Every finding on record at Westwood Healthcare and Rehabilitation

Based on observations, staff interviews, and review of the facility policy titled Preventative Maintenance Program, the facility failed to maintain a safe and sanitary environment in nine rooms on two of two halls (Blue Hall and Red Hall). These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment, and a potential for diminished quality of life. Findings include: Review of the facility's policy titled Preventative Maintenance Program, reviewed 4/1/2024, revealed the Policy section stated, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, and comfortable environment for residents, staff, and the public. Observation on 5/2/2025 at 8:17 am of the shared bathroom for rooms [ROOM NUMBERS] revealed a dark, black, thick substance around the base of the toilet. In addition, there was a metal drain fixture in the floor of the bathroom that was covered in a dark black substance. Observation on 5/2/2025 at 8:20 am of the shared bathroom for rooms [ROOM NUMBERS] revealed a hole in the ceiling and a yellow substance around the toilet base. Observation on 5/2/2025 at 8:23 am of the shared bathroom for rooms [ROOM NUMBERS] revealed a metal drain fixture on the floor covered in a dark gray substance. During a concurrent observational tour and interview on 5/4/2025 beginning at 8:30 am, the Administrator and Maintenance Director confirmed the identified concerns. The Administrator stated they would clean and repair the toilets as well as the ceiling. The Administrator stated it was important to her for the residents to have a clean and safe environment. 36377 Observation on 5/2/2025 in an Activity Sitting Room located on the Red Hall revealed a dark brown spot on the ceiling tiles and protruding sharp, rugged, rusty edges on the door sill. Observations on 5/2/2025 at 8:31 am and 2:44 pm, and on 5/3/2025 at 11:00 am and 2:01 pm in the bathroom for room [ROOM NUMBER] revealed a strong urine odor and dark, black, thick substance coating the floor drainage vent. Observation on 5/2/2025 at 8:32 am revealed broken blinds in room [ROOM NUMBER]. Observation on 5/2/2025 at 8:33 am in room [ROOM NUMBER] revealed a dark brown spot on the floor tiles near the entry door and a dark black substance coating the baseboard near bed A. Observation in the bathroom for room [ROOM NUMBER] revealed a dark brown substance coating the floor tiles near the toilet base and holes in the wall. Observation on 5/2/2025 at 8:37 am in the Blue Hall Shower Room revealed a large, greyish wet spot on the ceiling tile above the shower stall. Observation on 5/2/2025 at 8:40 am in the bathroom of room [ROOM NUMBER] revealed a strong musty odor, and a drainage vent covered with a dark, thick, sticky black substance. During a concurrent observational tour and interview on 5/4/2025 beginning at 8:38 am, the Administrator, Housekeeping Supervisor, and Maintenance Director confirmed the identified concerns. The Administrator, Maintenance Director, and Housekeeping Supervisor stated repairs would be made.

Based on resident and staff interviews, record reviews, and review of the facility's policies titled Bed Hold Notice and Transfer and Discharge, the facility failed to ensure one of 25 sampled residents (R) (R24) was provided with a written bed hold notice or reason for transfer at the time of transfer. This failure had the potential to place the residents or resident representative at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility. Findings include: Review of the facility policy titled Bed Hold, reviewed/revised 4/1/2024, revealed the Policy section stated, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. The Policy Explanation and Compliance Guidelines section included, 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies a. the duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. the reserve bed payment policy in the state plan policy if any. c. The facility policies regarding bed hold periods to include allowing a resident to return ot the next available bed. 3. The facility will keep a signed and dated copy of the bed hold notice information given to the resident and or resident representative in the resident's file and or medical record. 4. The facility will provide this written information to all facility residents, regardless of their payment source. Review of the facility policy titled Transfer and Discharge, reviewed/revised 4/1/2024, revealed the Policy Explanation and Guidelines section included, . 10.Emergency Transfers to Acute Care. g. Provide a notice of transfer and the facility's bed hold notice policy to the resident and resident representative as indicated. Review of R24's clinical record revealed an admitted [DATE] with diagnoses including, but not limited to, acute kidney failure and paroxysmal atrial fibrillation. Review of R24's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Review of R24's Clinical Census revealed R24 was transferred to the hospital from the facility on 6/22/2024 and 4/15/2025. Review of R24's clinical record revealed no evidence of the provision of a notice of bed hold or reason for transfer provided to R24 on 6/22/2024 or 4/15/2025. In an interview on 5/2/2025 at 2:02 pm, R24 stated the facility did not provide a written bed hold notice or reason for transfer form on 6/22/2024 or on 4/15/2025. In an interview on 5/3/2025 at 2:42 pm, Licensed Practical Nurse (LPN) BB stated that when a resident is transferred from the facility to a hospital, she prints the resident's orders, face sheet, and notifies the physician and family. She stated that nurses did not complete or issue bed holds to residents or representatives and that the administration was responsible for the bed hold notifications. She further stated that the nursing staff did not give anything in writing to the resident for the reason for transfer. In an interview on 5/3/2025 at 8:44 am, the Administrator stated that the Business Officer Manager (BOM) managed bed holds and was unavailable for interview. The Administrator was unable to locate proof that a written bed hold notice or reason for transfer was provided to the resident or representative for the hospital transfers on 6/22/2204 and 4/15/2025. In an interview on 5/4/2025 at 9:15 am, the resident representative stated that a written bed hold notice or reason for transfer was not provided when R24 was transferred to a hospital on 6/22/2204 and 4/15/2025.

Based on observations, staff interviews, and record reviews, the facility failed to implement care plans for two of 25 sampled residents (R) (R306 and R13). This deficient practice had the potential to place R306 and R13 at risk of medical complications, unmet needs, and a diminished quality of life. Findings include: 1. Review of R306's Quarterly Minimum Data Set (MDS) assessment, dated 3/24/2025, revealed Section E (Behaviors) documented physical behaviors toward others occurred one to three days, and other behavior symptoms not directed toward others occurred four to six days of the look-back period. Review of R306's Care Plan Report revealed a 'Focus initiated 10/23/2022 of Behaviors: has combative behaviors. Interventions included that the resident was seen by mental health services. Review of R306's clinical record revealed no documentation of mental health services for the last four months. In an interview on 5/3/2025 at 8:38 am, the Social Worker confirmed R306 had not been referred for behavioral health services as recommended by the Nurse Practitioner (NP). In an interview on 5/3/2025 at 12:22 pm, Registered Nurse (RN) EE stated the NP had recommended R306 to be evaluated by behavioral health services, but R306 had not been evaluated by behavioral health services. In an interview on 5/3/2025 at 12:28 pm, the Director of Nursing (DON) stated R306 should have been seen by the behavioral health services that provided weekly services at the facility. The DON stated the facility failed to arrange for R306 to have mental health services. In an interview on 5/3/2025 at 12:32 pm, the Administrator confirmed that R306's care plan included behavioral health services, and the services had not been provided. 49675 2. Review of 13's Quarterly MDS assessment, dated 4/22/2025, revealed Section J (Health Conditions) documented that the resident exhibited shortness of breath. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen therapy. Review of R13's Physician Orders revealed an order dated 1/18/2025 for oxygen at three liters per minute (LPM) via nasal canula, continuous. Observations on 5/2/2025 at 8:18 am, 8:34 am, and 5/3/2025 at 8:34 am and 10:30 am revealed the resident receiving oxygen at a rate set at 2 LPM. Review of R13's Care Plan Report revealed a Focus area of being at risk for ineffective gas exchange related to acute respiratory failure, chronic obstructive pulmonary disease COPD, dyspnea, and malignant neoplasm of unspecified lung. Interventions included giving oxygen as ordered by the physician. In an interview on 5/3/2025 at 12:45 pm, the MDS Coordinator stated she developed resident care plans. She confirmed staff failed to follow R13's care plan by not administering oxygen as prescribed by the physician. The MDS Coordinator stated that her expectations of staff were to follow the care plan. In an interview on 5/3/2025 at 12:45 pm, the DON confirmed the facility failed to follow the care plan for R13 related to oxygen. She revealed she expected nurses to provide care per the physician's orders and follow the care plans. Cross-Reference F695

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Accident and Supervision, the facility failed to ensure an environment free of accident hazards for three of 25 sampled residents (R) (R21, R25, and R18). This deficient practice had the potential to place R21, R25, and R18 at risk of avoidable accidents. Findings include: Review of the facility policy titled Accident and Supervision, dated 4/1/2024, revealed the Policy section stated, The resident environment will remain free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes. 1. Identifying hazards (s) and risks(s). 2. Evaluating and analyzing hazards(s) and risk(s) 3. Implementing interventions to reduce hazards and risks. 4. Monitoring for effectiveness and modifying interventions when necessary. The Policy Explanation and Compliance Guidelines included, 1. Identification of Hazards and Risks - the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: . ii. Environmental rounds. 1. Review of R21's electronic medical record (EMR) revealed diagnoses including, but not limited to, unspecified osteoarthritis, history of falling, chronic obstructive pulmonary disease, heart failure, and hypertension. Review of R21's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) of eight (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented R21 required supervision with ambulation and used a walker. Record review revealed R21 resided in room [ROOM NUMBER]. Observation revealed that rooms [ROOM NUMBERS] shared a bathroom. Observation on 5/2/2025 at 8:36 am revealed that while R21 was exiting the bathroom into her room, she slipped, without falling, and grabbed the sink and her rolling walker. Further observation revealed water around the base of the toilet in the bathroom. In an interview on 5/2/2025 at 8:36 am, R21 stated that water leaks from the toilet to the floor in the bathroom every time it is flushed. She stated the toilet had leaked for a few months, and she had reported it to staff. She further stated she was afraid of falling because of the water on the floor. 2. Review of R25 's EMR revealed diagnoses including, but not limited to, type two diabetes mellitus with hyperglycemia, cerebral ischemia, spinal stenosis, lumbar region with neurogenic age-related osteoporosis. Review of R25's Quarterly MDS, dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) of six (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented R25 required supervision with ambulation and did not use an assistive device for ambulation. Review of R25's Care Plan Report revealed a Focus area initiated 8/6/2023, of being at risk for falls related to poor safety awareness, weakness, lack of coordination, and pain. Record review revealed R25 resided in room [ROOM NUMBER]. In an interview on 5/2/2025 at 8:45 am, R25 stated that water had been on the bathroom floor for about one month. 3. Review of R18's EMR revealed diagnoses including, but not limited to, Alzheimer's disease, hypertension, glaucoma, history of falling, and repeated falls. Review of R18's Quarterly MDS, dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) of six (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented R18 required supervision with ambulation and did not use an assistive device for ambulation. Review of R18's Care Plan Report revealed a Focus area initiated 5/15/2024, of being at risk for falls related to history of falls, muscle weakness, pain, difficulty walking, and impaired vision. Interventions included keeping pathways free of clutter and any fall hazards Record review revealed R18 resided in room [ROOM NUMBER]. In an interview on 5/2/2025 at 8:42 am, Certified Nursing Assistant (CNA) CC verified that R21, R25, and R18 were ambulatory and used the shared bathroom. During a concurrent observation and interview on 5/2/2025 at 8:18 am, the Maintenance Supervisor and Director of Nursing (DON) confirmed the water on the floor and the leaking toilet in the shared bathroom of rooms [ROOM NUMBERS]. The Maintenance Supervisor reported being unaware of the toilet leaking at the base. In an interview on 5/4/2025 at 8:18 am, the Administrator reported being unaware of the leaking toilet in the shared bathroom for rooms [ROOM NUMBERS]. She stated that the facility staff conducted environmental rounds, and she would add checking for leaking toilets to the task list.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that the physician's order for oxygen administration was followed for one of 10 residents (R) (R13) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Oxygen Administration, dated reviewed/revised 4/1/2025, revealed the section titled Policy Explanation and Compliance Guidelines included, 1. Oxygen is administered under the orders of a physician, except in the case of an emergency. Review of R13's clinical record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) (acute) exacerbation and acute respiratory failure with hypoxia. Review of 13's Quarterly Minimum Data Set (MDS) assessment, dated 4/22/2025, revealed Section J (Health Conditions) documented that the resident exhibited shortness of breath. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen therapy. Review of R13's Physician Orders revealed an order dated 1/18/2025 for oxygen at three LPM (liters per minute) via nasal canula, continuous. Observations on 5/2/2025 at 8:18 am, 8:34 am, and 5/3/2025 at 8:34 am and 10:30 am revealed the resident receiving oxygen at a rate set at 2 LPM. During a concurrent observation and interview on 5/3/2025 at 10:42 am, Licensed Practical Nurse (LPN) AA revealed that she was responsible for making sure the oxygen setting was set on the prescribed rate during morning medication pass. She stated she did not check the rate on 5/2/2025 or 5/3/2025, and she confirmed R13's oxygen was set on two LPM. LPN AA reviewed R13's physician orders and verified that the physician's order was for three LPM. In an interview on 5/3/2025 at 10:49 am, the Director of Nursing (DON) stated her expectations were for staff to ensure oxygen was administered as ordered by the physician. She stated nurses should check oxygen settings during their medication pass and rounding, since oxygen is a medication.

Based on staff interviews, record review, and review of the facility policy titled Behavioral Health Services, the facility failed to ensure one of 25 sampled residents (R) (R306) received behavioral health services to address behaviors. The deficient practice had the potential to place R306 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Behavioral Health Services, reviewed/revised 4/1/2024, revealed the Policy section stated, It is policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being. The Policy Explanation and Compliance Guidelines section included, 3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goal for care, while maximizing the residents' dignity, autonomy, privacy, socialization, independence, choice, and safety. Review of R306's clinical record revealed diagnoses including, but not limited to, unspecified psychosis, dependence on renal dialysis, end-stage renal disease, restlessness and agitation, unspecified dementia, and mood disorder. Review of R306's Quarterly Minimum Data Set (MDS) assessment, dated 3/24/2025, revealed Section E (Behaviors) documented physical behaviors toward others occurred one to three days, and other behavior symptoms not directed toward others occurred four to six days of the look-back period. Review of R306's Progress Notes revealed an entry dated 2/27/2025 documenting that the resident was observed in another resident's room with his hands on another resident's neck and head. The Physician, Director of Nursing, Administrator, and responsible parties were notified. Review of R306's Progress Notes revealed a Social Service Note dated 3/1/2025, of Writer reached out to Psychiatric NP [Nurse Practitioner] for an emergency consult. NP was unavailable and recommended that the resident be immediately sent out to a behavioral health facility. Writer informed NP that resident is on dialysis and no known behavioral health facility is able to accommodate him. As of writing, writer has not heard back from NP. Writer will monitor and follow up as necessary. Review of R306's clinical record revealed no documentation of mental health services for the last four months. In an interview on 5/3/2025 at 8:38 am, the Social Worker stated that R306 had behaviors and sometimes needed redirection. The Social Worker stated that she monitored R306 and there had been no further incidents since 2/27/2025. She confirmed R306 had not been referred for behavioral health services as recommended by the NP. In an interview on 5/3/2025 at 12:22 pm, Registered Nurse (RN) EE stated the NP had recommended R306 to be evaluated by behavioral health services, but R306 had not been evaluated by behavioral health services due to R306 was out of the facility for dialysis on the days the behavioral health service provider was at the facility. RN EE stated the facility should have arranged an appointment for R306 to receive behavioral health services. In an interview on 5/3/2025 at 12:28 pm, the Director of Nursing (DON) stated R306 should have been seen by the behavioral health services that provided weekly services at the facility. The DON stated the services were provided on Mondays, when R306 was at dialysis, and the facility should have arranged for R306 to be seen on a different day. In an interview on 5/3/2025 at 12:32 pm, the Administrator stated she was unaware that R306 had not received behavioral health services as recommended by the NP, and stated the services should have been arranged.

Based on interviews, record review, and review of facility policy titled Infection Prevention and Control Program the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection and failed to implement a procedure to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water system. The facility census was 52. Findings include: Review of facility's policy titled Infection Prevention and Control Program with date implemented 2/2/2022: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following the policies and procedures related to the program. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documents of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. c. The RNs (Registered Nurses) and LPNs (Licenses Practical Nurses) participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. Infection control documents to include infection tracking, antibiotic stewardship, COVID-19, and immunization surveillance requested on 3/31/2023 during entrance conference at 7:45 a.m. and again on 3/31/2023 at 11:00 a.m. from the Infection Control Preventionist (ICP)/ Assistant Director of Nursing (ADON). ICP/ADON stated that she would go get the books and bring the books back to the surveyor. ICP exited conference room at this time. Interview with ICP/ADON on 3/31/2023 at 12:00 p.m. revealed she does not have the books at the facility. She stated that she was going to have to run home to get the books because she took the books home to make sure that she had everything in them. Interview with ICP/ADON on 3/31/2023 at 1:30 p.m. upon her return to the facility revealed she cannot find any of the infection control books. She stated that she had another nurse who used to do treatments come in and help her with infection control. She stated that the other nurse took the books with her, but she no longer works at the facility. She stated that the other nurse quit in January of 2023. When surveyor asked ICP/ADON if other nurse left with the infection control book in January 2023, was she not aware that the book was not at the facility until the last day of March 2023, ICP/ADON then stated that the books are at the facility, but she does not know where the other nurse put the books. ICP/ADON stated that she has placed several calls to the other nurse today to ask her where the books are, but the other nurse has not returned any of her calls. Interview with Administrator and Regional Nurse Consultant (RNC) on 4/1/2023 at 10:20 a.m. revealed they are unable to locate the infection control books. The Administrator stated that the ICP/ADON is now on vacation. The Administrator stated they will continue to look for the books but at this time they cannot be located. She stated they have a water management plan. She stated that the Maintenance Director is in charge of the Legionella testing. Interview with RNC on 4/1/2023 at 2:14 p.m. revealed they have an Antibiotic Stewardship Program however it is not working out with the current ICP/ADON regarding the IC program. She stated that she would provide documentation on the Antibiotic Stewardship Programs Plan. Interview with RNC on 4/2/2023 at 8:56 a.m. revealed that she agrees that the documentation for the infection control surveillance was not in the binder provided to the surveyor. She stated that she identified that, and they have a plan. The facility does not have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards (e.g., ASHRAE, CDC, U.S. Environmental Protection Agency or EPA). Interview with the Administrator on 4/2/2023 at 8:35 a.m. revealed she is not sure about the Infection Control Program. She stated that she would have to ask the RNC because she sticks to the operations, and she lets her handle clinical. The Administrator stated that they have not had Legionella testing. She stated she became aware of the need for one about a month ago. She stated that DON mentioned to her a month ago that she heard that they would have to start doing Legionella testing. She stated that she has to look up the regulations and find out how frequently they need to test and teach the maintenance person. She stated her plan is to order the kit and get started today. The Administrator stated that she did research, and she would have to order a kit from Amazon and see how often they need to test it. The Administrator stated that they currently do not have a Maintenance Director. She stated that the Housekeeping Supervisor is just filling in as maintenance director until they can find someone. She stated the last Maintenance Director left in January 2023. No resident concerns were identified related to infection control and/or outbreaks within the facility. There were no COVID-19 outbreaks.

Based on interviews, record review, and review of facility policy titled Infection Prevention and Control Program the facility failed to provide evidence that residents were offered the Influenza and/or Pneumococcal vaccine for three residents (R#11, R#6, and R#50) of five sampled residents reviewed for immunizations. Findings include: Review of facility's policy titled Infection Prevention and Control Program with date implemented 2/2/2022: Influenza and Pneumococcal Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time. b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere. c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d. Residents will have the opportunity to refuse immunizations. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations. 1. R#11 admitted to the facility on [DATE]. Review of R#11's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Section O revealed the Pneumococcal vaccine was not up to date and had not been received because it had not been offered. Influenza vaccine was offered and declined. Review of R#11 electronic medical records (EMR) revealed there was no documented evidence that R#11 was offered or declined the Influenza vaccine. 2. R#6 admitted to the facility on [DATE]. Review of R#6's Quarterly MDS assessment dated [DATE] revealed a BIMS score of three, indicating severe cognitive impairment. Section O revealed the Pneumococcal vaccine was not up to date and had not been received because it had not been offered. 3. R#50 was admitted to the facility on [DATE]. Review of R#50's Admission MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated cognitively intact. Section O revealed the Pneumococcal vaccine was not up to date and had not been received because it had not been offered. R#50 did not receive the Influenza vaccine in the facility for this year's influenza season. Interview with R#50 on 4/2/2023 at 11:50 a.m. revealed he had immunizations prior to admission. Review of R#50's EMR revealed there was no documented evidence that R#50 received the Pneumococcal or Influenza vaccine. Interview with the Regional Nurse Consultant (RNC) on 4/2/2023 at 11:25 a.m. revealed she looked in the EMR and she did not see any documentation of immunizations being offered and/or given for R#11, R#6, and R#50. She stated that she even looked in Georgia Immunization Registry (GRITS) and she did not see anything there. Interview with the Director of Nursing (DON) on 4/2/2023 at 11:42 a.m. revealed the Infection Control Preventionist (ICP) is responsible for getting the consent forms for residents. She stated that the ICP is responsible to make sure that residents have consent forms and receive their vaccines.

Based on interviews, record reviews, and review of facility policy titled Infection Prevention and Control Program the facility failed to ensure that three residents (R#6, R#11, and R#50) of five sampled residents were offered, received, and had documentation related to the COVID-19 vaccine. Findings include: Review of facility's policy titled Infection Prevention and Control Program with date implemented 2/2/2022: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: 8. COVID-19 Immunizations: a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. b. Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine candidacy for the vaccination. c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine. d. Residents or resident representatives and staff will have the opportunity to accept or refuse a COVID-19 vaccination and change their decision. e. Documentation will reflect the education provided and details regarding whether or not he resident or staff received the vaccine. 1. Resident #6 was admitted to the facility on [DATE]. Record review revealed there is no documentation of COVID-19 vaccines or COVID-19 vaccination status. 2. Resident #11 was admitted to the facility on [DATE]. Record review revealed there is no documentation of COVID-19 vaccines or COVID-19 vaccination status. 3. Resident #50 was admitted to the facility on [DATE]. Record review revealed there is no documentation of COVID-19 vaccines or COVID-19 vaccination status. Interview with the Regional Nurse Consultant (RNC) on 4/2/2023 at 11:25 a.m. revealed she looked in the electronic medical record (EMR) and she did not see any documentation that immunizations to include the COVID-19 vaccine was offered and given for R#6, R#11, and R#50. She stated that she even looked in Georgia Immunization Registry (GRITS) and she did not see anything there. Interview with the Director of Nursing (DON) on 4/2/2023 at 11:42 a.m. revealed the Infection Control Preventionist (ICP) is responsible for getting the consent forms for residents. She stated that the ICP is responsible to make sure that residents have consent forms and receive their vaccines. There were no COVID-19 outbreaks. COVID-19 Staff Vaccination rate was 100%.

Based on record review, facility policy review, and staff interviews, the facility failed to provide a discharge summary recapitulating the residents' stay upon discharge for two residents (Resident (R)2 and R5) out of a total sample of 10 residents. Findings include: Review of the facility's undated policy titled Discharge Summary and Plan of Care revealed, .3. Upon discharge of a resident (other than an emergency hospital or death) a discharge summary will be provided .and should include a. An overview of the resident's stay that includes diagnosis, course of treatment .instructions or precautions for ongoing care. b. A final summary of the resident's status at the time of discharge . 1. Review of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/07/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R2 was cognitively intact for decision making related to her health care. R2 was ambulatory via wheelchair and was admitted for strengthening and gait/safety awareness interventions with physical and occupational therapy. Review of the EMR Progress Note tab revealed a psychiatric progress note, dated 10/19/21, stating R2 had fallen at home and broken her leg resulting in hospitalization and rehabilitation. Review of the progress notes in the EMR from nursing, nurse aids, and the social services staff revealed R2 had scavenging and hoarding behaviors since her admission. Review of the progress notes revealed R2 scavenged from meal trays and pantries, as well as asked staff to bring her supplies that she had already received from the previous shift. Additional behaviors documented in the progress notes included R2 stated her desire to leave daily, was verbally abusive to staff and once to her roommate and called 911 from her room several times until the responding police officer of one of the calls scolded her for attempting to file false reports. An interview on 09/21/22 at 3:30 PM with the acting Social Services (SS) staff confirmed the events found in the progress note reviews. The SS staff stated, .[R2] never wanted to be here but the NP [Nurse Practitioner] didn't feel she was stable enough for self-care and discharge home alone - she doesn't have family or friends here . A progress note dated 11/07/21 at 3:10 PM revealed R2 demanded assistance loading her belongings because she intended to leave Against Medical Advice (AMA). R2 was advised she could not take the wheelchair, as it was facility property, and she could not take her medications, as she was not medically released for discharge. R2 arranged transportation and left the facility AMA. Continued record review revealed there was no discharge summary recapitulating R2's stay and/or documentation of the physician's assessment of R2's condition at time of discharge. 2. Review of the EMR undated face sheet revealed R5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS with an ARD of 10/07/22 revealed a BIMS score of 13 out of 15, indicating R5 was cognitively intact for decision making related to her health care. Review of an admitting nurse progress note, dated 12/13/21 and found in the EMR Progress Note tab, revealed .[R5] was a paraplegic female who was admitted to facility via stretcher from doctor's hospital. Resident has an indwelling foley catheter that is patent draining urine via gravity. resident has a JP drainage tube to right upper thigh draining a small amount of bright red blood. Resident has six stitches above the drainage tubing site. Resident has a sacrum wound and a wound to her right-side buttocks. also, resident has an open wound to her left heel. Resident has bilateral foot drop . Review of a progress note dated 05/03/22 revealed R5 left with arranged transport for a medical appointment at 10:34 AM. When R5 had not returned by 5:45 PM the facility contacted the transportation provider and was told that they waited for over an hour for the resident who never came out for her ride. The facility charge nurse called the local acute hospital and was told that R5 signed in for treatment and that's all the information they could share due to HIPPA. Another call was placed at 11:39 AM on 05/03/22 and the facility nurse was told, .[R5] did not want to return to the facility . Continued record review revealed there was no discharge summary recapitulating the resident's stay and/or documenting the physician's assessment of R5's condition at time of discharge. In an interview with the Director of Nursing (DON) and the Corporate Clinical Supervisor (CCS) on 09/22/22 at 3:00 PM, the CCS stated there was no discharge summary for R2 or R5 because they both left unexpectedly and without formal discharge planning.

Based on observation, review, facility policy review, and staff interviews, the facility failed to follow their policy for resident safety with a mechanical [Hoyer] lift transfers. This failure affected one resident (Resident (R) 1) out of a total sample of 10 residents. Specifically, R1 was transferred with only one staff member present for a mechanical lift transfer from the resident's bed to the wheelchair. This failure increased the risk of injury to the residents during transfers. Findings include: Review of the facility's undated policy titled Safe Resident Handling/Transfers revealed, Policy: It is the policy of this facility to ensure that residents are handled/transferred to prevent and/or minimize risk for injury and provide a safe and secure and comfortable experience for the resident .Compliance Guidelines: 10. Two staff members must be utilized when transferring residents by mechanical lift. During the initial tour on 09/21/22 at 9:50 AM, a random observation revealed R1 being transferred from her bed to her wheelchair which was located just outside her room. Certified Nurse Aid (CNA) 1 was noted to exit the room with R1 elevated in the sling of the mechanical lift. CNA 1 rolled the lift close to R1's wheelchair and attempted to lock and steady the wheelchair, while trying to stabilize the resident as she was lowered into the chair. Immediately following this observation, when the resident was safely in the chair and the lift was removed, CNA 1 was asked if the facility policy allowed single staff lift transfers. The CNA stated, no there's supposed to be two of us . Review of the electronic medical record (EMR) face sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], stage 4 pressure ulcer, and bilateral lower extremity [CONDITION(S)]. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact for decision making and could be reliably interviewed about her care. Immediately following the improper transfer on 09/21/22 at 10:00 AM, R1 stated she feels safe and well cared for in the facility and has not had any incidents involving the mechanical lift. An interview with the charge nurse Licensed Practical Nurse (LPN) 3 on 09/21/22 at 10:15 AM, revealed LPN 3's expectation and the facility policy was to always have two staff for lift transfers. In an interview with the Director of Nursing (DON) on 09/21/22 at 3:00 PM confirmed the facility policy was not followed and the DON stated she and the charge nurse had re-educated staff on all shifts about the importance of two person transfers with mechanical lifts to prevent resident injuries.

Based on staff interviews and review of facility policy titled Visitation and Infection Control Policy, the facility failed to designate a qualified infection preventionist who completed specialized training in infection prevention and control. The deficient practice placed all 49 residents at risk for potential transmission of COVID-19 infections and other communicable diseases. Findings include: Interview on 8/24/21 at 10:25 a.m. with Licensed Practical Nurse (LPN) CC revealed no clear knowledge of who the infection preventionist was for the facility. Interview on 8/24/21 at 10:45 a.m. with the Director of Nursing (DON) revealed the infection preventionist was the Assistant Director of Nursing (ADON). Further interview revealed that the DON was new to the facility and did have certification as an infection control preventionist but could not provide information pertaining to certification. Interview with Certified Nursing Assistant (CNA) FF on 8/24/21 at 11:15 a.m. revealed she had no knowledge of who was over the infection control program for the facility. Interview on 8/24/21 at 11:25 a.m. with the ADON revealed that there has not been an infection control nurse in the facility since the last DON resigned two weeks ago. The infection control program at the facility is overseen by Corporate Nurse Consultant GG and she was not in the role of the infection preventionist. Interview on 8/24/21 at 11:34 a.m. with Corporate Nurse Consultant GG revealed that currently the ADON is taking classes for certification as the Infection Control Preventionist (ICP). There is a weekly call that is conducted every Tuesday with the DON and ICP for all the facilities in the corporation. On this call any issues with infection control are discussed during this time. Further interview also revealed when there is a positive case in the facility the leadership team is notified that day or the following day of the status of the facility. DPH (Department of Public Health) is notified by the ADON when there is a new positive case in the facility and of any cluster infections that may arise. Continued interview also revealed the facility follows DPH guidelines for COVID positive residents and PPE (Personal Protective Equipment) management for residents on isolation precautions. Interview on 8/24/21 at 11:45 a.m. with ADON revealed that she was not currently taking classes for ICP certification and was not aware of an LPN being able to get certification for this course. Interview with ADON on 8/25/21 at 8:45 a.m. revealed that the previous DON was over the program but is no longer employed at the facility. Interview with the Administrator on 8/25/21 at 9:00 a.m. revealed that the DON is usually the one that is over the infection control program and currently the ADON is supposed to be overseeing the program and ensuring that staff are following the infection control guidelines and communicating with DPH. Review of the facility policy titled Visitation and Infection Control Policy updated 5/17/21 revealed in section five, plan to reopen, number six included: An infection preventionist with dedicated time for on-site infection prevention and monitoring.

Based on observations, review of facility policy titled Visitation and Infection Control, and staff interviews, the facility failed to ensure that infection control practices were followed and adhered to by facility staff. Specifically, the facility failed to provide Personal Protective Equipment (PPE) for staff use for one resident on observation isolation (room [ROOM NUMBER]) and failed to ensure that infection control practices were followed by staff during meal service on the COVID isolation unit. The deficient practice had the potential to affect 19 residents residing on the Blue Hall within the facility. Total census was 49. Findings include: 1. Observation on 8/24/21 at 9:15 a.m. revealed one resident was on observation isolation due to hospital return. There was no PPE equipment noted outside of room [ROOM NUMBER] (observation only resident), and one gown was noted hanging on the light fixture by the door. There was only one resident in this room. There were no other PPE supplies noted in the room at the time of observation. Interview on 8/24/21 at 10:25 a.m. with Licensed Practical Nurse (LPN) CC confirmed that the resident in room [ROOM NUMBER] did not have any PPE supplies available for staff use on the outside or inside of the room. Further interview also revealed that there should be supplies available even though resident is on observation only status. LPN CC had no knowledge of why there was a white isolation gown hung across the light fixture in room [ROOM NUMBER]. Observation of isolation room [ROOM NUMBER] not having any PPE supplies available for staff use was confirmed by the Director of Nursing (DON) on 8/24/21 at 10:30 a.m. Interview with DON revealed that PPE supplies should be available for staff use when caring for residents on isolation precautions. Interview with Certified Nursing Assistant (CNA) DD on 8/24/21 at 10:50 a.m. revealed she has been working at the facility for two weeks and had not received any form of PPE training from facility management but had received training from the nursing agency in which she is employed. Further interview also revealed that she does administer care to the resident who is on isolation precautions in room [ROOM NUMBER]. Before entering the resident's room, she knocks on the door and enters the room after the resident gives permission to enter and provides the care that is requested. The only PPE that is worn in the room is a mask and shield. CNA DD also disclosed that the question was asked to the charge nurse on the unit what PPE is needed for resident in 104. The response was the only PPE that needed to be worn was a mask and a shield because the resident was only on observation and was not positive for COVID so there was nothing to worry about. Observation on 8/24/21 at 10:55 a.m. revealed signage on the door of room [ROOM NUMBER] had postings of precautions for both droplet precautions and contact precautions posted on the door. Interview with CNA FF on 8/24/21 at 11:15 a.m. revealed that she works at the facility through agency and has not received any formal training from facility staff on PPE or COVID. Further interview also revealed that she also has worked with the resident in room [ROOM NUMBER], who is on isolation precautions for hospital return and was instructed by facility staff to only wear mask and shield in the room because the resident was not positive for COVID. CNA FF voiced concern of not having full PPE available for use while providing care for a resident on isolation. Interview on 8/24/21 at 11:25 a.m. with the Assistant Director of Nursing (ADON) revealed that (Department of Public Health) DPH is contacted every time there is a new positive case. Further interview also revealed that there has not been an infection control nurse in the facility since the last DON resigned two weeks ago. The infection control at the facility is overseen by Corporate Nurse Consultant GG. Review of facility policy titled Visitation and Infection Control updated 5/17/21 revealed that to prevent the spread of respiratory germs within the facility: F. Newly admitted resident: 7. Make PPE, including face masks, eye protection, gowns, gloves, and face shields/googles available immediately outside of the resident room when it's determined PPE is needed for the resident. 2. Observation on 8/24/21 at 9:15 a.m. revealed a total of four residents in COVID isolation rooms at the end of the Blue Hall divided by a barrier wall. Meal service observation on 8/24/21 at 12:33 p.m. revealed the food cart arrived on Blue Hall and staff started distributing food trays to the COVID unit first. Staff was observed passing each tray through the barrier to the CNA that was assigned to the COVID unit. The CNA did not have on any PPE except for a mask and shield during tray distribution. CNA on COVID unit was observed going in and out of all isolation rooms without proper PPE donned. After each meal was distributed to the residents on the COVID unit the empty trays were placed back on the food cart with the unserved trays. Interview on 8/24/21 at 12:45 p.m. with CNA EE revealed that while distributing the trays on the COVID unit the only PPE that was worn was a face mask and shield. Continued interview also revealed that while taking the residents tray to each room the food was taken off the food tray and transferred to their overbed tables. The trays were then given back to the CNA outside of the unit because there was not a place on the unit to put the empty trays. Continued interview also disclosed that there was no full PPE worn during meal distribution because she was only in the room for a minute. Second food service observation on 8/25/21 at 7:35 a.m. revealed the food cart arrived on Blue Hall and staff proceeded to distribute trays to residents. Staff was noted sanitizing hands before and after each tray delivery. Observation of food service on COVID unit revealed one CNA stood by the food cart on the outside of the unit and gave the tray to the nurse to distribute to residents on the unit. The tray was given to the nurse through the barrier. The nurse donned a gown, mask, and shield, but no gloves. On the four tray distributions, the nurse did not wear any PPE except for the mask and shield that was donned before entering the unit. After tray distribution was completed, the nurse did not change mask after exiting COVID unit. Interview with LPN HH on 8/25/21 at 8:05 a.m. revealed that the process for passing trays on the COVID unit is that, usually there is a nurse and CNA assigned to the unit and they would pass the trays on that unit. Today there was not a nurse or CNA on the unit to pass the trays, therefore LPN HH went to the unit to pass the trays. LPN HH confirmed that full PPE is required for admission to COVID unit and was not worn, neither was the mask changed after leaving unit and returning to general population to render care to other residents.

Based on observation, record review, and resident/staff interviews, the facility failed to allow one of 20 sampled residents (R) (R#31) the choice of when she could take a shower and failed to facilitate that choice in a bathing schedule. Findings include: During an initial interview conducted on 8/24/21 at 9:00 a.m., R#31 stated she prefers a morning shower but is on the 3-11 p.m. shower schedule. R#31 stated she use to receive her shower in the mornings, but they switched her showers to the afternoon. She stated she told an unnamed staff that her preference is to take her shower in the mornings. She stated that unnamed staff told her that she would have to stay on the 3-11 p.m. shower schedule. R#31 further stated unnamed staff told her she does not have a choice as to when she receives her shower. Review of the clinical record revealed R#31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R#31 had a Brief Interview for Mental status (BIMS) score of 15 (a score of 13 out of 15 indicates the resident is cognitively intact). Section F- Preference for Customary Routines and Activities documented it as very important to choose between tub bath, shower, bed bath, or sponge bath. Section G- Functional Status documented that R#31 required physical help in part of bathing activity. Review of undated shower sheets revealed R#31 is scheduled for a shower for mornings on Tuesdays and Saturdays, and shower is scheduled for evenings on Thursdays. During further observation and interview on 8/25/21 at 8:50 a.m., R#31 revealed she did not receive a shower yesterday or this morning. R#31 stated she cannot remember the exact date when she last received a shower. R#31 stated staff gave her a sponge bath a couple of days ago. Interview with Certified Nursing Assistant (CNA) FF on 8/25/21 at 2:00 p.m. revealed she is an agency CNA. She stated the shower schedule was in place when she started working at the facility. CNA FF stated if a resident is scheduled for a shower on the morning shift and they refuse it the CNA will go back later and ask them again if they want a shower, depending on if there's enough staff. CNA FF further stated if the resident receives their shower that afternoon their shower schedule will be switched to the afternoons. CNA FF stated she does not make the shower schedule. Interview with CNA II on 8/26/21 at 7:45 a.m. revealed she is an agency nurse. She stated residents receive showers according to the shower schedule. CNA II stated CNAs fill out a bath and skin audit sheet after they give showers. CNA II could not produce a bath and skin audit sheet for R#31. Further interview with R#31 on 8/26/21 at 7:50 a.m. revealed she did not receive a shower yesterday (8/25/21). She stated they told her she would get a shower in the afternoon, but no one came to give her a shower. Interview with Licensed Practical Nurse (LPN) HH on 8/26/21 at 8:05 a.m. revealed residents have a choice of a shower or bath, and residents have a choice of what time they receive their shower or bath. LPN HH stated showers are documented on the CNA bath and skin audit sheet. Further interview with LPN HH revealed R#31 received a shower last Saturday. LPN HH stated it should be documented in the CNA bath and skin audit book, however LPN HH could not produce any bath and skin audit sheets for R#31. Further interview with R#31 on 8/26/21 at 2:38 p.m. revealed she did not receive a shower today. R#31 stated she prefers to get a shower in the morning but if it would be easier for staff, she would get the shower in the afternoon. Interview with Assistant Director of Nursing (ADON) on 8/25/21 at 2:12 p.m. revealed residents can have a choice of when they want to take their shower. ADON stated the current shower sheet was updated by the past treatment nurse. ADON further stated showers and bath are documented on the CNA ADL (Activities of Daily Living) sheets. ADON verified copy of shower schedule provided to surveyor by the Director of Nursing is the current shower schedule. ADON verified R#31 is scheduled for a shower on Tuesdays and Saturdays in the mornings, and evenings on Thursdays. ADON could not provide an answer as to why residents shower was scheduled on Tuesdays and Saturdays in the mornings, and evenings on Thursdays. ADON provided copy of residents ADL sheet indicating there was no documentation that R#31 received a shower from 8/1/21- 8/24/21.

Based on observations, staff interviews, and review of facility policy titled Detailed Cleaning, the facility failed to ensure that there was a clean and comfortable environment as evidence by stained privacy curtains, over bed lighting not properly affixed to the wall, large brown stains on the floor, holes in closet door, missing tiles in the bathroom, a cracked trash can, and metal door frame in shared bathroom had a piece of protruding metal at the base. These environmental concerns were observed in 12 of 49 resident rooms and/or bathrooms (106, 108, 110, 112, 117, 118, 119, 120, 125, 126, 127, and 128). Findings include: Observation on 8/24/21 at 8:56 a.m. revealed room 106 privacy curtain had a large brown stain in the middle of the curtain at the bottom by the hem. Observation on 8/24/21 at 9:00 a.m. of room 108B revealed two holes in the wall behind the bed as well as a large brown spot on the floor streaming from A bed to the B bed. Observation on 8/24/21 at 9:02 a.m. of room 110 revealed missing tiles on the shared bathroom wall leading into room 112. Observation on 8/24/21 at 9:04 a.m. of room 112 revealed closet door has holes in the bottom with wood splinters exposed. Observation on 8/26/21 at 9:19 a.m. of room 117A revealed brown spots on privacy curtain. Observation on 8/26/21 at 9:30 a.m. of room 118B revealed overbed light loose and hanging from wall. Observation on 8/26/21 at 9:31 a.m. of room 119A revealed cracked trash can with jagged edges noted at top. Observation on 8/26/21 at 9:32 a.m. of room 120 privacy curtain bed A has brown spots throughout the curtain. Observation on 8/26/21 at 9:33 a.m. of room 125 revealed shared bathroom has metal protruding from the metal door frame at the bottom leading into the adjoining room. The privacy curtain for bed A had brown stains throughout curtain on the front and back of curtain. Observation on 8/26/21 at 9:36 a.m. of room 126 revealed headboard for bed A leaning against the wall not attached to bed. Observation on 8/26/21 at 9:37 a.m. of room 127A revealed brown stains noted to privacy curtain on the front and back of curtain. Observation on 8/26/21 at 9:38 a.m. of room 128 revealed privacy curtain for bed A had brown stains on front and back of curtain. Environmental rounds conducted with Administrator, Maintenance Director, and Environmental Services Director on 8/26/21 at 9:48 a.m. confirmed all environmental issues observed during facility observations. Interview on 8/26/21 at 9:48 a.m. with Environmental Services Director (EVS director) revealed the housekeeping department does complete deep cleans monthly. The process for deep cleanings includes cleaning the rooms from the front to the back starting with the room and ending in the bathroom. Further interview revealed during the deep cleaning process the privacy curtains sometimes get missed because they are usually pulled back, if the housekeeper notices the curtains need to be changed, they would be taken down and sent the laundry to be cleaned. Interview on 8/26/21 at 10:01 a.m. with Maintenance Director revealed that routine maintenance is completed daily. When there is any issue that needs to be addressed there is a maintenance book that is kept at the nursing station where staff should put in work orders. The maintenance book is checked daily, and any issues are addressed at that time. Review of the undated facility policy titled Detailed Cleaning revealed under the Procedure section number five: curtains should be taken down to be washed in the laundry and immediately replaced with clean curtains.

Based on observations, record review, review of facility policy titled Care Plans, Comprehensive Person-Centered, and staff interviews, the facility failed to follow the respiratory care plan for one of five residents (R) (#27) who required continuous oxygen. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered revised 2016 revealed the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of Face Sheet revealed R#27 was admitted into the facility on [DATE] with a secondary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#27 receives oxygen therapy while a resident at the facility. Review of the care plan dated 7/7/21 revealed R#27 was at risk for ineffective breathing pattern with interventions including but not limited to administering oxygen as prescribed or per standing order. Review of the current August 2021 Physicians Orders for R#27 revealed an order with a start date of 8/19/20 for oxygen at 3 lpm (liters per minute) via nasal cannula for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 8/24/21 at 9:52 a.m., 8/24/21 at 12:04 p.m., and 8/25/21 at 1:41 p.m., it was revealed R#27 was on oxygen via nasal cannula. However, the concentrator was set on 1.5 lpm and not 3 lpm as ordered by the physician. An interview on 8/26/21 at 9:12 a.m. with the facility's Director of Nursing (DON) revealed that it is the expectation that all staff read and follow the care plans as agreed upon by the IDT (Interdisciplinary Team). Cross refer to F695.

Based on observations, record review, and staff interviews, the facility failed to ensure that a resident received oxygen at the correct flow rate for one of five residents (R) (#27) who required continuous oxygen. Findings include: Review of Face Sheet revealed R#27 was admitted into the facility on [DATE] with a secondary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#27 receives oxygen therapy while a resident at the facility. Review of the current August 2021 Physicians Orders for R#27 revealed an order with a start date of 8/19/20 for oxygen at 3 lpm (liters per minute) via nasal cannula for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 8/24/21 at 9:52 a.m., 8/24/21 at 12:04 p.m., and 8/25/21 at 1:41 p.m., it was revealed R#27 was on oxygen via nasal cannula. However, the concentrator was set on 1.5 lpm and not 3 lpm as ordered by the physician. An interview on 8/25/21 at 2:03 p.m. with LPN KK revealed they have been caring for R#27 for about two weeks. LPN KK was aware of R#27 being on oxygen. She revealed that the concentrator should be set at 2 lpm. After reviewing R#27's physician orders, LPN KK acknowledged that R#27's orders are written for oxygen at 3 lpm via nasal cannula. Moments later, LPN KK observed that R#27's oxygen concentrator was set on 1.5 lpm. LPN KK acknowledged the concentrator should have been set to 3 lpm. She immediately adjusted the oxygen concentrator flow rate to 3 lpm. An interview on 8/26/21 at 9:12 a.m. with the facility's Director of Nursing (DON) revealed that it is the expectation that all staff read and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/26/21 at 9:15 a.m., the Administrator revealed there was no Oxygen Policy available.

Based on record review, review of the facility policy titled Assessing Falls and Their Causes, and staff interview, the facility failed to notify the resident's representative of a fall with injury for one resident (R) (#1) of three sampled residents. Findings include: Review of the clinical record revealed R#1 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed resident to be severely cognitively impaired and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the clinical record revealed R#1 was found in the bathroom of his room on the floor on 1/6/2021. He was unable to give a description of that fall/accident. He was found to have obtained a skin tear to his left elbow. The Physician was notified. However, there was no indication that the family and/or resident's representative were notified of the fall with injury. During an interview on 7/12/2021 at 11:09 a.m., the Director of Nursing and the Administrator confirmed that the family of R#1 had not been notified of his fall on 1/6/2021 and neither could say why this information was not relayed to the family member. A review of the facility policy titled Assessing Falls and Their Causes, revised October 2010, revealed: Steps in the Procedure After a Fall: 4. Nursing staff will notify the resident's family in an appropriate time frame. Documentation: 4. Notification of the Physician and family as indicated. Reporting: 1. Notify the following individuals when a resident has a fall: a. The resident's family. Cross refer to F689.

Based on record review, review of the facility policy titled Neurological Assessment, and staff interview, the facility failed to complete neurological assessments following two falls for one resident (R) (#1) of three sampled residents. Findings include: Review of the facility policy titled Neurological Assessment, revised October 2010, revealed the purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed resident to be severely cognitively impaired and had a history of falls prior to admission. Review of the clinical record revealed R#1 had an unwitnessed fall in the bathroom of his room on 1/6/2021. He was unable to describe the events that led to this fall. He was found to have a skin tear to his left elbow. On 1/19/2021, R#1 was walking out of his room, lost his balance and fell hitting his head. He was cognitively unable to relay the details of his accident. The Incident Report documented neurological checks were initiated. However, there was no documented evidence indicating that neurological checks were completed following the falls. During an interview with the Director of Nursing and Administrator on 7/12/2021 at 11:09 a.m., they both confirmed that during their search of the facility documentation there were no neurological assessments completed for the fall on 1/6/2021 and 1/19/2021 for R#1. They both agreed that neurological assessments should have been completed for these two falls.

Based on record review and staff interviews, the facility failed to document skin assessments, weekly wound measurements, and treatment administration for two residents (R) (R#1 and R#3) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the clinical record revealed R#1 was admitted to the facility on [DATE] and discharged on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] coded R#1 as being severely cognitively impaired as well as having a physical functioning level that required two staff members to assist him to complete his activities of daily living. There were no pressure ulcers for this resident upon admission to the facility. A Weekly Skin Assessment was completed on 1/7/2021, the day after admission, and R#1 was noted as having no areas of skin concern. On 2/1/2021, a Weekly Skin Assessment form was completed indicating a pressure ulcer to sacrum was present measuring 7 centimeters (cm) x 7 cm x 0.1 cm (depth of the wound). The form indicated this to be a Stage II Pressure Ulcer with the onset date of 2/1/2021. It describes the wound as red, with granulation tissue, no undermining, without drainage and healthy surrounding tissue. The treatment was to clean with wound cleanser, pat dry and apply [MEDICATION(S)]. Prevention was noted as: A&D (vitamin A and D) ointment to sacrum and buttocks. Further investigation revealed that no other Weekly Skin Assessments were documented between 1/7/2021 and 2/1/2021 when the Stage II wound on his sacrum was found. Review of a Weekly Wound Tracking Worksheet form, provided by Wound Care Nurse AA, revealed R#1's name, stage of wound, location and onset date. There were no measurements noted on this form. R#1 was found to have no Treatment Administration Record (TAR) for the month of February 2021. 2. Resident #3 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] revealed the resident had pressure ulcers upon admission to the facility of one stage II, one stage IV and one DTI (deep tissue injury). A review of R#'3's TARs for March 2021 and April 2021 reveal the following lack of documentation on the TAR or in the nursing notes that the wounds were treated on the following dates: March 2021 TAR: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation for treatments on 3/17/2021, 3/19/2021, 3/22/2021, 3/24/2021, and 3/26/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation for treatments on 3/5/2021, 3/17/2021, 3/19/2021, 3/22/2021, 3/24/2021, and 3/26/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation for treatments on 3/17/2021, 3/19/2021, 3/22/2021, 3/24/2021, and 3/26/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation on 3/18/2021 and 3/25/2021. April 2021 TAR: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation for treatments on 4/9/2021, 4/16/2021, 4/19/2021, 4/21/2021, 4/23/2021, 4/26/2021, 4/28/2021, and 4/30/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation for treatments on 4/9/2021, 4/16/2021, 4/19/2021, 4/21/2021, 4/23/2021, 4/26/2021, 4/28/2021, and 4/30/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation for treatments on 4/9/2021, 4/16/2021, 4/19/2021, 4/21/2021, 4/23/2021, 4/26/2021, 4/28/2021, and 4/30/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a blank indicating lack of documentation on 4/22/2021 and 4/29/2021. During an interview on 7/12/2021 at 11:01 a.m., Wound Care Nurse AA stated that Weekly Skin Assessments are conducted by the nurses on the hall, and they will notify her if there are changes or skin problems. She stated that she was notified on 2/1/2021 that this resident had an open area on his sacrum and after investigating she found it to measure 7 cm x 7 cm x 0.1 cm in depth. The Wound Care Nurse AA was asked how she effectively tracks and compares measurements and other wound qualities from week to week and she did not answer. During an interview with the Director of Nursing on 7/13/2021 at 8:07 a.m., she confirmed that there was no TAR created for R#1's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She also confirmed that for the timeframe of 1/6/2021 through 2/1/2021 there were no ADL (activity of Daily Living) sheets, shower sheets or any documentation to prove that R#1 had his skin reviewed on a regular basis for any concerns. During further interview with the Wound Care Nurse AA on 7/13/2021 at 9:46 a.m., she stated she had no idea why there were so many holes in the TARs.

Based on observation, record review, review of the facility policy titled Care Plans, Comprehensive Person-Centered and staff interviews, the facility failed to develop a comprehensive care plan to address pressure ulcers for one resident (R) (#6) and failed to implement the care plans related to weekly wound assessments/ skin assessments and wound treatments for three residents (R C, R#5 and R#7) from a sample of 10 residents with pressure ulcers. On 9/22/20 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Minimum Data Set (MDS) Coordinator were informed of the Immediate Jeopardy (IJ) on 9/22/20 at 1:45 p.m. The noncompliance related to the IJ was identified to have existed on 2/23/20. The IJ is outlined as follows: 1. On 2/9/20, it was documented that R C had a Stage III to the sacrum. On 3/3/20, Wound Physician identified the pressure ulcer as a Stage IV to sacrum with bone exposed; deteriorated due to pressure. [MEDICATION NAME] ointment was ordered to be applied to bone. There was no indication that [MEDICATION NAME] was applied as ordered or that treatment was done on 3/8, 3/11, 4/24, 4/27, 4/28, 5/16, and 5/18-5/30/20. There was also no evidence of weekly skin checks for April or May 20. On 5/20/20, Wound Physician identified a Stage IV to the left ischium, chronic reopening, with necrotic tissue. There was no evidence that the recommended treatment was done on 5/1-5/8, 5/10-5/14, 5/16, and 5/18-5/30, 6/2, 6/5, and 6/7/20. A culture was ordered of the sacrum; however, there is no evidence that the culture was obtained. R C was hosptalized on [DATE] where a new wound infection to the thigh was identified that required incision and drain (I&D) and packing. 2. R#5 had treatment orders for a Stage III to the left ischium, right outer ischium, Stage IV to the right inner ischium, and Unstageable to the left buttocks. There was no evidence that treatments were done on 2/10, 2/14, and 2/18-2/28/20. On 3/3/20, Wound Physician identified the wounds as Stage IV proximal sacrum, Stage IV distal sacrum, Stage IV right ischium, and Stage III right distal buttock. There was no evidence that treatments were done 3/4, 3/5, and 3/8/20. On 3/10/20, Wound Physician documented the Stage IV to proximal sacrum for R#5 had deteriorated to 2.3x1.6x0.6 cm with 3.5 cm undermining with 10% thick adherent devitalized necrotic tissue and 5% slough. On 3/31/20, the Stage IV to right ischium had deteriorated due to infection. [MEDICATION NAME] ointment was ordered. There is no evidence that the treatments were done on 4/8-4/11, and 4/13-4/14/20. There is no evidence that the antibiotic ointment was used. R#5 was hosptalized on [DATE] [MEDICAL CONDITION] from UTI and wound infections and returned to the facility on Hospice, expiring on 5/2/20. 3. R#6 was admitted to the facility on [DATE] with pressure ulcers to his mid spine, right ischium, and sacrum. There was no evidence of an initial assessment or staging upon admission. On 2/17/20, the physician ordered a wound culture and ordered [MEDICATION NAME] 100 mgs BID x 10 days. There was no evidence that the [MEDICATION NAME] was administered for six scheduled doses. On 2/18/20, odor was noted to the wounds and the facility did not have correct culture supplies. Foul odor and drainage to the sacrum and right ischium continued 2/22/20 and physician was notified. Culture was obtained and sent to the lab on 2/23/20, six days later. There was no evidence that skin checks were done from 2/6-2/23/20. R#6 was hosptalized on [DATE] with wound infections and osteo[DIAGNOSES REDACTED]. 4. During record review, it was identified that routine skin checks were not being done for R#7 in February 2020. On 2/8/20, an open area was noted to the gluteal fold. The area was not staged, measured, or described. Wound treatment was ordered on [DATE]; however, there is no evidence that treatments were done on 2/10, 2/16, and 2/19/20. On 2/17/20, foul odor was noted. Foul odor was noted again on 2/22/20 and the physician was notified via fax. On 2/23/20, resident was noted with foul odor and drainage to bandage on coccyx. Physician was notified verbally, and resident was sent to the ER. Resident had a large sacral decubitus ulcer which was sealed by eschar and measured 10x6 cm. Sharp excisional debridement of the ulcer was performed down to the sacral fascia and gluteus muscle to control local infection. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.21 (b)(3) Services Provided Meet Professional Standards, F658; 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75(g), QAPI/QAA Improvement Activities, F867. F656, F658, F686, F835 and F867 were at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. At the time of the exit on 9/24/20, the IJ remained ongoing. Findings include: Review of the facility Care Plans, Comprehensive Person-Centered Policy and Procedure (revised 12/2016) revealed that the comprehensive care plan was developed within 7 days of the completion of the required comprehensive assessment (Minimum Data Set). The care plan incorporated identified problem areas and risk factors associated with identified concerns. Professional services responsible for each element of care were identified. The care plan included measurable objectives and timeframes to meet the resident's physical, psychosocial and functional needs. 1. R# 6 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed that R#6 had severe cognitive impairment; no behaviors; was non-ambulatory; was totally dependent on two staff for bed mobility; had no limitations in range of motion; had an indwelling urinary catheter and a [MEDICAL CONDITION]; and was admitted with one Stage III pressure ulcer, two Stage IV pressure ulcers, one Suspected Deep Tissue Injury (SDTI), [MEDICAL CONDITION] and foot infection. Review of the blank Baseline Care Plan located in the resident's medical record revealed that staff failed to complete it with interventions to address his basic care needs including his existing pressure ulcers. Continued review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Staff failed to provide treatment to the right hip pressure ulcer twice a day as ordered from 2/7/20-2/16/20 when treatment was changed due to possible infection. Staff failed to obtain a wound culture timely as ordered on [DATE] when the resident's wounds had an odor until 6 days later on 2/23/20. Staff failed to administer [MEDICATION NAME] twice a day as ordered on [DATE], 2/20/20, 2/21/20 and 2/22/20 and the resident was hospitalized [DATE] -3/9/20 with wound infections. Staff failed to notify the Physician via telephone on 2/22/20 about the resident's deteriorating wounds until 2/23/20 when the resident was sent to the emergency room (ER) and admitted with wound infections. Interview with Licensed Practical Nurse (LPN)/ MDS Coordinator on 8/26/20 at 11:20 a.m. revealed that the nurse who admitted the resident was responsible for completing the Baseline Care Plan within 24 hours of admission. She stated that she was responsible for developing the comprehensive care plan within 7 days of the resident's MDS dated [DATE]. Further interview revealed that she had been pulled frequently to administer medications to the residents and had forgotten to complete the resident's comprehensive care plan. 2. R C was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for R C dated 2/9/20 revealed he was admitted with extensive skin breakdown and had the potential for further pressure sore development related to his immobility with a goal that he would have intact skin by/through the review date (5/10/20). Interventions for nursing staff included administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing process and report any declines to the physician; follow facility policies/protocols for the prevention/treatment of [REDACTED]. review of the resident's medical record revealed [REDACTED]. Staff failed to perform weekly wound assessments of the pressure ulcers for RC to monitor the deterioration/progression of his wounds in 1/2020-2/2020 as care planned. Staff failed to perform weekly skin assessments as per facility protocol as scheduled on 5/1/20, 5/8/20 and 5/15/20 prior to the Wound Physician identifying a reopened Stage IV pressure ulcer that measured 4 cm x 2.6 cm x 0.2 cm and had 35% thick adherent devitalized necrotic tissue and 5% slough on 5/20/20. Staff failed to perform a weekly skin assessment on 6/6/20 prior the resident's hospitalization for bilateral thigh abscesses on 6/7/20 as per facility protocol. Staff failed to obtain and follow-up on the Wound Physician's Order dated 6/4/20 for a wound culture of the resident's sacral and left leg wounds as care planned. 3. R#5 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 2/19/20 revealed that R#5 had actual skin impairment related to his surgical sites and ulcers with interventions to administer skin treatment; administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the Physician as necessary; follow facility policies/protocols for the prevention/treatment of [REDACTED]. Report results to MD and follow-up as indicated. Review of the medical record for R#5 revealed that staff failed to perform consistent weekly skin assessments as ordered by the Physician and per facility protocol in 2/2020, 3/2020 and 4/2020. Staff failed to use appropriate infection control during observation of wound treatments on 2/27/20 as care planned. Staff failed to provide treatments as per the Wound Physician's treatment plans in 3/2020, 4/2020 and on 5/1/20 as care planned. Staff failed to ensure that the culture of the infected right ischium was obtained as per the Wound Physician's recommendation on 3/31/20 as care planned and R#5 was hospitalized from [DATE] to 4/20/20 for wound infection. 4. R#7 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 9/14/19 revealed that he had the potential for pressure ulcer development related to immobility and incontinence with interventions to administer treatments as ordered and monitor for effectiveness; follow facility policies/protocols for the prevention/treatment of [REDACTED]. Report results to MD and follow-up as indicated. review of the resident's medical record revealed [REDACTED].#7 as per facility policy for ten days from 1/30/20 to 2/8/20 and the resident was identified with an open wound/pressure ulcer on his gluteal fold on 2/8/20. Staff failed to provide an initial assessment of the resident's wound on 2/8/20 and on-going weekly assessments of the wound on 2/15/20 and 2/22/20 to include staging, measurement and description of the wound bed in order to monitor the deterioration or progression of the wound. Staff failed to provide treatments daily to the wound as ordered on [DATE], 2/17/20 and 2/19/20 as care planned. Staff failed to verbally notify the Attending Physician about the infection of the pressure ulcer on 2/17/20 and 2/22/20 per facility protocol and the resident was hosptalized on [DATE] [MEDICAL CONDITION] secondary to an infected sacral pressure ulcer. Interview with the Regional Nurse Consultant (RNC)/interim Director of Nursing (DON) on 9/24/20 at 8:53 a.m. revealed that nursing staff should follow the residents' care plans to promote healing of existing pressure ulcers and prevent the development of further pressure ulcers. Cross Refer to F686.

Based on observation, record review, review of the Georgia Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the Georgia Nurse Practice Act, Chapter 410-10, and staff interview, the facility failed to ensure that services were provided in accordance with professional standards of quality as evidenced by the failure in multiple areas of skin and wound management for four residents (R) (C, #5, #6 and #7) of 10 residents reviewed for pressure ulcers. On 9/22/20 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Minimum Data Set (MDS) Coordinator were informed of the Immediate Jeopardy (IJ) on 9/22/20 at 1:45 p.m. The noncompliance related to the IJ was identified to have existed on 2/23/20. The IJ is outlined as follows: 1. On 2/9/20, it was documented that R C had a Stage III to the sacrum. On 3/3/20, Wound Physician identified the pressure ulcer as a Stage IV to sacrum with bone exposed; deteriorated due to pressure. [MEDICATION NAME] ointment was ordered to be applied to bone. There was no indication that [MEDICATION NAME] was applied as ordered or that treatment was done on 3/8, 3/11, 4/24, 4/27, 4/28, 5/16, and 5/18-5/30/20. There was also no evidence of weekly skin checks for April or May 20. On 5/20/20, Wound Physician identified a Stage IV to the left ischium, chronic reopening, with necrotic tissue. There was no evidence that the recommended treatment was done on 5/1-5/8, 5/10-5/14, 5/16, and 5/18-5/30, 6/2, 6/5, and 6/7/20. A culture was ordered of the sacrum; however, there is no evidence that the culture was obtained. R C was hosptalized on [DATE] where a new wound infection to the thigh was identified that required incision and drain (I&D) and packing. 2. R#5 had treatment orders for a Stage III to the left ischium, right outer ischium, Stage IV to the right inner ischium, and Unstageable to the left buttocks. There was no evidence that treatments were done on 2/10, 2/14, and 2/18-2/28/20. On 3/3/20, Wound Physician identified the wounds as Stage IV proximal sacrum, Stage IV distal sacrum, Stage IV right ischium, and Stage III right distal buttock. There was no evidence that treatments were done 3/4, 3/5, and 3/8/20. On 3/10/20, Wound Physician documented the Stage IV to proximal sacrum for R#5 had deteriorated to 2.3x1.6x0.6 cm with 3.5 cm undermining with 10% thick adherent devitalized necrotic tissue and 5% slough. On 3/31/20, the Stage IV to right ischium had deteriorated due to infection. [MEDICATION NAME] ointment was ordered. There is no evidence that the treatments were done on 4/8-4/11, and 4/13-4/14/20. There is no evidence that the antibiotic ointment was used. R#5 was hosptalized on [DATE] [MEDICAL CONDITION] from UTI and wound infections and returned to the facility on Hospice, expiring on 5/2/20. 3. R#6 was admitted to the facility on [DATE] with pressure ulcers to his mid spine, right ischium, and sacrum. There was no evidence of an initial assessment or staging upon admission. On 2/17/20, the physician ordered a wound culture and ordered [MEDICATION NAME] 100 mgs BID x 10 days. There was no evidence that the [MEDICATION NAME] was administered for six scheduled doses. On 2/18/20, odor was noted to the wounds and the facility did not have correct culture supplies. Foul odor and drainage to the sacrum and right ischium continued 2/22/20 and physician was notified. Culture was obtained and sent to the lab on 2/23/20, six days later. There was no evidence that skin checks were done from 2/6-2/23/20. R#6 was hosptalized on [DATE] with wound infections and osteo[DIAGNOSES REDACTED]. 4. During record review, it was identified that routine skin checks were not being done for R#7 in February 2020. On 2/8/20, an open area was noted to the gluteal fold. The area was not staged, measured, or described. Wound treatment was ordered on [DATE]; however, there is no evidence that treatments were done on 2/10, 2/16, and 2/19/20. On 2/17/20, foul odor was noted. Foul odor was noted again on 2/22/20 and the physician was notified via fax. On 2/23/20, resident was noted with foul odor and drainage to bandage on coccyx. Physician was notified verbally, and resident was sent to the ER. Resident had a large sacral decubitus ulcer which was sealed by eschar and measured 10x6 cm. Sharp excisional debridement of the ulcer was performed down to the sacral fascia and gluteus muscle to control local infection. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.21 (b)(3) Services Provided Meet Professional Standards, F658; 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75(g), QAPI/QAA Improvement Activities, F867. F656, F658, F686, F835 and F867 were at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. At the time of the exit on 9/24/20, the IJ remained ongoing. Findings include: Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. Review of the Georgia Nurse Practice Act, Chapter 410-10 revealed, Practice nursing as a registered professional nurse means to practice nursing by performing for compensation any of the following: Assessing the health status of individuals, groups, or both throughout the life span; Establishing a nursing diagnosis; Establishing nursing goals to meet identified health care needs; Planning, implementing, and evaluating nursing care; Providing for safe and effective nursing care rendered directly or indirectly; Managing and supervising the practice of nursing; Collaborating with other members of the health care team in the management of care, and teaching the theory and practice of nursing. 1. RC was admitted [DATE] with multiple wounds. Review of his medical record revealed that Licensed/Registered Nursing staff failed to obtain weekly comprehensive wound assessments of the pressure ulcers/wounds for RC in order to monitor the deterioration/progression of his wounds from 1/2020-2/2020. Licensed/Registered Nursing staff failed to administer antibiotic therapy for his sacral wound infection for 10 days as ordered by the Physician from 4/1/20-4/5/20. Licensed/Registered Nursing staff failed to perform weekly skin assessments on R C as scheduled on 5/1/20, 5/8/20 and 5/15/20 prior to the Wound Physician identifying a reopened Stage IV pressure ulcer that measured 4 cm x 2.6 cm x 0.2 cm and had 35% thick adherent devitalized necrotic tissue and 5% slough on 5/20/20. Licensed/Registered Nursing staff failed to perform a weekly skin assessment on 6/6/20 prior to the resident's hospitalization for bilateral thigh abscesses on 6/7/20. Licensed/ Registered Nursing staff failed to obtain and follow-up on the Wound physician's orders [REDACTED]. Licensed/Registered Nursing staff failed to provide treatments as ordered by the Attending Physician and recommended by the Wound Physician in order to facilitate wound healing. 2. R#5 was admitted [DATE] with multiple pressure ulcers. Review of his medical record revealed that Licensed/Registered Nursing staff failed to perform consistent weekly skin assessments as ordered by the Physician in 2/2020, 3/2020 and 4/2020. Licensed Practical Nursing staff failed to use appropriate infection control during observation of wound treatments on 2/27/20. Licensed/ Registered Nursing staff failed to provide treatments as per the Wound Physician's treatment plans in 3/2020, 4/2020 and on 5/1/20. Licensed/ Registered Nursing staff failed to ensure that the culture of the infected right ischium was obtained as per the Wound Physician's recommendation on 3/31/20 so that possible antibiotic therapy could be initiated and R#5 was hospitalized from [DATE] to 4/20/20 for wound infection. Licensed/Registered Nursing staff failed to ensure that an orthopedic referral was made for possible right hip infection/wound tunneling as recommended by the Wound Physician on 3/31/20. 3. R#6 was admitted [DATE] with multiple wounds. Review of his medical record revealed that Licensed/Registered Nursing staff failed to provide an initial assessment and on-going weekly assessments of the resident's wounds to include type of wound, staging, measurements, and description of wounds. Licensed/ Registered Nursing staff failed to provide treatment to the right hip pressure ulcer twice a day as ordered from 2/7/20-2/16/20 when treatment was changed due to possible infection. Licensed/ Registered Nursing staff failed to obtain a wound culture timely as ordered on [DATE] when the resident's wounds had an odor until 6 days later on 2/23/20 when the resident was hospitalized for [REDACTED]. Licensed Nursing staff failed to notify the Physician via telephone on 2/22/20 about the resident's wounds until 2/23/20 when the resident was sent to the emergency room (ER) and admitted with wound infections. 4. R#7 was admitted on [DATE] with no pressure ulcers and developed an unavoidable pressure ulcer on 2/8/20. review of the resident's medical record revealed [REDACTED].#7 for ten days from 1/30/20 to 2/8/20 and the resident was identified with an open wound/pressure ulcer on his gluteal fold on 2/8/20. Licensed/Registered Nursing staff failed to provide an initial assessment of the resident's wound on 2/8/20 and on-going weekly assessments of the wound on 2/15/20 and 2/22/20 to include staging, measurement, and description of the wound bed. This failure prevented staff from monitoring the deterioration or progression of the wound so that treatment could be changed if needed. Licensed/Registered Nursing staff failed to provide treatments daily to the wound as ordered on [DATE], 2/17/20 and 2/19/20. Licensed Nursing staff failed to verbally notify the Attending Physician about the wound odor noted on 2/17/20 so that the Physician could determine a change in treatment if necessary. Licensed Nursing staff failed to verbally notify the Attending Physician about the worsening of the wound on 2/22/20 and the resident was hosptalized on [DATE] [MEDICAL CONDITION] secondary to an infected sacral pressure ulcer. Interview with LPN XX on 2/26/20 at 1:06 p.m. revealed that she was nervous about providing wound care because she had not received any training. Continued interview revealed that she was hired in 11/2019 but had not participated in a competency test related to the provision of treatments. Interview with interim Director of Nursing (DON) EE on 2/27/20 at 1:41 p.m. revealed that the facility had a treatment nurse on the weekends who performed weekly wound assessments but she had been out a lot approximately two weekends per month. Continued interview revealed that when the treatment nurse was out, the medication nurses were responsible for providing treatments and performing wound assessments. Interview with LPN VV on 3/4/20 at 1:19 p.m. revealed that she had not received any training on wound care especially assessing wounds. Interview with LPN BB on 8/20/20 at 8:51 a.m. revealed that she did not know how to enter the Wound Physician's verbal treatment orders or her treatment documentation into PCC because she had not been trained on the computer program. She stated that it was difficult to obtain direction or help from the previous interim DON EE if she had questions. Further interview with former interim Director of Nursing (DON) EE on 9/23/20 at 10:23 a.m. revealed that she was interim DON from late January 2020/early February 2020 until the facility hired a permanent DON in March 2020. Continued interview revealed that he (the one hired as permanent) resigned in April 2020 and she was interim DON again until 5/13/20 when former DON/current Treatment Nurse GG was hired as DON. Further interview revealed that as DON she was responsible for staffing and supervision of resident care. Former interim DON EE stated that she frequently worked the floor during her time as DON because of staff call outs or no shows. Continued interview revealed that she was aware that wound treatments were not provided as ordered and that Licensed Nursing staff told her that they did not have time. However, she was able to provide treatments to her residents when she worked the floor and believed it was a time management issue with the other nurses. Further interview revealed that she provided one on one in-services to the nurses regarding the need to complete wound treatments. Interview with the Administrator on 9/23/20 at 11:23 a.m. revealed that the DON was responsible for ensuring that wound treatments were provided, weekly skin assessments performed, physician orders [REDACTED]. Continued interview revealed that there had been four DONs since 2/2020. She stated that the DONs have been putting out fires and some things had been overlooked in the process. Further interview revealed that she believed that the nurses needed to be more accountable. Cross refer to F686.

Based on observation, record review, review of the facility's Skin and Wound Management policy, and resident and staff interview, it was determined that the facility failed to have an effective pressure ulcer recognition and management program as evidenced by failure to perform consistent weekly skin assessments for residents at risk for skin breakdown in order to identify breakdown timely (R C, R#5, R#6, and R#7); failure to provide initial assessment and/or ongoing weekly assessments of wounds to include staging, measurements and description of wounds in order to monitor progression/deterioration of wounds (R#5, R#6, and R#7); failure to perform treatments as ordered by the Attending Physician and/or recommended by the Wound Care Physician to facilitate wound healing (R C, R#5, R#6, and R#7); failure to notify the Attending Physician of the wounds infections timely prior to hospitalization (R#6 and R#7); and failure to utilize appropriate infection control in order to prevent cross contamination during wound care for one resident (R#5) of ten residents reviewed for pressure ulcers. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Minimum Data Set (MDS) Coordinator were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:45 p.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: 1. On [DATE], it was documented that R C had a Stage III to the sacrum. On [DATE], Wound Physician identified the pressure ulcer as a Stage IV to sacrum with bone exposed; deteriorated due to pressure. [MEDICATION NAME] ointment was ordered to be applied to bone. There was no indication that [MEDICATION NAME] was applied as ordered or that treatment was done on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]-[DATE]. There was also no evidence of weekly skin checks for April or [DATE]. On [DATE], Wound Physician identified a Stage IV to the left ischium, chronic reopening, with necrotic tissue. There was no evidence that the recommended treatment was done on ,[DATE]-,[DATE], ,[DATE]-,[DATE], ,[DATE], and ,[DATE]-,[DATE], ,[DATE], ,[DATE], and [DATE]. A culture was ordered of the sacrum; however, there is no evidence that the culture was obtained. R C was hospitalized on [DATE] where a new wound infection to the thigh was identified that required incision and drain (I&D) and packing. 2. R#5 had treatment orders for a Stage III to the left ischium, right outer ischium, Stage IV to the right inner ischium, and Unstageable to the left buttocks. There was no evidence that treatments were done on ,[DATE], ,[DATE], and ,[DATE]-[DATE]. On [DATE], Wound Physician identified the wounds as Stage IV proximal sacrum, Stage IV distal sacrum, Stage IV right ischium, and Stage III right distal buttock. There was no evidence that treatments were done ,[DATE], ,[DATE], and [DATE]. On [DATE], Wound Physician documented the Stage IV to proximal sacrum for R#5 had deteriorated to 2.3x1.6x0.6 cm with 3.5 cm undermining with 10% thick adherent devitalized necrotic tissue and 5% slough. On [DATE], the Stage IV to right ischium had deteriorated due to infection. [MEDICATION NAME] ointment was ordered. There is no evidence that the treatments were done on ,[DATE]-,[DATE], and ,[DATE]-[DATE]. There is no evidence that the antibiotic ointment was used. R#5 was hospitalized on [DATE] [MEDICAL CONDITION] from UTI and wound infections and returned to the facility on Hospice, expiring on [DATE]. 3. R#6 was admitted to the facility on [DATE] with pressure ulcers to his mid spine, right ischium, and sacrum. There was no evidence of an initial assessment or staging upon admission. On [DATE], the physician ordered a wound culture and ordered [MEDICATION NAME] 100 mgs twice daily x 10 days. There was no evidence that the [MEDICATION NAME] was administered for six scheduled doses. On [DATE], odor was noted to the wounds and the facility did not have correct culture supplies. Foul odor and drainage to the sacrum and right ischium continued [DATE] and physician was notified. Culture was obtained and sent to the lab on [DATE], six days later. There was no evidence that skin checks were done from ,[DATE]-[DATE]. R#6 was hospitalized on [DATE] with wound infections and osteo[DIAGNOSES REDACTED]. 4. During record review, it was identified that routine skin checks were not being done for R#7 in February 2020. On [DATE], an open area was noted to the gluteal fold. The area was not staged, measured, or described. Wound treatment was ordered on [DATE]; however, there is no evidence that treatments were done on ,[DATE], ,[DATE], and [DATE]. On [DATE], foul odor was noted. Foul odor was noted again on [DATE] and the physician was notified via fax. On [DATE], resident was noted with foul odor and drainage to bandage on coccyx. Physician was notified verbally, and resident was sent to the ER. Resident had a large sacral decubitus ulcer which was sealed by eschar and measured 10x6 cm. Sharp excisional debridement of the ulcer was performed down to the sacral fascia and gluteus muscle to control local infection. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.21 (b)(3) Services Provided Meet Professional Standards, F658; 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75(g), QAPI/QAA Improvement Activities, F867. F656, F658, F686, F835 and F867 were at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of the facility policy and procedure titled Skin and Wound Management: Prevention of Pressure Ulcers (revised ,[DATE]), revealed that if pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. Risk factors for the development of skin breakdown should be identified and preventive measures placed. Further review of the policy revealed that the history of a healed pressure ulcer and its stage (if known) is important since areas of healed Stage III or IV pressure sores are more likely to have recurrent breakdown. Continued review revealed that the facility should have a system in place to assure assessments were timely and appropriate and changes in condition were recognized, evaluated and reported to the physician and family, and addressed. Review of the facility policy and procedure titled Skin and Wound Management: Pressure Ulcer Risk Assessment (revised ,[DATE]) revealed that pressure ulcer risk assessment will be completed upon admission, and then weekly times three weeks and with each additional quarterly, annual and/or significant change assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Staff will perform routine skin inspections with daily care and nurses will conduct skin assessments at least weekly to identify changes. Review of the facility policy and procedure titled Skin and Wound Management: Pressure Ulcer Treatment (revised ,[DATE]) revealed the pressure ulcer treatment program should focus on the following strategies: assessing the resident and current status of the pressure ulcer (s), current support surfaces, pressure ulcer care, managing bacterial colonization and infection, and education and quality improvement. Continued review revealed that wound treatment is determined by wound status, exudate, bioburden, location, and the resident's underlying support system. If the wound does not improve in 2 to 3 weeks, the physician is notified. Documentation to be recorded in the resident's medical record, treatment sheet or designated wound form should include wound bed color, size of wound, edges, and presence of drainage. Further review of the policy revealed that pressure ulcers are defined as the following: 1. Suspected Deep Tissue Injury (SDTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. 2. Stage I Pressure Ulcer: Intact skin with non-blanchable redness of a localized area usually over a boney prominence. 3. Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed without slough (yellow, tan, gray, green or brown necrotic tissue) or an intact or open/ruptured serum-filled blister. 4. Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Undermining and tunneling may be present. 5. Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (tan, brown or black necrotic tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteo[DIAGNOSES REDACTED] (bone infection) possible. 6. Unstageable Pressure Ulcer: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. 1. R C was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 indicating that he was cognitively intact. The resident had one Stage II pressure sore, two Stage III pressure sores and two Stage IV pressure sores. Review of the Braden Scale-For Predicting Pressure Sore Risk form dated [DATE] revealed that R C had a pressure sore risk score of 10, indicating that he was at high risk of developing pressure ulcers due to his very limited sensory perception, occasionally moist skin, bedfast status, complete immobility, inadequate nutrition, and problem with friction and shear. There was no indication that staff had assessed his pressure ulcer risk quarterly as per policy after [DATE]. Review of the Weekly Wound Tracking Worksheets revealed that staff assessed the resident's pressure ulcers/wounds on [DATE] as follows: Stage III pressure ulcer on left ischium that measured 3.1 cm x 2 cm x 0.2 cm with granulation tissue in the wound bed. Stage III pressure ulcer on right ischium that measured 2.4 cm x 1.5 cm x 0.2 cm with granulation tissue in the wound bed. Stage III pressure ulcer on sacrum that measured 4.5 cm x 8.7 cm x 0.2 cm with granulation tissue in the wound bed. Stage II pressure ulcer on the back of his neck that measured 2.5 cm x 1.5 cm x 0.1 cm with granulation tissue. Review of the Weekly Wound Tracking Worksheet dated [DATE] revealed that R C had wounds on his right heel, back of his left calf, stoma site, left ischium, sacrum, right ischium, and top of his left leg. However, there was no indication as to type of wound (pressure ulcer, surgical, abrasion, etc.), stage (if pressure ulcer), onset date, type of tissue present ([MEDICATION NAME], granulation, slough, necrotic) or measurements. There was no indication that staff assessed his wounds on [DATE]. On [DATE], the facility assessed the wounds of all residents who had wounds at that time. Although location of wounds, measurements and type of tissue were documented, there was no indication which wounds developed in house, date of onset, the type of wound, or if pressure related, and the staging of pressure ulcers. On [DATE] at 9:10 a.m., R C was lying on his back watching television. Staff had applied bilateral heel protectors to his feet. Interview with the resident revealed that his wound treatments were due every day but that he missed a treatment the previous week. Interview with Licensed Practical Nurse (LPN) UU on [DATE] at 1:50 p.m. revealed that she used to be the full-time treatment nurse at facility but now only works PRN (as needed). Continued interview revealed that she was on leave and when she came back, the facility had decided they needed a treatment nurse on the weekends only. Further review revealed that she was supposed to provide wound treatments today but, a medication nurse had called out and she was now responsible for medication administration and the provision of care for all the residents on her floor. LPN UU stated that when she had to work on the floor, she was able to provide wound treatments for the residents on her floor because she stayed after her shift to provide treatments. Continued interview revealed that some wound supplies such as border gauze were not available, but it was not often. During observation of wound treatment for [REDACTED]. There were no signs of infection of the wounds. Review of the measurements obtained of the resident's wounds on [DATE], during this observation, with those obtained on [DATE] revealed that the sacral and left ischial wounds had increased slightly in size. Interview with interim Director of Nursing (DON) EE on [DATE] at 1:41 p.m. revealed that the facility had a treatment nurse on the weekends who performed weekly wound assessments but she had been out a lot approximately two weekends per month. Continued interview revealed that when the treatment nurse was out, the medication nurses were responsible for providing treatments and performing wound assessments. Interview with the Regional Nurse Consultant (RNC)/current interim DON on [DATE] at 2:01 p.m. revealed that the weekend treatment nurse provided treatments on Friday, Saturday and Sunday and the medication nurses provided treatments on Monday through Thursday. The nurses were supposed to report any changes in a resident's wounds to the interim DON EE. The facility initiated a contract with (Name) Wound Physicians starting on [DATE]. The Wound Physician had a previous contract with the facility that ended in [DATE] with last assessments completed on [DATE]. On [DATE], R C was assessed by the facility contracted Wound Care Physician who assessed the resident's wounds weekly and made treatment plan recommendations for the facility to follow. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed that the resident had the following pressure ulcers: 1. Stage IV pressure ulcer of sacrum that measured 6 cm x 9.5 cm x 0.2 cm with moderate serosanguinous exudate, 90% granulation tissue and 10% other viable tissue (two areas of bone). The Wound Physician documented that the wound had deteriorated due to pressure since his last assessment of the resident's wounds on [DATE]. 2. Stage III pressure ulcer of the left ischium that measured 3.4 cm x 2.1 cm x 0.1 cm with moderate serosanguinous exudate and 100% granulation tissue. The Wound Physician documented that the wound had deteriorated due to pressure since his last assessment of the resident's wounds on [DATE]. 3. Stage III pressure ulcer of the posterior neck that measured 5 cm x 1.6 cm x 0.1 cm with light serous exudate, 50% granulation tissue and 50% skin. The Wound Physician documented that the wound had deteriorated due to pressure since his last assessment of the resident's wounds on [DATE]. 4. Stage III pressure ulcer of right ischium that measured 1.9 cm x 2.1 cm x 0.1 cm with moderate serosanguinous exudate and 100% granulation tissue. The Wound Physician documented that this was an initial evaluation of the pressure ulcer. Interview with LPN VV on [DATE] at 1:19 p.m. revealed that prior to [DATE] there was no Calcium alginate or border gauze available to provide treatments per physician orders. Continued interview revealed that there was one treatment cart with one bottle of Dakins solution and one bottle of wound cleanser to be shared with all the residents with wounds. Further interview revealed that there used to be a Unit Manager who was responsible for monitoring and ordering wound supplies and staff did not run out. However, another staff member was assigned the task and it took several days to obtain supplies. Further interview revealed that she had not received any training on wound care especially assessing wounds. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed there was a new Stage II pressure ulcer on the right calf that measured 0.3 cm x 0.2 cm x 0.1 cm with light serosanguinous exudate and a new Stage II pressure ulcer on the left heel that measured 1 cm x 1.2 cm x 0.1 cm with light serosanguinous exudate. The treatment plan for both of the new pressure ulcers was to apply Xeroform sterile gauze and gauze island with border daily. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed that previous treatments were to continue for the left calf wound, the sacrum, the posterior neck, the right calf, and the left heel. On [DATE], a culture of the resident's sacral wound was obtained and showed light growth Proteus mirabilis. The Attending Physician was notified and on [DATE] [MEDICATION NAME] milligrams (mg) twice a day for 10 days and Keflex 500 mg twice a day for 10 days. Review of the ,[DATE] Medication Administration Record (MAR) revealed that [MEDICATION NAME] Keflex were initiated on [DATE]. However, review of the ,[DATE] MAR revealed that staff failed to administer [MEDICATION NAME] Keflex to the resident as ordered from [DATE]-[DATE]. Staff restarted the antibiotics on [DATE] and the antibiotic therapy was completed [DATE]. Interview with LPN AA on [DATE] at 11:25 a.m. revealed that prior to implementation of Point Click Care (PCC) electronic records (implemented [DATE]), the night shift nurse was responsible for checking the residents' medical records and ensuring that the physician's orders for that day had been transcribed to the MAR and/or Treatment Record. Review of the ,[DATE] Treatment Record revealed that there was no indication that staff had written the Wound Physician's treatment orders and transcribed his orders to the Treatment Record. There was no indication that staff provided wound treatments per the Wound Physician's treatment plans. There was no indication that staff applied [MEDICATION NAME] ointment and secondary dressings, as ordered, to the resident's sacral pressure ulcer from [DATE]-[DATE]. There was no indication that staff provided any treatment to the resident's posterior neck pressure ulcer [DATE]-[DATE]. Although staff had treated the left ischial and right ischial wounds with Xeroform, there was no indication that the secondary dressings were applied [DATE]-[DATE]. There was no indication that the two new Stage II pressure ulcers on the resident's left heel and right calf identified [DATE] were treated ,[DATE]-[DATE]. There was no indication that any treatments were provided to the resident's wounds on [DATE] (Saturday) and [DATE] (Sunday) or [DATE]. Further review of the ,[DATE] Treatment Record revealed that there was no indication that staff assessed the resident's skin weekly to identify new breakdown timely in ,[DATE]. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed the pressure ulcers of the posterior neck had deteriorated due to shear; the pressure ulcer of the right calf had deteriorated due to shear; and the pressure ulcer of the left heel had deteriorated due to positioning/pressure. Continued review of the Wound Evaluation revealed that a deep swab culture of the Stage IV pressure ulcer of the sacrum done [DATE] showed Proteus. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed the pressure ulcer of the right calf had deteriorated from a Stage II on [DATE] to a Stage III pressure ulcer that measured 1 cm x 2 cm x 0.2 cm and was deeper than the previous evaluation on [DATE]. The pressure ulcer to the left heel had deteriorated from a Stage II on [DATE] to a Stage IV pressure ulcer that was larger in size with 80% slough and 20% granulation tissue. Review of the ,[DATE] Treatment Record revealed that there was no indication that staff had written the Wound Physician's treatment orders and transcribed his orders to the Treatment Record. There was no indication that staff applied [MEDICATION NAME] ointment on the sacral pressure ulcer from ,[DATE]-[DATE]. (The sacral wound culture was positive for Proteus on [DATE].) There was no indication that staff discontinued the Xeroform and foam without border and added Leptospermum Honey, as ordered, to the sacral pressure ulcer from ,[DATE]-[DATE]. There was no indication that staff had provided treatment to the pressure ulcer on the resident's posterior neck from ,[DATE]-[DATE]. There was no indication that staff provided treatment to the pressure ulcers of the right calf or left heel from ,[DATE]-[DATE]. There was no indication that any of the resident's wounds were treated [DATE], [DATE] and [DATE]. There was no indication that R C had refused treatments on those days. Furthermore, there was no indication that staff had assessed the resident's skin weekly in ,[DATE] to identify breakdown timely. Review of the medical record for R C revealed that on [DATE] staff had written the following Physician's treatment orders and transcribed them to the Treatment Record: Cleanse the sacrum with wound cleanser, pat dry, apply Mesalt and dressing daily. Staff failed to include the [MEDICATION NAME] ointment in the order per the [DATE] Wound Physician's treatment plan. Cleanse left calf with wound cleanser, pat dry, apply Mesalt and cover with dressing daily. Staff failed to include the [MEDICATION NAME] pad in the order per the [DATE] Wound Physician's treatment plan. Cleanse right calf with wound cleanser, pat dry, apply Mesalt and cover with dry dressing daily. Staff failed to document that Leptospermum Honey ([MEDICATION NAME]) should be applied per the [DATE] Wound Physician's treatment plan. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed that a Stage IV pressure ulcer of the left ischium was identified and measured 4 cm x 2.6 cm x 0.2 cm with moderate serosanguinous exudate, 35% thick adherent devitalized necrotic tissue, 5% slough and 60% granulation tissue. The Wound Physician noted that this was a chronic wound that reopened, and a wound biopsy was obtained to determine neoplastic process. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed the right calf ulcer had deteriorated due to inflammation. Review of the ,[DATE] Treatment Record revealed that staff failed to provide any treatments to the resident's wounds ,[DATE]-[DATE], ,[DATE]-[DATE], ,[DATE]-[DATE], ,[DATE]-[DATE], ,[DATE]-[DATE] and [DATE]. Continued review revealed that staff failed to discontinue the Mesalt and add Leptospermum Honey and [MEDICATION NAME] pad daily for the left calf wound from ,[DATE]-[DATE] as per the Wound Physician's recommendations. Staff failed to apply [MEDICATION NAME] ointment on the sacral pressure ulcer from [DATE] to [DATE] when the [MEDICATION NAME] was discontinued. There was no indication that staff discontinued the Mesalt and added Leptospermum Honey for the sacral pressure ulcer from ,[DATE]-[DATE]. Staff failed to apply Leptospermum Honey on the right calf pressure ulcer from ,[DATE]-[DATE] per the Wound Physician's treatment plan. Furthermore, there was no indication that staff provided any treatment to the reopened Stage IV left ischial pressure ulcer from ,[DATE]-[DATE]. There was no indication that staff performed weekly skin assessments as scheduled on [DATE], [DATE], [DATE] prior to the Wound Physician identifying the reopened Stage IV left ischial pressure ulcer on [DATE]. On [DATE], the resident's skin assessments were changed to Saturday on the 7 p.m. to 7 a.m. shift and were performed on [DATE] and [DATE]. Interview with LPN RR on [DATE] at 10:08 a.m. revealed that she worked at the facility since ,[DATE] or ,[DATE] and currently worked night shift. When asked if she performed head to toe skin assessments on the residents, LPN RR stated this is the first time I have heard about it. Continued interview revealed that she looked at her residents during medication administration for any bruising or discoloration and that the Certified Nursing Assistants (CNAs) assessed the residents' skin during care. Review of the ,[DATE] e-TAR revealed that staff failed to provide any treatments to the resident's wounds on [DATE], [DATE] and [DATE]. Staff failed to apply Leptospermum Honey, [MEDICATION NAME] pad and gauze roll daily to the left calf wound as per the [DATE] and [DATE] Wound Physician's treatment plans on [DATE], [DATE] and [DATE]. Staff failed to apply Leptospermum Honey and foam with border daily on the sacral pressure ulcer as per the [DATE] and [DATE] Wound Physician's treatment plans on [DATE], [DATE] and [DATE]. Staff failed to apply Leptospermum Honey and gauze island daily to the right calf pressure ulcer as per the [DATE] and [DATE] Wound Physician's treatment plans on [DATE], [DATE] and [DATE]. Staff failed to apply Calcium alginate, Leptospermum Honey and gauze island with border daily to the left ischium pressure ulcer as per the [DATE] and [DATE] Wound Physician's treatment plans on [DATE], [DATE] and [DATE]. There was no indication that staff performed a skin assessment as scheduled on [DATE]. The last skin assessment performed by staff was on [DATE]. Review of the Wound Physician's Order dated [DATE] revealed that cultures of the resident's sacral and left leg wounds were to be obtained STAT (immediately). review of the resident's medical record revealed [REDACTED]. On [DATE] at 11:20 a.m., the interim Director of Nursing (DON)/Regional Nurse Consultant (RNC) reviewed the resident's medical record and confirmed that there were no culture results for the resident's sacral or left leg wounds. On [DATE] at 1:20 p.m., the Wound Physician stated that he usually obtained deep wound cultures himself. Continued interview revealed that sometimes the facility did not have the correct culturettes or the culturettes had expired. He stated that he could not remember if incorrect culturettes or expired culturettes were the reasons that the culture was not obtained for R C. Review of the e-Nurse's Progress Note dated [DATE] at 22:01 (10:01 p.m.) revealed that RC complained that his indwelling catheter was leaking. The LPN was unable to remove his catheter. Pus was noted coming from the resident's right inner leg and the Attending Physician was notified. RC was sent to the emergency room (ER) for catheter replacement. Review of the Hospital History and Physical Report dated [DATE] revealed that the resident was admitted to the hospital on [DATE] with abscesses to his bilateral inner thighs. The right thigh abscess was draining purulent and serosanguinous drainage. The ER Physician performed an incision and drainage (I&D) of the abscesses at that time. A CT of the abdomen and pelvis dated [DATE] showed extensive [MEDICAL CONDITION] with associated abscess of the bilateral thighs. The left thigh abscess measured 5.2 cm x 2.7 cm and the right thigh abscess measured 3.7 cm x 1.2 cm. The wound culture dated [DATE] showed moderate growth Staphylococcus aureus, moderate growth [MEDICATION NAME] faecalis and light growth Proteus mirabilis. The blood culture dated [DATE] was positive for Staphylococcus aureus. The resident was administered intravenous (IV) antibiotics. Review of the Hospital Discharge Summary revealed RC was discharged back to the facility on [DATE]. Review of the ,[DATE] Treatment Record revealed that treatment to an open area on the resident's left thigh was discontinued on [DATE]. Review of the ,[DATE], ,[DATE], ,[DATE] and ,[DATE] TAR revealed that staff had provided sporadic treatments to an area on the resident's left thigh. However, there was no documentation in the resident's medical record as to the type of wound, measurements, or description of the wound. Interview with the Wound Physician on [DATE] at 1:20 p.m. revealed that he did not remember treating the bilateral thigh abscesses prior to the resident's return on [DATE]. Interview with the interim DON/Regional Nurse Consultant (RNC) on [DATE] at 9:02 a.m. revealed that there was no indication that the bilateral thigh abscesses were identified prior to the resident's admission to the hospital on [DATE]. review of the resident's medical record revealed [REDACTED]. Review of the (Name) Wound Physicians: Wound Evaluation and Management Summary dated [DATE] revealed that there were three new wounds. A wound on the left proximal medial thigh, a wound on the right proximal medial thigh and a shear wound on the posterior neck. Review of the ,[DATE] e-TAR revealed that there was no indication that staff had provided any treatment to the resident's left calf wound from ,[DATE]-[DATE]. There was no indication that staff had provided any treatment to the resident's right calf pressure ulcer from ,[DATE]-[DATE]. There was no indication that staff had treated the sacral pressure ulcer with Mesalt and foam border daily as per the [DATE] and [DATE] Wound Physician's treatment plans from ,[DATE]-[DATE]. Review of the e-TAR revealed that staff treated the sacral pressure ulcer with [MEDICATION NAME] on [DATE] and [DATE] only. There was no indication that staff provided treatment to the resident's left ischium pressure ulcer daily as per the [DATE] and [DATE] Wound Physician's treatment plans from ,[DATE]-[DATE]. There was no indication that staff provided treatment to the left proximal medial thigh wound and the right proximal medial thigh wound daily as per the [DATE] and [DATE] Wound Physician's treatment plans on ,[DATE]-[DATE], ,[DATE]-[DATE], ,[DATE]-[DATE] and ,[DATE]-[DATE]. There was no indication that staff applied Leptospermum Honey to the shear wound of the posterior neck daily per the [DATE] and [DATE] Wound Physician's treatment plans on ,[DATE]-[DATE], ,[DATE]-[DATE], and ,[DATE]-[DATE]. On [DATE], staff changed the resident's weekly skin assessment to Wednesday night. There was no indication that staff assessed the resident's skin on [DATE] as scheduled. Review of the ,[DATE] e-TAR revealed that staff provided sporadic treatments to a left posterior wound, left anterior wound, posterior wound, right anterior wound, and right posterior wound. There was no information as to the specific location of those wounds. There was no indication that staff provided treatment to the left calf pressure ulcer daily ,[DATE]-[DATE]. There was no indication that staff provided treatment to the sacral pressure ulcer daily ,[DATE]-[DATE], ,[DATE]-[DATE], [DATE], [DATE], ,[DATE]-[DATE] and [DATE]. There was no indication that staff provided treatment to the right calf pressure ulcer ,[DATE]-[DATE]. There was no indication that staff provided treatment to the left ischium ,[DATE]-[DATE]. There was no indication that staff provided treatment to the posterior neck shear wound ,[DATE]-[DATE], [DATE], ,[DATE]-[DATE] and [DATE]. There was no indication that staff performed skin assessments every Wednesday night as scheduled on [DATE] and [DATE]. Review of the ,[DATE] e-TAR revealed there was no indication that staff provided treatment to the resident's left

Based on record review, review of the 8/12/2020 Performance Improvement Plan (PIP), staff interviews and review of the Administrator's Job description, the Administrator failed to ensure that staff were performing weekly skin assessments and wound treatments as ordered; and failed to provide oversight and monitoring of implemented actions for the skin integrity program. The census was 29. On 9/22/20 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Minimum Data Set (MDS) Coordinator were informed of the Immediate Jeopardy (IJ) on 9/22/20 at 1:45 p.m. The noncompliance related to the IJ was identified to have existed on 2/23/20. The IJ is outlined as follows: 1. On 2/9/20, it was documented that R C had a Stage III to the sacrum. On 3/3/20, Wound Physician identified the pressure ulcer as a Stage IV to sacrum with bone exposed; deteriorated due to pressure. [MEDICATION NAME] ointment was ordered to be applied to bone. There was no indication that [MEDICATION NAME] was applied as ordered or that treatment was done on 3/8, 3/11, 4/24, 4/27, 4/28, 5/16, and 5/18-5/30/20. There was also no evidence of weekly skin checks for April or May 2020. On 5/20/20, Wound Physician identified a Stage IV to the left ischium, chronic reopening, with necrotic tissue. There was no evidence that the recommended treatment was done on 5/1-5/8, 5/10-5/14, 5/16, and 5/18-5/30, 6/2, 6/5, and 6/7/20. A culture was ordered of the sacrum; however, there is no evidence that the culture was obtained. R C was hosptalized on [DATE] where a new wound infection to the thigh was identified that required incision and drain (I&D) and packing. 2. R#5 had treatment orders for a Stage III to the left ischium, right outer ischium, Stage IV to the right inner ischium, and Unstageable to the left buttocks. There was no evidence that treatments were done on 2/10, 2/14, and 2/18-2/28/20. On 3/3/20, Wound Physician identified the wounds as Stage IV proximal sacrum, Stage IV distal sacrum, Stage IV right ischium, and Stage III right distal buttock. There was no evidence that treatments were done 3/4, 3/5, and 3/8/20. On 3/10/20, Wound Physician documented the Stage IV to proximal sacrum for R#5 had deteriorated to 2.3x1.6x0.6 cm with 3.5 cm undermining with 10% thick adherent devitalized necrotic tissue and 5% slough. On 3/31/20, the Stage IV to right ischium had deteriorated due to infection. [MEDICATION NAME] ointment was ordered. There is no evidence that the treatments were done on 4/8-4/11, and 4/13-4/14/20. There is no evidence that the antibiotic ointment was used. R#5 was hosptalized on [DATE] [MEDICAL CONDITION] from UTI and wound infections and returned to the facility on Hospice, expiring on 5/2/20. 3. R#6 was admitted to the facility on [DATE] with pressure ulcers to his mid spine, right ischium, and sacrum. There was no evidence of an initial assessment or staging upon admission. On 2/17/20, the physician ordered a wound culture and ordered [MEDICATION NAME] 100 mgs BID x 10 days. There was no evidence that the [MEDICATION NAME] was administered for six scheduled doses. On 2/18/20, odor was noted to the wounds and the facility did not have correct culture supplies. Foul odor and drainage to the sacrum and right ischium continued 2/22/20 and physician was notified. Culture was obtained and sent to the lab on 2/23/20, six days later. There was no evidence that skin checks were done from 2/6-2/23/20. R#6 was hosptalized on [DATE] with wound infections and osteo[DIAGNOSES REDACTED]. 4. During record review, it was identified that routine skin checks were not being done for R#7 in February 2020. On 2/8/20, an open area was noted to the gluteal fold. The area was not staged, measured, or described. Wound treatment was ordered on [DATE]; however, there is no evidence that treatments were done on 2/10, 2/16, and 2/19/20. On 2/17/20, foul odor was noted. Foul odor was noted again on 2/22/20 and the physician was notified via fax. On 2/23/20, resident was noted with foul odor and drainage to bandage on coccyx. Physician was notified verbally, and resident was sent to the ER. Resident had a large sacral decubitus ulcer which was sealed by eschar and measured 10x6 cm. Sharp excisional debridement of the ulcer was performed down to the sacral fascia and gluteus muscle to control local infection. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.21 (b)(3) Services Provided Meet Professional Standards, F658; 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75(g), QAPI/QAA Improvement Activities, F867. F656, F658, F686, F835 and F867 were at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. At the time of the exit on 9/24/2020, the IJ remained ongoing. Findings include: Review of the facility Administrator Job Description revealed: This position acts as the director of the facility and is ultimately responsible for all patient care and business decisions. Specifically, the Nursing Home Administrator job duties may include: -Manage the day to day operations of the facility and keep the organization on tract for its long-term goals and mission. -Coordinate and provide leadership to each clinical, managerial, and custodial team, and ensure that they are working together effectively. -Ensure that the facility operates in compliance with all local, state, and federal regulations. -Coordinate with clinical staff to ensure residents' individual care plans are being followed. -Provide regular safety and compliance training. The facility had a change in Director of Nursing (DON) on 3/3/2020, 4/20/2020, 5/19/2020, and on 7/31/2020 when the Regional Nurse consultant began acting as interim DON. The facility failed to provide effective oversight and monitoring of their skin integrity system. This system failure included not ensuring that skin assessments were completed routinely by licensed nurses on residents at risk for altered skin integrity, treatment orders were documented and completed as ordered, and weekly wound assessments of pressure ulcers were consistently completed. 1. Administration failed to ensure that a care plan was developed to address the pressure ulcers for R#6 and failed to ensure care plan interventions were implemented for skin assessments and wound treatments for R C, R#5 and R#7. Cross Refer to F656. 2. Administration failed to ensure services were provided in accordance with professional standards of practice as evidenced by the failure of nursing staff to identify and treat wound infections for R C, R#5, R#6 and R#7. Cross refer to F658. 3. Administration failed to ensure necessary treatment and services were provided to prevent the development of new pressure ulcers, to promote healing of existing pressure ulcers and to prevent infection of wounds for R C, R#5, R#6 and R#7. Cross Refer to F686. 4. Administration failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents with pressure ulcers. The QAA committee also failed to identify that their established policy for Skin and Wound Management was not being fully operationalized, and therefore failed to implement corrective actions to address the deterioration of wounds and wound infections for R C, R#5, R#6 and R#7. Cross refer to F867. Review of the Performance Improvement Project (PIP) Worksheet dated 8/12/2020 revealed a fractured process for identifying skin impairments. Skin assessments were not routinely performed due to lack of education, lack of follow through and they were not scheduled. There is lack of follow up by a clinical leader. Project goal was to decrease incidents of new skin impairments of admitted residents, timely notification and treatment of [REDACTED]. The PIP was signed only by the interim DON and treatment nurse. During an interview on 9/23/2020 at 10:58 a.m., the Administrator reported that she is responsible for the planning/directing of the building and checking behind departments to see that they are doing as they should. The Administrator stated she will pull the 72-hour report to see if there are any critical issues and she will assign those issues to someone to follow up. Then, she will have a stand down meeting in the afternoon to see what has been done. The Administrator continued that sometimes tasks are assigned throughout the day. The Administrator acknowledged that she had difficulty getting things approved around March for wound supplies. However, she reported that they have gotten better with the wound care supplies now and they have the supplies for wound care that are needed. She stated that nurses should provide order sheets every Monday indicating what items they need but they do not say anything until all items are gone. The Administrator reported that she was aware of skin assessments not being done and she had reached out to home office for a wound care nurse but there was a delay with that because they wanted to review if there was a need for it. The Administrator reported that she thinks she started requesting for a wound care nurse in February or March 2020. She further reported that some nurses said they did not do treatments because they did not have time. The Administrator revealed that in speaking with the Regional Nurse Consultant, it was reported that based on level of care nurses should have had time to get the treatments done. She reported that she then asked if treatments could be split up between day shift and night shift. The Administrator stated that it was the DON's responsibility to check behind the treatment nurse to assure treatments are being done. It was her expectation that the DON should do random audits of notes and skin assessments to assure that things are in order. The DON was also expected to check and order supplies. There was a DON in orientation, but she text that she is resigning this morning. There has been a lot of instability with DONs. The DONs come in and try to get systems in place and try to put out fires; things got overlooked. The Administrator stated she would always stress the need to make the nurses more accountable. If the nurses were not documenting, written education was requested but not ever implemented. During a post survey interview on 9/25/20 at 3:19 pm, the Medical Director, who is also the attending physician for all residents in the facility, stated that facility Administration had not notified her of the immediate jeopardy. She stated that she makes rounds every day and gives orders but that they are sometimes not carried out by nursing staff. She revealed that she has had on-going concerns for the last six months that Administration has failed to resolve and that she gave her 60 day notice today. She stated that the facility has lost most of their good nurses. The Medical Director further revealed that she has had several meetings with corporate and has accommodated their requests in an attempt to resolve issues; however, although she has accommodated their requests, the facility failed to do their part to resolve the issues.

Based on staff interviews, record review, and review of the Facility Assessment and Quality Assurance Performance Improvement (QAPI) policy, the facility failed to have an effective Quality Assurance process that identified concerns related to the care and management of the skin integrity program, specifically residents with pressure ulcers. The facility census was 29. On 9/22/20 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Minimum Data Set (MDS) Coordinator were informed of the Immediate Jeopardy (IJ) on 9/22/20 at 1:45 p.m. The noncompliance related to the IJ was identified to have existed on 2/23/20. The IJ is outlined as follows: 1. On 2/9/20, it was documented that R C had a Stage III to the sacrum. On 3/3/20, Wound Physician identified the pressure ulcer as a Stage IV to sacrum with bone exposed; deteriorated due to pressure. [MEDICATION NAME] ointment was ordered to be applied to bone. There was no indication that [MEDICATION NAME] was applied as ordered or that treatment was done on 3/8, 3/11, 4/24, 4/27, 4/28, 5/16, and 5/18-5/30/20. There was also no evidence of weekly skin checks for April or May 20. On 5/20/20, Wound Physician identified a Stage IV to the left ischium, chronic reopening, with necrotic tissue. There was no evidence that the recommended treatment was done on 5/1-5/8, 5/10-5/14, 5/16, and 5/18-5/30, 6/2, 6/5, and 6/7/20. A culture was ordered of the sacrum; however, there is no evidence that the culture was obtained. R C was hosptalized on [DATE] where a new wound infection to the thigh was identified that required incision and drain (I&D) and packing. 2. R#5 had treatment orders for a Stage III to the left ischium, right outer ischium, Stage IV to the right inner ischium, and Unstageable to the left buttocks. There was no evidence that treatments were done on 2/10, 2/14, and 2/18-2/28/20. On 3/3/20, Wound Physician identified the wounds as Stage IV proximal sacrum, Stage IV distal sacrum, Stage IV right ischium, and Stage III right distal buttock. There was no evidence that treatments were done 3/4, 3/5, and 3/8/20. On 3/10/20, Wound Physician documented the Stage IV to proximal sacrum for R#5 had deteriorated to 2.3x1.6x0.6 cm with 3.5 cm undermining with 10% thick adherent devitalized necrotic tissue and 5% slough. On 3/31/20, the Stage IV to right ischium had deteriorated due to infection. [MEDICATION NAME] ointment was ordered. There is no evidence that the treatments were done on 4/8-4/11, and 4/13-4/14/20. There is no evidence that the antibiotic ointment was used. R#5 was hosptalized on [DATE] [MEDICAL CONDITION] from UTI and wound infections and returned to the facility on Hospice, expiring on 5/2/20. 3. R#6 was admitted to the facility on [DATE] with pressure ulcers to his mid spine, right ischium, and sacrum. There was no evidence of an initial assessment or staging upon admission. On 2/17/20, the physician ordered a wound culture and ordered [MEDICATION NAME] 100 mgs BID x 10 days. There was no evidence that the [MEDICATION NAME] was administered for six scheduled doses. On 2/18/20, odor was noted to the wounds and the facility did not have correct culture supplies. Foul odor and drainage to the sacrum and right ischium continued 2/22/20 and physician was notified. Culture was obtained and sent to the lab on 2/23/20, six days later. There was no evidence that skin checks were done from 2/6-2/23/20. R#6 was hosptalized on [DATE] with wound infections and osteo[DIAGNOSES REDACTED]. 4. During record review, it was identified that routine skin checks were not being done for R#7 in February 2020. On 2/8/20, an open area was noted to the gluteal fold. The area was not staged, measured, or described. Wound treatment was ordered on [DATE]; however, there is no evidence that treatments were done on 2/10, 2/16, and 2/19/20. On 2/17/20, foul odor was noted. Foul odor was noted again on 2/22/20 and the physician was notified via fax. On 2/23/20, resident was noted with foul odor and drainage to bandage on coccyx. Physician was notified verbally, and resident was sent to the ER. Resident had a large sacral decubitus ulcer which was sealed by eschar and measured 10x6 cm. Sharp excisional debridement of the ulcer was performed down to the sacral fascia and gluteus muscle to control local infection. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.21 (b)(3) Services Provided Meet Professional Standards, F658; 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75(g), QAPI/QAA Improvement Activities, F867. F656, F658, F686, F835 and F867 were at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 (b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686. At the time of the exit on 9/24/20, the IJ remained ongoing. Findings include: The Facility assessment dated [DATE] revealed that one of the top three systems affecting the healthcare needs of patients/ residents served is integumentary (wound) care. The facility had an undated Quality Assurance Performance Improvement (QAPI) policy. The policy documented that the QAPI program represents the facility's commitment to continuous quality improvement. The program ensures systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve the performance goals. Policy Explanation and Guidelines: 5. The QAPI Committee shall meet at least quarterly to review facility data, identify opportunities for improvement, and review the activities of its PIP (Process Improvement Plan) sub-committees. 6. The QAPI Committee's oversight responsibilities shall include but are not limited to the following: utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to; grievance logs, medical record review, skilled care claims, fall log, pressure ulcer log, treatments logs, staffing trends . quality measures, survey outcomes, etc. A review of the Quality Assurance (QA) committee meeting sign in sheet revealed that the members of the committee included the Administrator, Physician, Director of Nursing, Physical Therapy Assistant, Registered Nurse Supervisor, Minimum Data Set (MDS) Coordinator, Activities Director, Housekeeping Director, Dietary Manager, Maintenance Director, Accounts Manager, and Human Resources. Review of the June 2020 Quality Assurance (QA) Report revealed a QA topic: pressure ulcers. It was identified that weekly skin checks were not being done for all residents. There was no other information listed and the section titled opportunities to improve was blank. The July 2020 QA topic: pressure ulcers revealed that weekly skin checks were not being done for all residents. Opportunities to improve included to continue to review body audits, skin assessments, nutritional support, and interventions. There was evidence provided that support that body audits and skin assessments were reviewed. During an interview on 9/23/2020 at 10:58 a.m. the Administrator stated that the QAPI committee is supposed to meet monthly. In the beginning a nurse would lead. However, the nurse got COVID-19 results while on duty on 7/4/20 and left for a month at that time. The Medical Director has sometimes done meetings via telephone. She has access to technology of what identifiers may be for areas of concerns but does not remember the name at this time. The Administrator revealed that the lack of routine skin assessments was identified as a result of a Process Improvement Plan (PIP). She stated that wound care is an ongoing conversation but will have to look at notes to see if anything other than skin assessments were put into place. Audits were to be completed by the Director of Nursing (DON). If a problem is identified in QAPI the next process would be to reach out to the nurse consultant to follow up with the DON. If things are not getting done, staff are provided written education followed by write ups, suspension, and then termination, but she does not think that has been happening in this building. During a post survey interview on 9/25/20 at 3:19 pm, the Medical Director revealed that she was not involved in developing the facility's policy and procedures for its wound care program. She did attend the quarterly QAPI meetings and sometimes the monthly meetings. The last QAPI meeting was in 8/2020 and wounds were discussed-wound protocol and ways to address wound healing. The Medical Director further revealed that the previous DONs have not been able to resolve issues because they meet resistance from Regional Nurse Consultant and the Administrator.

Based on observations, record reviews and staff interviews, it was determined that the facility failed to implement care plan interventions for three residents (#35, "C" and #31) from a total sample of 27 residents. This failure resulted in actual harm for resident #35. Findings include: 1. Resident #35 was admitted on [DATE] with [DIAGNOSES REDACTED]. On the 8/6/10 annual Minimum Data Set (MDS) assessment, licensed staff coded resident #35 as totally dependent on one person for bed mobility and toilet use and, as being incontinent of bowel and bladder. He/She was coded as having limitations in range of motion of his/her right leg, foot, arm and hand. According to staff's documentation on the Resident Assessment Protocol Summary (RAPS) for pressure sores, the resident was at risk of developing pressure sores because of his/her limited mobility and incontinence of bowel and bladder. There was a care plan since 5/6/09 which addressed his/her potential for skin breakdown related to incontinence and limited mobility. The interventions included that certified nursing assistants were to observe all of the resident's boney prominences daily and report (any) redness or breaks in skin to the charge nurse. However, nursing staff failed to observe the bony prominences daily and the resident was identified by staff on 3/18/11 as having developed an unstageable pressure sore on his/her right foot. See F314 for additional information regarding resident #35. 2. Resident "C" was admitted on 3/31/10 with [DIAGNOSES REDACTED]. On his/her 3/23/11 Minimum Data Set (MDS) comprehensive assessment, staff coded the resident as having short term and long term memory problems and moderately impaired decision making skills. Licensed staff coded the resident as totally dependent on two persons for bed mobility and transfers. According to the staff's documentation on the Care Area Assessments (CAAs), the resident was sometimes able to answer simple direct questions; enjoyed listening to music and attending large group activities like parties and special events and, used a geri-chair when out of the bed. The resident had a care plan since 4/16/10 which included his/her potential for social isolation. The interventions to address that problem included that staff was supposed to get the resident out of bed and into the geri-chair daily as tolerated. However, staff had not gotten the resident out of bed daily as planned. See F246 for additional information regarding resident "C". 3. Resident # 31 had [DIAGNOSES REDACTED]. On the 8/29/10 MDS comprehensive assessment, licensed staff coded him/her as needing total staff assistance for activities of daily living. There was a care plan since 9/24/09 that addressed his/her self care deficit problem related to his/her cognitive loss and limited mobility. The interventions included that the certified nursing assistants would provide the resident with oral care each shift and, grooming daily and as needed. However, the resident was observed to have dry, chapped lips on 8/8/11 at 1:20 p.m. and 3:40 p.m., on 8/9/11 at 9:10 a.m., noon and 1:10 p.m., on 8/10/11 at 1:50 p.m. and, on 8/11/11 at 7:45 a.m. and 10:30 a.m. See F312 for additional information regarding resident #31.

Based on observation, record review and staff interview, it was determined that the facility failed to identify a pressure sore prior to an unstageable pressure sore for one resident (#35) from a total sample of 27 residents. This failure resulted in harm for resident #35. Findings include: Resident #35 was admitted on [DATE] with [DIAGNOSES REDACTED]. On the 8/6/10 annual Minimum Data Set (MDS) assessment, licensed staff coded the resident as being totally dependent on one person for bed mobility and toilet use and, as being incontinent of bowel and bladder. The resident was also coded as having functional limitations of his/her right leg,foot, arm and hand. According to the 8/6/10 Resident Assessment Protocol Summary (RAPS) documentation, the resident triggered for additional assessment for pressure sores. According to the nursing documentation on the RAPS for pressure sores, the resident was at risk for developing pressure sores due to his/her limited mobility and incontinence of bowel and bladder, wore heel protectors, and had a redistribution mattress and a cushion for his/her geri-chair. There was a care plan since 5/6/09 to address his/her potential for skin breakdown related to incontinence and limited mobility with interventions for certified nursing staff to turn and reposition the resident every two hours and, to observe all of his/her boney prominences daily and report (any) redness or breaks in skin to the charge nurse. According to the 3/18/11 nurses' note, the resident was observed to have an unstageable pressure sore on the malleolus (the boney protuberance on the side of the ankle joint) of his/her right foot. The nurse documented that the resident's right foot turned inward causing the malleolus to protrude and that he/she had worn an AFO boot since the removal of pins from tendon release surgery in December 2010. According to the 3/18/11 Wound Assessment Report, the previously unidentified pressure sore measured 1.0 centimeters (cm) x 1.9 cm and the wound bed was 100% covered with yellow/tan colored adherent eschar. According to the staff's documentation on the 4/7/11 Interdisciplinary Progress Note, the pressure from the AFO boot on the protruding malleolus had caused the pressure sore. On 8/8/11 at 12:45 p.m., the resident was sitting in his/her geri-chair in his/her room. A dressing was on his/her right foot dated 8/7/11. His/her right foot was contracted and turned inward. A foam boot was on his/her left foot. On 8/10/11 at 8:45 a.m., the treatment nurse provided pressure sore treatment for [REDACTED]. The resident had an approximately 0.1 cm x 1.0 cm scabbed area on his/her right malleolus. There was no odor or drainage The nurse stated that the pressure sore was a healing Stage III. On 8/11/11 at 1:40 p.m., the treatment nurse stated that the resident's family member had told staff that he/she did not want the resident's AFO boot removed so, staff did not remove the boot to check the resident's skin. According to the Skin Assessment and Prevention Check sheet, nursing staff had assessed the resident's skin weekly prior to the identification of the unstageable pressure sore with the last assessment having been done on 3/11/11. Nursing staff documented that the resident did not have any skin breakdown at that time. Review of the resident's clinical record revealed that there was not a physician's orders [REDACTED]. There was no indication that staff had checked the resident's skin for breakdown daily as planned between 3/11/11, when the last weekly skin assessment was done by nursing staff, and 3/18/11 when nursing staff first identified the unstageable pressure sore. On 8/11/11 at 3:20 p.m., the Director of Nursing stated that she would have expected certified nursing staff to remove the resident's AFO boot every day during care and check the resident's skin for redness or breakdown. However, nursing staff had failed to assess the resident's skin as planned and, the pressure sore was not identified by nursing staff before it was an unstageable pressure sore.