided to the resident. 3b. On 1/7/19 at 10:30 am an interview was conducted with Resident #36 who stated he had not always received incontinence care when needed and had gotten soaked through with urine to his bed on a few occasions. The last time was when his family member assisted him with a bath. The resident commented that at times he had to wait for staff to respond to his call light. The resident stated he would call out or [MEDICATION NAME] for assistance because the staff did not always respond to the light. The resident stated one a couple of occasion he had to wait up to 45 minutes for assistance. On 1/7/19 at 11:00 am an interview was conducted with the family who stated she was informed by the resident he had to wait a long time for staff to answer the call light and when he called out for staff assistance. The family member had observed the last week in (MONTH) that the resident was soaked through his undergarment and the bed was wet. The family member commented that she observed a 45-minute time frame for staff to answer Resident #36 ' s call light when he needed assistance with incontinence care. On 1/8/19 at 10:25 am an observation was conducted of the resident ' s incontinence care by the TN who was assigned to nursing assistant duties today. The resident ' s undergarment was soaked through with urine. The resident commented that he had put his call light on for assistance. On 1/8/19 at 1:15 pm an interview was conducted with Nursing Assistant (NA) #8 who regularly cared for Resident #36. NA #8 stated that there was currently a nursing shortage at the facility. NA #8 stated she had 17 residents assigned to her on two different halls. NA #8 stated that incontinence care was always completed but was sometimes delayed. NA #8 stated that she was aware Resident #36 used calling out or [MEDICATION NAME] to summon staff for assistance. On 1/10/19 at 10:12 am an interview was conducted with the DON who stated she expected the staff to provide incontinence care on the 2-hour schedule and as needed. The DON also commented that if the resident was observed or requested incontinence care the staff should provide care