**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, staff interview, and review of the State Survey Agency's Long-Term Care Reporting Portal, it was determined the facility failed to protect Resident #5's right to be free from neglect when CPR was not provided. This was true for 1 of 5 residents (Resident #5) whose closed records were reviewed. This deficient practice resulted in a serious adverse outcome to Resident #5 when CPR was not provided per her wishes and physician order. Findings include: The facility's policy, Cardiopulmonary Resuscitation, updated [DATE], stated residents who requested Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status were to receive basic life support, including initiation of CPR in the event they experienced cessation of respirations and/or pulse. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), epilepsy, and colostomy (surgical opening in the abdomen that creates a passage from the large intestine to the outside of the body). Resident #5's POST form, signed by Resident #5 and her physician on [DATE], documented she requested to be a Full Code in the event she did not have a pulse and/or was not breathing. Resident #5's care plan, initiated on [DATE], documented Resident #5 was a Full Code and she had a POST in place. A facility Reported Incident, dated [DATE], documented at 3:00 PM, Resident #5 complained to her CNA of leg pain. At 4:00 PM on [DATE], Resident #5 complained to her CNA of stomach and leg pain. CNAs were called to Resident #5's room two more times that afternoon to find her laying sideways on her bed, appearing pale, and complaining that she did not feel well. The incidents and complaints were reported to Resident #5's nurse, LPN #1. At approximately 5:20 PM, Resident #5 was found by 2 CNAs, laying sideways on her bed, with shallow breathing, cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood) of her fingers and lips, and her eyes half opened. The CNAs notified LPN #1 and the RCM. The RCM responded and assessed Resident #5 for a pulse and did not find one. LPN #1 performed a sternal rub (application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) on Resident #5 resulting in no response from her. The RCM instructed LPN #1 not to perform CPR until she verified Resident #5's code status. After determining Resident #5 was a Full Code, the RCM returned to Resident #5's room and informed LPN #1. The RCM then left the room and proceeded to call the facility's CNO to report the event and received instructions to have an RN on staff pronounce Resident #5's death, notify Resident #5's physician and family, and obtain staff statements related to the event. The RCM was interviewed by phone on [DATE] beginning at 5:35 PM. She stated she did not know why she told LPN #1 not to perform CPR until she checked Resident #5's code status, but she wanted to be sure CPR was appropriate for Resident #5. When asked if she expected LPN #1 to initiate CPR, she stated, I don't know. I didn't know to do that. She stated after she told LPN #1 that Resident #5 was a Full Code, she left the room to call the CNO to tell her Resident #5 had passed. When asked how she determined Resident #5 had passed, she stated, Because I checked her pulse. On [DATE] at 3:27 PM, the CNO, Administrator, and CRN were interviewed together. They stated staff did not initiate CPR for Resident #5 when she did not have a pulse and was a Full Code. The facility failed to protect Resident #5's right to be free from neglect when CPR was not provided per her wishes and physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of facility policies, it was determined the facility failed to prevent the development and worsening of pressure ulcers. This was true for 3 of 4 residents (#10, #52, and #162) reviewed for pressure ulcers. This deficient practice caused harm to Resident #10, #52, and #162 when: * Resident #10 developed an unstageable pressure ulcer on his coccyx. * Resident #52 developed a bruise on his right lower leg that deteriorated and became an unstageable pressure ulcer, and he developed unstageable pressure ulcers on the left ankle and right ankle. * Resident #162 developed an unstageable pressure ulcer on her right heel. Findings include: The facility's policy and procedure for Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, dated 11/28/17, documented the following: * A risk assessment would be performed on admission and at designated times throughout the resident's stay. * The Braden Scale would be used to identify residents at risk for pressure ulcers. * Based upon the assessment and the resident's clinical condition, choices, and identified needs, basic or routine care could include, but is not limited to, interventions to: - Redistribute pressure (such as repositioning, protecting, and/or offloading heels, etc.) - Minimize exposure to moisture and keep skin clean, especially of fecal contamination. - Provide appropriate, pressure-redistributing, support surfaces. - Provide non-irritating surfaces. - Maintain or improve nutrition and hydration status, where feasible . * Treatment of new or already-present pressure and non-pressure wounds would be initiated following the principles of wound healing. 1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses, including unspecified dementia with behavioral disturbance, contracture of muscle, multiple sites, and edema (swelling). Resident #10 was transferred to another facility on 5/8/18. Resident #10's annual MDS assessment, dated 2/7/18, documented the following: * Severe cognitive impairment * Not at risk for pressure ulcers. * No unhealed pressure ulcers. * Moisture associated skin damage. * Pressure reducing device for chair. * Pressure reducing device for bed. Resident #10's quarterly MDS assessment, dated 3/16/18, documented the following: * Short term and long term memory problems. * Severe cognitive impairment in daily decision making. * At risk for pressure ulcers. * No unhealed pressure ulcers. * A skin tear was present. * Moisture associated skin damage. * Pressure reducing device for chair. * Pressure reducing device for bed. * Application of nonsurgical dressings. Resident #10's care plan documented: Potential impairment to skin integrity related to incontinence was initiated on 2/10/17. A pressure relieving/reducing chair cushion, pressure relieving/reducing mattress, and weekly skin assessments by the licensed nurse were initiated on 2/10/17 and revised on 9/21/17. A Progress Note, dated 3/6/18 at 5:39 AM, documented blisters developed above Resident #10's coccyx that were fluid-filled and intact. A Weekly Skin Check, dated 3/12/18 at 1:02 AM, documented Resident #10 had no skin conditions or changes, ulcers, or injuries, and Skin is intact. Has slightly abraded area on buttock responding rapidly to treatment. A Progress Note, dated 3/16/18 at 8:23 PM, documented Resident #10 had a weight loss of 15.8 pounds over the past 30 days. Resident #10 was recently fitted for a new wheelchair. There was a skin tear on the coccyx and treatment was in place. A Progress Note, dated 3/17/18 at 11:35 PM, documented there was a large wound on Resident #10's coccyx that was draining and had white eschar (dead tissue) at the base. The wound was covered with a dressing and was unstageable. The assessing nurse would call the morning nurse the next day and measurements would be done in the morning. A Weekly Pressure Ulcer/BWAT Report, dated 3/18/18 at 1:46 PM, documented a new onset pressure ulcer on Resident #10's coccyx measuring 7.0 cm (length) by 4.0 cm (width) by 0.2 cm (depth) and was unstageable. The date of initial observation was 3/18/18. The wound was treated with Silvasorb and a sacral dressing. A Progress Note, dated 3/18/18 at 1:57 PM, documented Resident #10 developed an open wound on the coccyx measuring 7 cm by 4 cm by 0.2 cm. The wound was cleansed and a temporary dressing was applied. Staff were to turn Resident #10 side to side, and he was to be the last person to get up and first person to bed at mealtimes. A Progress Note, dated 3/19/18 at 10:36 AM, documented a pressure ulcer on Resident #10's coccyx that measured 1 by 1 on 3/15/18, then 7 cm by 4 cm by 0.2 cm on 3/18/18. The wound care nurse was to assess the wound on that day and discuss it with the physician. Occupational therapy (OT) had recently changed the wheelchair to a cube chair, and it was to be evaluated to determine whether the wheelchair caused pressure to the coccyx. Staff members were educated to turn the resident side to side and not onto his back. A Progress Note, dated 3/19/18 at 11:00 AM, documented Resident #10's wound was evaluated by the Assistant Director of Nursing (ADON) and the floor nurse. The wound was between Stage 2 and Stage 3. Treatment orders were requested from the physician for Silver Triact (brand name Restore, a type of wound dressing) to the base of the wound covered by Optifoam basic and a Mepilex dressing. OT was consulted regarding placing a Roho (pressure relief) cushion in the resident's chair. A Weekly Skin Check, dated 3/19/18 at 12:40 PM, documented a linear or elongated pressure ulcer on Resident #10's coccyx (tailbone area) and new suspected ulcer/deep tissue injury. Wound care orders were as follows: Cleanse the wound with wound cleaner, apply silver with a soft pad and a sacral dressing. A Progress Note, dated 3/19/18 at 2:46 PM, documented Resident #10's weight loss was discussed with a family member. The facility was going to obtain an air bed, turn him side to side, try to encourage nutritional intake, and limit time out of bed. Resident #10's physician orders documented wound care to the sacral wound started on 3/20/18 as follows: clean with wound cleanser and 4 by 4 dressing, apply Triact Silver to the wound bed, Optifoam Basic and cover with a Mepilex dressing every other day. Resident #10's Weekly Pressure Ulcer/BWAT Reports documented the following: * On 3/25/18 at 1:46 AM: The pressure ulcer on the coccyx measured 6 cm by 6.5 cm by 0.1 cm and was Stage 2. There was significant improvement, there was no sign of infection, and the wound width increased due to irregular shape and spreading his buttocks for treatment. * On 4/1/18 at 1:46 AM: The pressure ulcer on the coccyx measured 6 cm by 4.5 cm by 0.1 cm and was Stage 2. The area was significantly improved. There was no sign of infection. The wound center remained red and surrounding tissue was a pink scar. * On 4/8/18 at 1:46 AM: The pressure ulcer on the coccyx measured 3.5 cm by 4 cm by 0.1 cm and was Stage 2. Treatment was to continue a few more days. The wound was essentially healed, skin is intact, pink scar is very fragile and fresh. * On 4/14/18 at 1:46 AM: The pressure ulcer on the coccyx measured 1.5 cm by 1 cm by 0.1 cm and was Stage 2. The wound was almost healed and had a small open area in the center of fresh pink scar tissue. The surrounding skin was very fragile. The resident was incontinent, on an air bed, had contractures, and required routine turning as he could not reposition himself. * On 4/21/18 at 10:10 AM: The pressure ulcer on the coccyx measured 1.4 cm by 1 cm by 0 cm and was Stage 2. The area was almost healed and had a fresh pink scar. The skin remained fragile. The resident was incontinent of bowel and bladder. Staff continued the air bed and every two hour turning, and contractures limited his mobility. * On 4/28/18 at 9:56 AM: The pressure ulcer on the coccyx measured 1.0 cm by 1 cm by 0 cm and was Stage 2. The area was almost healed. The resident continued to have fragile skin, incontinence, and contractures. Staff continued every two hour turning. On 6/29/18 at 9:23 AM, the Unit Manager said Resident #10 had a skin tear on his coccyx on 3/15/18 and she did not recall how it happened. The Unit Manager said the wound was 1 cm x 1 cm x 0.1 cm, and it progressed and was determined to be a pressure sore on on 3/18/18. The Unit Manager said the wound had improved on 3/22/18, and slough (layer of dead tissue separated from surrounding living tissue) made it impossible to measure the depth. The Unit Manager said the pressure ulcer showed significant improvement with visible depth on 3/25/18. On 6/29/18 at 9:35 AM, the Unit Manager said Resident #10 was on an air mattress, although she did not know when it was applied. 2. Resident #52 was readmitted to the facility on [DATE] with multiple diagnoses, including heart failure, acute and chronic respiratory failure, muscle weakness, and dementia. Resident #52's Braden Scale for Predicting Pressure Sore Risk, dated 2/5/18, 2/12/18, 2/19/18, 2/26/18, and 3/5/18, documented he was at risk for pressure sores. Resident #52's quarterly MDS assessment, dated 2/18/18, documented the following: * Moderate cognitive impairment. * Total dependence on the physical assistance of two people for bed mobility and transfers. * At risk for pressure ulcers. * No unhealed pressure ulcers. * Skin and ulcer treatments, including a pressure reducing device for the chair and bed. Resident #52's quarterly MDS assessment, dated 5/18/18, documented the following: * Severe cognitive impairment. * Total dependence on two person physical assistance with bed mobility and transfers. * At risk for pressure ulcers. * One unstageable pressure ulcer with suspected deep tissue injury. * Skin and ulcer treatments, including a pressure reducing device for the chair and bed, nutrition or hydration intervention, pressure ulcer care, application of non-surgical dressings. Resident #52's physician orders directed staff to float the heels at all times starting on 2/27/18. Resident #52's current care plan documented the following: * Initiated and last revised on 3/28/18: A wound on the left gluteal fold. The care plan directed staff to float heels at all times, check that the head of the bed was not higher than 30 degrees, administer wound care as ordered by the physician, and turn side to side every two hours when in bed. *Initiated and last revised on 3/28/18: Impaired circulation and edema (swelling) related to congestive heart failure, and directed staff to elevate legs when resting, ensure proper-fitting footwear, inspect feet frequently for areas of injury, and inspect foot/ankle/calf frequently for changes. Resident #52's Weekly Skin Checks, dated 4/3/18 and 4/10/18, documented there were no skin conditions, changes, ulcers, or injuries. A Progress Note, dated 4/19/18 at 12:35 PM, documented the physician examined an unusual spot on Resident #52's right calf and determined it was a bruise. Staff were directed to apply Betadine (an antiseptic) and cover it with a foam dressing daily until resolved. A physician's note, dated 4/19/18, documented the physician saw Resident #52 at the request of nursing staff. A dark purple spot was noted on the left lateral leg two days prior. An oval area of purple discoloration with some mild erythema (redness) right around the edge. The area measured approximately 2.5 cm by 1.5 cm, and the central area was going to slough. The area was diagnosed as a superficial bruise on the right lateral leg. The physician ordered swabbing the wound with Betadine and applying a foam dressing. The physician said the resident has advanced age, poor circulation, nutrition and is a risk for a wound . A physician's order, started on 4/19/18, documented staff were to clean the bruise on Resident #52's right calf with Betadine and cover with a foam dressing once a day until resolved, and notify physician if worse or not improving. A Weekly Skin Check, dated 4/24/18 at 2:49 AM, documented there was a dressing to the bruise on Resident #52's right calf. A Progress Note, dated 5/8/18 at 9:42 PM documented the physician examined Resident #52 on that day, wanted to continue treatment to a sloughing bruise on the leg, and the resident was to wear Prevalon boots when in bed. A physician's note, dated 5/8/18, documented the physician examined Resident #52 and documented the area on the right lateral leg was a superficial bruise with thickening and slough. There were no signs of infection. The wound was slow to heal. There were no signs of infection, and the resident was to wear Prevalon boots. A Progress Note, dated 5/15/18 at 7:25 PM documented an antibiotic was ordered four times a day for 7 days for Resident #52's wound with dressing changes. A Progress Note, dated 5/15/18 at 10:37 PM documented the physician examined Resident #52, new wound care orders were received for the RLE, Prevalon boots were to be on at all times, and Keflex (antibiotic) four times a day for 7 days for mild RLE infection. Resident #52's physician's order, starting on 5/15/18, documented he was to wear Prevalon boots on at all times, and RLE wound: dry completely, apply Bacitracin (antibiotic) ointment and cover with an island dressing. Change every other day, and Cephalexin capsule (antibiotic) 500 mg four times a day for RLE wound infection. A Weekly Skin Check, dated 5/15/18 at 2:49 AM, documented there was a sloughing bruise and Resident #52 was on an antibiotic. A physician note, dated 5/15/18, documented the physician examined Resident #52 and said the bruise had some thickening of the eschar (dark, crusty dead tissue). The wound was not getting worse but was not improving. Staff had been applying Betadine and an island dressing. There was also an abrasion to the ankle area at that time. The resident had multiple illnesses and was declining fairly rapidly since he came here. There was some tenderness to the wound on the right lateral leg and some swelling behind it. The assessment included a bruise to the right lateral lower extremity that was slow to resolve and had possible very early onset wound infection, and there was an abrasion to the right ankle area. The wounds were to be cleaned, dried thoroughly, Bacitracin ointment applied, and covered with an island dressing every other day. Betadine was discontinued. Prevalon boots were to be on at all times, and Cephalexin was started four times a day for 7 days. Resident #52 was at high risk for skin breakdown related to his poor nutritional status, weight loss, and protein calorie malnutrition, and was at risk for poor wound healing due to his overall condition. A physician's note, dated 5/17/18, documented Resident #52's condition was poor and he continued to decline. A Progress Note, dated 5/18/18 at 2:36 PM, documented Keflex was continued for Resident #52's RLE wound. Resident #52's Progress Note, dated 5/19/18 at 9:21 AM documented RLE wound: dry thoroughly, apply [B]acitracin ointment and cover with island dressing/change every other day . A Progress Note, dated 5/20/18 at 10:06 PM, documented Keflex was continued for Resident #52's RLE wound. A Progress Note, dated 5/21/18 at 5:41 PM, documented Resident #52's wound started as a small bruise, and it had increased in size and severity. The ADON assessed the wound and it measured 1.5 cm by 0.5 cm by 0.1 cm. The wound was oblong-shaped and had a yellow wound bed. The skin at the outer perimeter of the wound was very red and the resident complained of soreness at the outer edges of the wound. There was minimal drainage which was serosanguinous (bloody) in color. A new dressing was placed, and the nurse would notify the physician at the next visit. A Progress Note, dated 5/22/18 at 3:43 PM, documented the physician examined Resident #52. The wound ointment was changed to Santyl and the dressing was to be changed daily. A physician note, dated 5/22/18, documented Resident #52's right lower leg had a linear wound measuring 1 cm wide by 2.5 cm long. The base had 100% yellow slough. The assessment was an ulceration of the right lateral lower extremity and the antibiotic ointment was discontinued. Santyl was ordered to the wound base and cover with an island dressing daily. A Progress Note, dated 5/23/18 at 10:00 PM, documented Resident #52 had completed the course of antibiotics, and the Wound changes between a white [NAME] wound bed and a dark brown pliable crust. There is no drainage. Now being treated with daily Santyl. A wound healing note, dated 5/25/18 documented pressure ulcers on Resident #52's right lateral calf, right ankle, right second toe, and left ankle. It was ordered to encourage repositioning every 2 to 3 hours, encourage offloading of heels and bony prominences, provide a supportive cushion in the wheelchair, and reposition the resident every 2 to 3 hours when up in wheelchair. A Progress Note, dated 5/31/18 at 4:30 AM, documented a new dressing was applied to Resident #52's wounds on the lower right leg. A Weekly Skin Check, dated 6/8/18 at 2:44 AM documented there were open wounds on Resident #52's right lower leg (rear), right ankle (outer) and left ankle (outer). A Progress Note, dated 6/8/18 at 12:28 PM, documented the Interdisciplinary Team met and discussed Resident #52's weight loss and wound status. A low air loss mattress was started on the previous day at the recommendation of the wound nurse practitioner for wounds to legs. A Progress Note, dated 6/10/18 at 2:28 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right lower leg (rear) pressure wound measured 4.0 cm (length) by 2.1 cm (width), undetermined depth and unstageable. The wound was initially observed on 5/23/18. The right ankle (outer) pressure wound measured 1.8 cm by 1.0 cm and depth was undetermined and unstageable. The wound was initially observed on 5/23/18. A Progress Note, dated 6/10/18 at 9:37 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The left ankle (outer) pressure wound measured 0.5 cm by 0.5 cm, and depth was undetermined and unstageable. The wound was initially observed on 5/23/18. A Progress Note, dated 6/15/18 at 9:48 AM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right lateral calf pressure wound measured 3.7 cm by 2.7 cm, depth was zero and unstageable. The wound was initially observed on 4/19/18. The eschar was separating from the wound edges leaving a narrow pink-red ring around it. This could account for the slightly larger size of the wound this week. Will consider cornstarch next Friday. A Progress Note, dated 6/15/18 at 10:11 AM, documented Resident #52's Pressure Ulcer BWAT report was completed. The left ankle (outer) pressure wound measured 0.6 cm by 0.4 cm, and depth was zero and unstageable. The wound was initially observed on 5/25/18. The wound was improved and slightly smaller with no signs of infection. A Progress Note, dated 6/15/18 at 9:37 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right ankle (outer) pressure wound measured 1.8 cm by 1.7 cm, and depth was zero and unstageable. The wound was initially observed on 5/25/18. The wound was slightly smaller than the previous week, and still had slough on the wound bed. A Progress Note, dated 6/18/18 at 11:03 AM, documented the wounds to Resident #52's left ankle and right second toe were improved and had smaller measurements. The wound on the right lateral calf and right ankle were slightly larger. There were no signs of infection. A Progress Note, dated 6/19/18 at 10:57 AM documented the physician ordered Juven (a nutrition powder) twice a day for 14 days per the dietician's recommendations to promote wound healing for Resident #52. A Progress Note, dated 6/22/18 at 10:27 AM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right ankle (outer) pressure wound measured 1.9 cm by 1.4, cm depth was 0 and suspected deep tissue injury. The wound was initially observed on 5/25/18. There was no change in treatment. A Progress Note, dated 6/22/18 at 1:55 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The right lateral calf pressure wound measured 4 cm by 2.5 cm, and depth was zero and unstageable. The wound was initially observed on 4/19/18. The eschar was separating from the wound edges and the base of the wound was covered with soft black eschar. The resident winced when the area was touched. A Progress Note, dated 6/22/18 at 2:03 PM, documented Resident #52's Pressure Ulcer BWAT report was completed. The left ankle (outer) pressure wound measured 0.6 cm by 0.4 cm, and depth was zero and unstageable. The wound was initially observed on 5/25/18. Current treatment was continued and make effort to offload. Resident #52's wound healing notes documented the following: On 6/1/18, 6/8/18, 6/15/18, and 6/22/18: Pressure ulcers on the right lateral calf, right ankle, right second toe, and left ankle. Wound orders included the following: *To the right calf: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * Apply Iodosorb (a common wound treatment) * Cover the wound with bordered foam. * Change the dressing daily or as needed. * To the right ankle: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * Cover the wound with bordered foam. * Change the dressing daily or as needed. * To the right second toe: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * To the left ankle: cleanse with normal saline or wound spray. * Protect around the wound with skin protectant. * Cover the wound with bordered foam. * Change the dressing daily or as needed. Additional orders included painting the wound with Betadine, encourage repositioning every 2 to 3 hours, a total air loss mattress per the primary physician's orders, encourage repositioning every 2 to 3 hours, encourage offloading of heels and bony prominences, provide a supportive cushion in the wheelchair, and reposition the resident every 2 to 3 hours when up in wheelchair. Resident #52's TAR documented the following: Turn side to side every two hours when in the bed. It was not documented the every 2 hour turns were completed on the following dates/times: * Day shift on 4/4/18, 1/14/18, 4/19/18, 4/22/18, 4/23/18, 5/2/18, 5/23/18, 5/26/18, 5/31/18, 6/2/18, 6/4/18, 6/8/18, 6/9/18, 6/15/18, and 6/18/18. * Evening shift on 4/2/18, 4/6/18, 4/13/18, 4/17/18, 4/22/18, 5/8/18, 5/9/18, 5/19/18, 5/26/18, 6/2/18, 6/3/18, 6/11/18, and 6/14/18. * Night shift on 5/3/18, 5/10/18, 5/11/18, 5/18/18, 5/21/18, 5/25/18, 5/28/18, 5/30/18, 6/2/18, 6/13/18, 6/15/18, 6/18/18, 6/24/18, and 6/25/18. On 6/26/18 at 9:47 AM, LPN #1 was observed performing wound care to Resident #52's right ankle, left ankle, and right lateral leg. The wound on the right lateral leg appeared mildly reddened around the edges. The wound on the right ankle and left ankle appeared as ulcerations on the bony prominences of the outer ankles. At that time, LPN #1 stated the wounds were measured on Fridays, there was a physician's assistant following the resident for the wounds, the wounds were from pressure, and she believed the wounds developed in the facility. On 6/27/18 at 9:32 AM, CNA #3 said staff repositioned Resident #52 every 2 hours, he had boots, and staff were to keep his feet up. CNA #3 said she did not know where to document it but staff did turn him every 2 hours. On 6/27/18 at 9:35 AM, LPN #1 said there were no wounds on Resident #52's buttock area at that time. LPN #1 said the wound on his outer calf came first, it started as a small open area, he was treated with an antibiotic then it got hard eschar. LPN #1 said there was a different treatment on it at that time, and there was a red area on it. LPN #1 said the wound on Resident #52's calf was caused from him not getting up and from his disease process, then the right ankle wound came next from pressure. LPN #1 said she thought the left ankle wound was fairly recent and it was just from positioning. LPN #1 said pillows were placed underneath Resident #52's legs and a wedge was placed under his legs after the first ulcer developed. LPN #1 said Resident #52 had always been on an air mattress and turned every 2 hours. On 6/27/18 at 9:45 AM, the Unit Manager said the CNAs would report signs of a pressure ulcer and the resident would be put on alert charting. The Unit Manager said the physician saw an unusual bruise on Resident #52's leg on 4/19/18, and it was treated it with Betadine and a foam dressing. The Unit Manager said the physician indicated on 5/8/18 that it was not from pressure and it was a sloughing bruise. The Unit Manager said Resident #52's leg was protected with Prevalon boots and he was put on Keflex. The Unit Manager said it was determined the Prevalon boot was causing pressure on Resident #52's leg. The Unit Manager said the wound care nurse practitioner started seeing Resident #52 and he did not wear the Prevalon boot anymore. The Unit Manager said the CNA noticed the area on Resident #52's leg and reported it to the nurse on approximately 5/20/18. The physician evaluated the wound 1 to 2 days later and ordered the wound to be covered and protected. The Unit Manager said the wound team evaluated Resident #52's wound and said the wound was pressure related on 5/23/18. The Unit Manager said Resident #52 was turned often, had an air mattress, had his heels floated, and staff did not elevate his head more than 30 degrees for comfort if he was sleeping. The Unit Manager said the right ankle wound came next, that it was on a bony prominence and had to be from pressure. The Unit Manager said floating the heels was done shortly after the Prevalon boot was removed and there was a protective dressing over it. The Unit Manager said the left ankle was the same thing, and staff were putting skin prep around it and applying a protective dressing. On 6/27/18 at 10:23 AM, the Unit Manager said Resident #52 received an air mattress on 6/7/18. On 6/27/18 at 10:30 AM, the DNS said Resident #52 was being followed by a wound care nurse practitioner for multiple wounds on his legs. The DNS said it started on 4/19/18 as an unusual bruise, it was observed by the physician and was treated with Betadine. The DNS said the Prevalon boot might have contributed to the pressure ulcer, so the boot was removed and a wedge and air mattress were put in place. The DNS said Resident #52 did not like to be turned, and the wound nurse did not think the wounds would heal due his medical state. The DNS said when the first wound came up, the physician looked at it and prescribed an order, and the physician did not feel it was pressure related. The physician described it as a sloughing bruise. The DNS said staff added Prevalon boots and floating his heels to relieve pressure. The DNS said wound care started in May, and the wound care team thought it was from pressure from the Prevalon boot so an air mattress and a wedge were added. The DNS said the physician saw the right lower leg wound again on 5/15/18 and wrote an order for Keflex. On 5/21/18 it looked worse and the physician was notified. The physician saw the wound again on 5/22/18 and changed treatment to a Santyl dressing. The DNS said the wound care nurse practitioner saw the wound for the first time on 5/18/18, and no orders were made until the first official wound team visit on 5/25/18. The DNS said the low loss air mattress was put in place on 6/7/18. The DNS said staff should check the skin integrity on the resident's leg whenever the Prevalon boot is removed and before placing it back on the leg. The DNS said the staff were monitoring the skin under Resident #52's Prevalon boot and the weekly skin checks would document status of his skin. The DNS said Resident #52 was at risk for pressure ulcers. On 6/29/18 at 9:45 AM, the DNS said repositioning was considered a standard of care and it was not necessarily documented. The DNS said Resident #52 was resistant to turning. 3. Resident #162 was readmitted to the facility on [DATE] with multiple diagnoses, including Type 2 diabetes mellitus and hereditary and idiopathic neuropathy (nerve damage). Resident #162 passed away in the facility on 4/5/18. Resident #162's quarterly MDS assessment, dated 1/8/18, documented severe cognitive impairment, not at risk for developing pressure ulcers, and no unhealed pressure ulcers. Resident #162's Significant change MDS assessment, dated 3/8/18, documented severe cognitive impairment, extensive assistance of two persons with bed mobility and transfers, at risk for pressure ulcers, one unhealed pressure ulcer that was unstageable, presence of and pressure reducing device for the chair and bed, pressure ulcer care, and application of dressings to feet. Resident #162's care plan documented the following: * A potential for skin integrity issues related to incontinence and decreased mobility was initiated on 12/23/14. Staff interventions included the following: A pressure reduction mattress was initiated on 12/23/14. Float heels with pillows while in bed and Prevalon boots in place when in wheelchair was initiated on 2/1/18. Encourage turning and repositioning every 2 hours or assist if she unable to reposition independently was initiated on 9/27/15. * Resident #162 had a deep tissue injury to her right heel was initiated on 1/30/18 and revised on 4/6/18. Staff interventions included the following: One to one staff supervision while awake due to the resident attempting to remove the boots was initiated on 2/27/18. Apply Betadine and heel cup every shift was initiated on 1/30/18 and revised on 3/1/18. A [NAME] wedge to the bed for absolute pressure relief was initiated on 1/30/18 and revised on 3/1/18. Encourage a high protein diet and protein-rich snacks was initiated on 3/26/18. Prevalon boots on at all times was initiated on 1/30/18. Wound care as prescribed by the physician was initiated on 3/12/18. Resident #162's February 2018 physician orders documented the following: * Started on 1/30/18: Right heel deep tissue injury: Apply Betadine and cover with a protective heel cup every shift, and Prevalon boot on at all times. * Started on 2/14/18: Complete the pressure ulcer report weekly, document findings in the nurse's notes and on the appropriate evaluation every Wednesday, A Weekly Pressure Ulcer BWAT Report, dated 1/30/18 at 5:25 PM, documented a pressure ulcer on Resident #162's right heel that measured 3.0 cm by 3.5 cm and was unstageable. Deep tissue injury was suspected. The wound was first observed on that date. Betadine was to be applied every shift per physician's order, as well as Prevalon boots at all times and a heel cup. A Progress Note, dated 1/21/18 at 9:49 PM, documented a CNA reported to the nurse there was discoloration to Resident #162's feet. The nurse assessed the feet and noted bluish discoloration to the left second, third, and fourth toes and a red area on the right fifth toe. The skin was intact, and the resident was to be added to the podiatrist's schedule that week. A Progress Note, dated 1/30/18 at 5:25 PM, documented Resident #162's Pressure Ulcer BWAT Report was completed for a right heel wound measuring 3.0 cm by 3.5 cm and was unstageable. There was a suspected deep tissue injury initially observed on 1/30/18. Staff were to apply Betadine every shif[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure there was behavior monitoring for a resident receiving an anti-anxiety medication. This was true for 1 of 6 residents (#18) reviewed for psychotropic medications. This failed practice created the potential for harm should residents experience adverse reactions and behaviors from psychotropic medications. Findings include: The facility's policy and procedure for Unnecessary Medications and Psychotropic Drugs/Antipsychotic Medication, dated 11/28/17, documented the following: * A resident's medication regimen is free of any medication used in excessive dose (including duplicative therapy), excessive duration, without adequate monitoring, without adequate indications for its use . * Documentation of signs of distress, delirium, or other changes in status. * Medications are monitored for to follow progress towards goals and to detect any adverse effects. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses, including generalized anxiety disorder. Resident #18's quarterly MDS assessment, dated 4/10/18, documented the following: * Short term and long term memory problems. * Some difficulty in new situations with making decisions regarding daily tasks of life-modified independence. * Anxiety disorder. * Anti-anxiety medication received on 7 of the last 7 days. Resident #18's physician orders documented Xanax tablet (anti-anxiety medication) 0.25 mg 1 tablet once a day for generalized anxiety disorder was started on 11/28/17. Resident #18's current care plan documented the following: * Resident #18 had anxiety. * Allow him to make decisions about treatment. * When he is anxious, offer a walk, visiting, calling his spouse, and reassurance. * Encourage participation and interaction as much as possible during cares. * Provide activities that focus on life history and present strengths. Resident #18's May 2018 and June 2018 MARs documented the Xanax was administered each day except for 5/19/18. Documentation of the monitoring of resident specific behaviors related to Resident #18's anxiety, was not completed prior to 6/28/18, the day prior to the survey exit conference on 6/29/18. On 6/28/18 at 3:49 PM, the Unit Manager said the behavior monitoring was not completed for Resident #18's Xanax and it should be. On 6/29/18 at 9:45 AM, the DNS said if a resident was on Xanax, the nurse should get an order and sign off on behavior monitoring and side effects.