**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) For Resident #629, the facility failed to obtain an antibiotic medication from the pharmacy in a timely manner, resulting in a worsening skin infection. Resident #629 was admitted in July 2024 with diagnoses including type 2 diabetes and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #629 scored a 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating intact cognition. During an interview on 3/7/25 at 8:40 A.M., Nurse Practitioner #1 said that she had concerns regarding communication between the facility and the providers. Nurse Practitioner #1 said that she ordered an antibiotic for Resident #629 due to an infection. She said that she was not notified timely by the facility that the order flagged an allergy alert that required her to address, and that therefore the antibiotic was not sent. Nurse Practitioner #1 said that following this incident she filed a safety report with the facility because the infection worsened and the Resident had increased pain because of the delay. Review of the nurse progress note, dated 8/17/24, indicated the following: Spoke to on call NP regarding changes to skin tear to R shin. Noted skin around tear is red, warm to the touch, and mildly painful to the patient. Redness continues throughout the front of the patient's shin. Bilateral swelling, which is baseline for patient noted to both legs. R leg noted to be significantly warmer to the left . New orders for Keflex 500 mg TID x 5 days. Override to penicillin allergy. Order to follow up with MD/NP on Monday 8/19/24. Review of the progress note, dated 8/18/24, indicated Keflex Oral Capsule 500 mg - Pharmacy notified. Unable to pull from Medwhiz. (the facility's contracted pharmacy). Review of the progress note, dated 8/19/24, indicated Keflex Oral Capsule 500 mg- Awaiting clarification for pharmacy to send. The record failed to indicate the Physician or Nurse Practitioner were notified that the facility was unable to obtain the medication on 8/17/24, 8/18/24 or 8/19/24. Review of the Medication Administration Record (MAR) for August 2024 indicated that on 8/18/24 and 8/19/24, Resident #629 did not receive the Keflex of 500 mg. During an interview on 3/10/25 at 11:37 P.M., the Director of Nursing said if there is a delay with a pharmacy then the nurses should notify the provider and then the provider would determine the course of action. The Director of Nursing said that they should also let him know if they are missing a medication because he keeps backup medications in the emergency kit. The Director of Nursing said that all of the actions should be documented in the progress notes, but were not. 3.) Resident #130 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #130's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #130 was dependent on staff for all care. On 3/04/25 at 9:02 A.M., Resident #130 was observed lying in bed with the sheets lifted to expose both legs. The Resident was observed to have black scabs on bilateral knees. Review of Resident #130's physician orders indicated the following orders: - Right buttocks area, cleanse with NS (normal saline). Pat dry and apply xeroform dressing. Cover with DPD dressing every day and pm (night), initiated on 2/7/25. - Check skin daily and report if skin irritation is notes, in the evening for skin breakdown, initiated 1/10/25. Review of Resident #130's nursing notes from 2/7/25 to present failed to indicate skin impairment on the right buttocks requiring the above stated order. Review of Resident #130's Treatment Administration Record (TAR) failed to indicate the nursing documented any skin irritation or abnormalities per the order. Review of Resident #130's weekly skin assessments, dated 2/17/25, 2/20/25, 2/22/25 and 3/1/25, failed to indicate the right buttock area or the bilateral knee scabs were observed and documented. During an interview on 3/6/25 at 7:39 A.M., Unit Manager #1 said all skin impairments should be included on the weekly skin assessments. Unit Manager #1 said she was unsure if Resident #130 had a skin impairment on his/her buttocks, however said if there was an impairment this should be included on the skin assessment. Unit Manager #1 then entered the Resident's room and observed the two black scabs on the Resident's bilateral knees and also observed a reddened small opened area on the Resident's buttock. Nurse #1 then entered Resident #130's room, observed the two scabs and buttocks and said these areas have been present for a couple of weeks. Both Nurse #1 and Unit Manager #1 said all three of these skin impairments should have been documented on the past skin assessments. During an interview on 3/6/25 at 9:31 A.M., the Director of Nursing said all skin impairments should be documented on the weekly skin assessment, with descriptions of the impairment included. Based on observation, record review and interview the facility failed to ensure that three Residents (#70, #629, and #130) out of a total sample of 42 residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically: 1. For Resident #70, the facility failed to a) initiate a treatment for a genital wound which subsequently became infected and deteriorated and b) failed to implement the wound Nurse Practitioner's (NP) recommendation for a change in wound treatment. 2. For Resident #629, the facility failed to obtain an antibiotic medication from the pharmacy in a timely manner, resulting in a worsening skin infection. 3. For Resident #130, the facility failed to complete weekly documentation of skin conditions. Findings Include: 1a.) Resident #70 was admitted to the facility in October 2022 with a diagnosis of diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/30/24, indicated that Resident #70 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating the Resident was cognitively intact. Review of Resident #70's activities of daily living (ADL) care plan indicated the Resident was at risk for decreased ability to performs ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to weakness. Interventions in the care plan included: -Provide resident/patient with total assist of 1 for personal hygiene (grooming), initiated 10/18/22. Review of Resident #70's most recent [NAME] plus pressure ulcer scale, dated 12/30/24, indicated the Resident was at high risk for developing pressure injuries. Review of Resident #70's hospital discharge paperwork, dated 12/29/24 indicated Resident #70 was hospitalized from [DATE] to 12/29/24. Further review of the hospital paperwork indicated the Resident had a genital lesion, that the Resident had first noticed the lesion in his/her nursing facility after his/her most recent admission (13 days earlier) and that the Resident associated the lesion with a cut he/she experienced from his/her urinary catheter. Further review of the hospital paperwork indicated that the hospital assessed the genital wound on 12/28/24, described the wound as scabbed and were cleansing the wound with soap and water. Review of NP #2's progress note dated 12/31/24 indicated Resident #70 returned to the facility from the hospital on [DATE] and that the Resident's hospitalization was complicated by a genital lesion. Further review of NP #2's progress note indicated the Resident had a small genital lesion most likely related to pressure from a urinary catheter. Review of the physician note, dated 1/2/25, indicated Resident #70 had a history of foley trauma of his/her urethra with a cut which was slow healing. Review of a nursing progress note, dated 1/8/25, indicated that therapy reported blood dripping from Resident #70's genitals. Review of a nursing note, dated 1/13/25, indicated that the nurse had reported a small pressure area on Resident #70's genitals to the NP. Review of the incident report titled new pressure ulcer, dated 1/13/25, indicated Resident #70 had an area on his/her genitals which was previously seen by the NP and documented as pressure due to the Foley catheter; the wound was noted with slough. Review of NP #2's progress note, dated 1/14/25 indicated Resident #70 had a small ulcer on his/her genitals that was tender and draining purulent discharge. Further review of NP #2's progress note indicated that the lesion appeared bigger than previously observed with a recommendation to continue to clean the lesion daily with NS (normal saline). Review of a nursing progress note, dated 1/14/25, indicated that Resident #70 was started on an antibiotic by the NP for infection. Review of a nursing progress note, dated 1/15/25, indicated Resident #70 was started on an antibiotic due to a pressure area on his/her genitals. Review of NP #2's progress note, dated 1/21/25, indicated Resident #70's genital lesion improved after treatment with antibiotics but remains open with yellow slough with a plan to wash the wound daily with NS. Review of Resident #70's physician orders indicated the following order: Genitals: Cleanse wound area with NS pad dry twice daily, initiated 1/20/25. Genitals: Monitor for bleeding until the end of the month, if bleeding continue, will refer PT (patient) to urology. Notify NP/MD (medical doctor) for excessive bleeding, initiated 1/8/25 Further review of Resident #70's physician orders indicated that the order for cleansing the wound area with NS was initiated 20 days after the facility became aware of Resident #70's genital wound and an order to monitor for genital bleeding was initiated eight days after the facility became aware of Resident #70's genital wound. Review of Resident #70's Medication Administration Records and Treatment Administration Records (MAR/TAR) failed to indicate that the Residents genital wound was being cleansed with normal saline until 1/21/25, 21 days after the facility became aware of Resident #70's genital wound. Review of the wound NP's progress note, dated 1/21/25, indicated Resident #70 had a traumatic wound on his/her genitals measuring 3 x 2.5 x 0.6 cm (centimeters) with 60% soft tissue and 40% slough. Further review of the progress note indicated a recommendation for the following treatment: Wash with wound cleanser, pat dry, medihoney to slough, cover with collagen wafer and ABD (a gauze pad). Prompt peri care and frequent repositioning. Keep area dry. During an interview on 3/6/25 at 12:28 P.M., Nurse # 7 said when a resident had a wound, nursing would notify the provider who would either ask nursing what kind of treatment they think would be appropriate for the wound or would place a treatment order themselves. Nurse #7 said she would expect a treatment to be in place for all wounds. Nurse #7 said Resident #70 had a laceration on his/her genitals. During interviews on 3/6/25 at 3:51 P.M., and 3/7/25 at 8:40 A.M. and 11:48 A.M. NP #2 said all wounds should have treatments in place. NP #2 said that if a treatment was not implemented that it would put the resident at high risk for wound infection. NP #2 said Resident #70 had a wound on his/her genitals which developed from a urinary catheter. NP #2 said she had first noticed that the Resident had an open wound on his/her genitals when she assessed the Resident on 12/31/24 after his/her re-admission from the hospital. NP #2 said she would have expected an order for cleansing the wound with normal saline to have been initiated when the Resident was re-admitted from the hospital on [DATE]. NP #2 said that on 1/14/25 she was concerned the Resident's wound was infected because it was draining pus, white exudate, was red and macerated so she started the resident on antibiotics; NP #2 said that Resident #70's genital wound looked worse on 1/14/25 than it did on 12/31/24. NP #2 said she assessed the Resident again on 1/21/25 and the wound had no pus but was still open and had slough. During an interview on 3/7/25 at 2:17 P.M. the wound NP said she would have expected that someone started a treatment plan before she was consulted to assess Resident #70's genital wound on 1/21/25 as the wound could deteriorate without a treatment and/or become infected. The wound NP said that on 12/31/24 she had noticed that Resident #70 had a small open wound on his/her genitals while she was assessing a different wound in proximity of the genital wound and that the other wound had since resolved. The wound NP said she wasn't consulted to assess the Resident's genital wound until 1/21/25, but would have expected a treatment to cleanse the wound with NS to have been initiated on 12/31/24 and that she had failed to documented her observation of the newer genital wound in her 12/31/24 assessment in error. During an interview on 3/6/25 at 5:06 P.M. Unit Manager #4 said she would have expected a treatment order to be in place for Resident #70's genital wound when he/she first returned from the hospital in December 2024. 1b.) Review of the wound NP's progress note, dated 2/25/25, indicated Resident #70's traumatic genital wound had increased in measurement and that the Resident reported the wound was tender to the touch. Further review of the progress note indicated the genital wound measured 6 x 3.5 x 0.6 cm. with 100% soft tissue with the following recommended treatment: Wash with wound cleanser, pat dry, collagen powder to wound and leave OTA (open to air). Keep wound clean and dry Qday (every day)/PRN (and as needed). During an interview on 3/6/25 at 12:28 P.M., Nurse # 7 said the wound NP saw Resident #7 and that they received the wound NP's report on 2/26/25. Nurse #7 said she was not sure if there were new recommendations but if there were she would expect them to be implemented right away. Review of Resident #70's physician orders indicated the wound NP's recommended treatment was not implemented until 3/6/25, 8 days after the facility received the recommendation and after the surveyor brought the concern to the attention of the facility. During an interview on 3/6/25 at 3:51 P.M. NP #2 said the wound NP comes in on a weekly basis and that she would expect wound NP recommendations to be implemented within 24 hours of the facility receiving them. NP #2 said she was not aware of any new recommendations to change Resident #70's genital wound treatment. During an interview on 3/7/25 at 2:17 P.M. the wound NP said she comes in once a week and that her notes with recommendations were emailed to the facility by the next day; the wound NP said she would expect her recommendations to be implemented as soon as the facility received them. The wound NP said that Resident #70's gauze pad was getting moist, gross and wadded so she recommended to change the treatment to leave the wound open to air to reduce moisture accumulation on 2/25/25. The wound NP said she was unaware that her most recent recommendation was not implemented until 3/6/25. During an interview on 3/6/25 at 5:06 P.M. Unit Manager # 4 said the wound NP's recommendation was implemented today and that if a wound retains too much moisture that it could make the wound worse; UM #4 said the recommendation should have been implemented earlier. During an interview on 3/6/25 at 7:30 P.M., the Director of Nursing (DON) said he would expect an order for a wound treatment and that he would expect wound NP recommendations to be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #109 was admitted in 5/2021 with diagnoses including dementia and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/30/25, indicated Resident #109 could not participate in the Brief Interview for Mental Status exam due to severe cognitive impairment. Review of the facility policy titled Psychotropic Medication, dated 4/2022, indicates the following - The consultant pharmacist reviews the appropriateness of the psychoactive medication order as part of each drug regimen review and monitors for; - Appropriateness of psychoactive administration based on diagnosis, clinical indications and prescribing guidelines and; - Reassessment for trial reduction in dose in accordance with state/federal regulations. On 3/4/25 at 9:55 A.M., Resident #109 was observed lying in bed. The Resident was not interviewable and at the time of observation, his/her mouth was moving with repetitive involuntary movement, similar to tardive dyskinesia. Review of the psychiatric follow up note, dated 1/14/25, indicated the following recommendations: - GDR (gradual dose reduction) recommended for Seroquel (an antipsychotic medication used to treat Schizophrenia), lower to 25 mg (milligrams) in AM (morning) and 50 mg in the evening. Review of the clinical record failed to indicate that the recommendation was reviewed by the Physician or Nurse Practitioner or that it was implemented. Review of the psychiatric follow up note, dated 2/4/25, indicated the following: - Resident #109 was seen on 1/14 and a GDR for Seroquel was recommended at that time but was not completed. There is no accompanying documentation in his/her chart as to why this was not completed. Review of the active physician orders indicated Resident #109's Seroquel order was changed on 2/4/25 to 25 mg in the morning and 50 mg in the evening, 18 days after the initial recommendation. Review of the psychiatric follow up note, dated 2/25/25, indicated the following recommendations: - Depression and agitation with positive response from current medications and no adverse effects from current Seroquel GDR. I would like to continue this dose reduction today and would recommend a lowering of his/her Seroquel to 25 mg 2x daily at this time. Review of the physician's orders failed to indicate that the recommendation from 2/25/25 had been implemented or reviewed. During an interview on 3/10/25 at 10:07 A.M., Unit Manager #1 said that the psychiatric nurse speaks with the charge nurse or nurse on duty when making recommendations. Unit Manager #1 said that the psychiatric nurse also sends an email that all the nurses have access to. The nurse who receives the recommendation will then notify the physician. During an interview on 3/10/25 at 11:42 A.M., the Director of Nursing said that the nurses receive the recommendations from the psychiatric nurse but also need to read the psychiatric nurse progress notes. Once the nurse reads the recommendation, they are to notify the physician and healthcare proxy. The Director of Nursing said that psychiatric nurse recommendations is a process that the facility is working on and is a work in progress. Based on observations, interviews and record review, the facility failed to ensure two Residents (#138 and #109) were free from the administration of unnecessary psychotropic medications (medications that affect brain activity associated with mental processes and behavior) out of a total sample of 42 residents. Specifically, 1.) For Resident #138, upon readmission to the facility, a new physician's order for ramelteon (a hypnotic medication) was implemented without informing the Resident or his/her representative of it's use or risks/benefits. Nurse Practitioner #2 recommended to evaluate the discontinuation of this medication, but it was never done, and as a result, Resident #138 experienced a significant decline in functional and cognitive status that included increased somnolence, decline in ability to self-feed, decline in ability to reposition himself/herself in bed, and the development of pressure injuries. 2.) For Resident #109, the facility failed to implement a gradual dose reduction in a timely manner as recommended by the psychiatric nurse practitioner. Findings include: 1.) Review of the facility policy titled 'Psychotropic Medications', revised April 2022, indicated, but was not limited to: - Policy: To administer and monitor effects of psychoactive medications when prescribed. Monitoring for drug side effects leads to early identification and reporting in accordance with state/federal regulations. - An informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychoactive medication. - Reassessment for trial reduction in dose in accordance with state/federal regulations. Review of the facility policy titled 'Behavioral Management', revised April 2022, indicated, but was not limited to: - The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. - The resident and/or representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions. - Psychiatric recommendations will be reviewed by the IDT (interdisciplinary team) and will implement as indicated. - When medications are prescribed for behavioral symptoms, documentation will include: potential risks and benefits of medications as discussed with the resident and/or representative, monitoring for efficacy and adverse consequences. - Monitoring: If the resident is being treated for altered behavior or mood, the IDT will observe for changes in the individual's behavior, mood, and function. Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she was never made aware and never consented to Resident #138 receiving ramelteon. Resident #138's health care proxy said she was very angry because she had told the facility many times that she believed Resident #138 was overmedicated and receiving medications that affected him/her mentally, but the facility denied it. Resident #138's health care proxy said she had asked for a medication list many times, but it was never provided to her. Resident #138's health care proxy said she would have never consented to ramelteon, or any other hypnotic medication. Resident #138's health care proxy said before Resident #138 went to the hospital on [DATE] he/she was able to communicate in full sentences, was able to feed himself/herself, was able to get out of bed, and did not have pressure ulcers. Resident #138's health care proxy said since he/she returned from the hospital on [DATE] he/she has significantly declined. Resident #138's health care proxy said he/she no longer talks, except yes/no questions, and is often difficult to arouse. Resident #138's health care proxy said sometimes she has to shake him/her to wake them up and even then they fall back asleep right away. Resident #138's health care proxy said sometimes she must watch his/her chest to check to see if he/she is breathing because she thinks he/she's dead. Resident #138's health care proxy said he/she has also lost the ability to feed himself/herself or even able to sit up in his/her chair and is now bedbound with multiple pressure ulcers. Review of Resident #138's medical record indicated he/she was discharged to the hospital on [DATE] and did not receive Ramelteon, or any other hypnotic medication, prior to this hospital discharge. Further review of Resident #138 medical record indicated he/she was readmitted to the facility on [DATE]. Review of quarterly Minimum Data Set (MDS) assessment prior to discharge to hospital, dated 9/11/24, indicated Resident #138 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. This MDS indicated Resident #138: - Was understood by staff and usually able to understand staff communication. - Had no pressure ulcers. - Was able to roll in bed with supervision or touching assistance - Was able to feed himself/herself after set-up. This MDS indicated Resident #138 was not receiving hypnotic medication. Review of discharge Minimum Data Set (MDS) assessment, dated 10/24/24, did not include any cognitive assessments and indicated Resident #138: - Had no pressure ulcers - Was able to roll in bed with partial/moderate assistance - Was able to feed himself/herself after set-up. This MDS indicated Resident #138 was not receiving hypnotic medication. Review of Resident #138's hospital Discharge summary, dated [DATE], indicated: - Indication for admission: diarrhea and altered mental status found to have Clostridium difficile (a bacterium that causes diarrhea and inflammation of the colon). - Delirium: Patient has trouble sleeping with intermittent yelling/vocalizations throughout the night during admission. Psych was consulted due to concern for delirium. - Discharge medication list includes: Start taking these medications: Ramelteon 8 milligram (mg) tablet by mouth nightly. Review of Resident #138's physician orders upon readmission to the facility from the hospital, dated 10/24/24, indicated a new physician order for Ramelteon 8 mg once daily for anxiety. Review of Resident #138's medical record failed to indicate the Resident or the Resident's representative was informed of the risks/benefits or gave consent to administer Ramelteon 8 mg. Review of Manufacturer's guidelines for ramelteon indicated: - Ramelteon is a hypnotic (sleep) medicine. - Common side effects include drowsiness and tiredness. - Most common adverse reactions (>3% and more common than with placebo) are: somnolence, dizziness, fatigue, nausea, and exacerbated insomnia. Review of Resident #138's progress note from Nurse Practitioner #1, dated 10/28/24, indicated: - Consider stopping ramelteon next week once settled in if no new issues - this was started because of delirium in the hospital. Review of Resident #138's nursing progress note, dated 10/30/24, indicated: - Significant change identified by IDT today due to decline in ADL (activities of daily living) and mobility function, decline in cognition and increase assistance with decision making. Review of Significant Change in Status Minimum Data Set (MDS) assessment, dated 11/6/24, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS indicated Resident #138: - Was rarely/never understood. - Had one new stage three pressure ulcer - Required substantial/maximal assist to roll in bed - Was dependent on staff to feed him/her. This MDS indicated Resident #138 was receiving hypnotic medication. Review of Resident #138's medical record indicated he/she was discharged to the hospital on [DATE]. Further review of medical record indicated Resident #138 had received ramelteon daily as ordered from 10/24/24 until this discharge on [DATE]. Review of Resident #138's hospital Discharge summary, dated [DATE], indicated: - Sent to hospital for hypoxia, more somnolence, and decreased level of alertness and poor po (by mouth) intake. - According to the prior record even though patient has history of dementia his/her baseline mental status is usually very talkative person, very social. Last known well 10/1/24. - Somnolent. Hypoactive since prior hospital discharge (on 10/24/24). Review of Resident #138's medical record indicated he/she was readmitted to the facility on [DATE] and that the ramelteon 8 mg was continued without a re-evaluation by the provider to consider stopping the hypnotic medication. Review of Resident #138's progress note written by Unit Manager #2, dated 11/13/24, indicated: - HCP (health care proxy) came to visit resident, states he/she is sleepy and not arousable. Verbalizes the nurse is overmedicating Resident. This writer reviewed meds (medications) given this morning with HCP, which included Tramadol PRN (as needed) due to pain r/t (related to) wound tx (treatment). During a follow-up interview on 3/6/25 at 9:35 A.M., Unit Manager #2 said she was hired at the facility after Resident #138's October hospitalization and she never knew his/her cognitive/functional status prior to that hospitalization. Unit Manager #2 said since that hospitalization he/she had episodes of somnolence and spoke in yes/no questions only, but she believed that was his/her baseline. Review of Resident #138's nursing progress note, dated 12/2/24, indicated: -(Health care proxy) stating she does not want Resident overmedicated. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS also indicated Resident #138: - Had one stage three pressure ulcer. - Required substantial/maximal assistance to roll in bed. - Was dependent of staff on staff to feed him/her. This MDS indicated Resident #138 was receiving hypnotic medication. Review of Resident #138's medical record, dated 10/24/24 to 3/4/25, failed to indicate any re-evaluation to consider stopping ramelteon. During this timeframe Resident #138 was not seen by psychiatric services. Further review indicated Resident #138 received ramelteon daily during this time frame. During an interview on 3/6/25 at 9:31 A.M., Nurse Supervisor #1 said side effects for ramelteon include somnolence, fatigue, drowsiness, and behavior disorders. Nurse Supervisor #1 said was hired at the facility after Resident #138's October hospitalization and she never knew his/her cognitive/functional status prior to that hospitalization and believed this was his/her baseline. Nurse Supervisor #1 said if a family member or health care proxy reported increased somnolence or any mental status change from his/her baseline, she would expect the physician to be notified and a medication review to be completed. During an interview on 3/6/25 at 10:26 A.M., the Social Worker said he had known Resident #138 since he/she was admitted in June 2024. The Social Worker said before his/her October 2024 hospitalization he/she had cognitive deficits but was able to communicate and was more alert. The Social Worker said since his/her hospitalization in October 2024 they completed a significant change in status assessment because he/she had a decline functionally and cognitively. The Social Worker said following the October 2024 hospitalization Resident #138's alertness decreased, and his communication deficit was too poor to complete the Brief Interview for Mental Status (BIMS) assessment anymore, when he/she previously could. During an interview on 3/6/25 at 11:02 A.M., the Director of Nursing (DON) said a consent, including education of risks/benefits of the medication, must be obtained and a consent form signed before administration of psychotropic medication. During a telephone interview on 3/7/25 at 6:29 A.M., Certified Nurse's Assistant (CNA) #7 said she had known Resident #138 since he/she was admitted in June 2024. CNA #7 said before his/her October 2024 hospitalization he/she was able to communicate in full sentences and was more alert. CNA #7 said when he/she returned from the hospital at the end of October 2024 he/she was less alert and required more assistance functionally. CNA #7 said he/she lost the ability to self-feed and became dependent on staff for assistance to eat. CNA #7 said he/she could no longer communicate in full sentences and could only respond to yes/no questions. During an interview on 3/7/25 at 8:40 A.M., Nurse Practitioner #1 said Resident #138 had a cognitive and functional decline after his/her hospitalization in October 2024. Nurse Practitioner #1 said she was not aware Resident #138 was receiving ramelteon. Nurse Practitioner #1 said somnolence or decreased alertness is a common side effect of ramelteon. Nurse Practitioner #1 said if a provider documented consider stopping ramelteon next week once settled in if no new issues - this was started because of delirium in the hospital one of the providers should have re-evaluated the ramelteon the next week and documented it. During an interview on 3/10/25 at 10:12 P.M., the DON said if a provider documented consider stopping ramelteon next week once settled in if no new issues - this was started because of delirium in the hospital the facility would expect the provider to follow up with a re-evaluation of the medication and document it the next week. The DON declined to answer questions regarding the monitoring and reporting of adverse effects of ramelteon and said the facility should be following their policy regarding psychotropic medications. Review of Resident #138's hospitalist progress note, dated 3/9/25, indicated: - Resident #138 is no longer receiving ramelteon. During a follow-up telephone interview on 3/10/25 at 8:56 A.M., Resident #138's health care proxy said the Resident is no longer receiving ramelteon and is more alert during meals and his/her intake is improving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a.) Resident #110 was admitted to the facility in April 2022 with diagnoses including dementia. Review of Resident #110's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated the Resident scored a 0 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. The MDS indicated the Resident requires substantial assistance for toilet transfers and is dependent on staff for toileting tasks. Section H of the MDS indicated Resident #110 is always incontinent of both bowel and bladder. On 3/5/25 at 9:00 A.M., Resident #110 was observed sitting in his/her wheelchair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #110 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25 at 8:05 A.M., Resident #110 was observed sitting in his/her wheelchair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 11:57 A.M. Throughout this time Resident #110 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #110 was observed lying in bed. Review of Resident #110's most recent Norton Pressure Ulcer assessment dated [DATE], indicated the Resident has double incontinence and is a high risk for pressure ulcer development. Review of Resident #110's ADL care plan indicated the following intervention: - Provide resident/patient with limited assist of 1 for toileting after meals and as needed. Review of Resident #110's incontinence care plan, failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/7/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #5 said she did not provide care to Resident #110 while the surveyor was off the unit. CNA #5 said Resident #110 requires maximal assistance from staff for toileting and is incontinent of both bladder and bowel. CNA #5 said she provided care to Resident #110 and assisted him/her back to lunch after bed. CNA #5 said she did not provide incontinent care to the Resident when she placed him/her back in bed and she was waiting until after she completed her afternoon paperwork. During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #1 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/24 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. 2b.) Resident #106 was admitted to the facility in March 2018 with diagnoses including dementia. Review of Resident #106's most recent Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the Resident scored 3 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she has severe cognitive impairment. Section H of the MDS also indicated the Resident is always incontinent of bladder and bowel and is dependent on staff for toileting tasks. On 3/5/25 at 9:00 A.M., Resident #106 was observed sitting on the couch in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25 at 8:05 A.M., Resident #106 was observed lying on the couch in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 11:57 A.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #106 was observed still sitting on the couch. Review of Resident #106's most recent Norton Pressure Ulcer assessment dated [DATE], indicated the Resident has urinal incontinence and is a moderate risk for pressure ulcer development. Review of Resident #106's ADL care plan indicated the following intervention: -(The Resident) needs assistance of one with bathing, dressing, grooming (needs extra encouragement for hygiene), locomotion, transfers, and toileting. (The Resident) can eat independently with set up of a tray. (He/she) is incontinent of both bowel and bladder. Review of Resident #106's incontinence care plan, failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/7/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #6 said she did not provide care to Resident #106 while the surveyor was off the unit. CNA #6 said Resident #106 requires maximal assistance from staff for toileting and is incontinent of both bladder and bowel. CNA #6 said she provided care to Resident #106 and will be providing care to the Resident again. On 3/7/25 at 1:22 P.M., CNA #5 transferred Resident #106 from the couch to a wheelchair. When Resident #106 stood, a strong odor similar to urine was observed by the surveyor. CNA #5 then assisted the Resident to the bathroom to provide care. Once care was provided, CNA #5 showed the surveyor Resident #106's brief that had just been removed. The brief was soiled with a significant amount of urine. During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #1 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/24 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. 2c.) Resident #130 was admitted to the facility in December 2020 with diagnoses including Alzheimer's Disease. Review of Resident #130's most recent Minimum Data Set (MDS) assessment, dated 12/19/24, indicated the Resident was unable to complete the Brief Interview for Mental Status exam and staff had assessed him/her to have severe cognitive impairment. Section H of the MDS also indicated the Resident is always incontinent of bladder and bowel and is dependent on staff for toileting tasks. On 3/5/25 at 9:00 A.M., Resident #130 was observed reclined in his/her reclining Broda chair in the dining room. The Resident was observed sitting in the dining room from 9:00 A.M. until 12:00 P.M. Throughout this time Resident #130 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. On 3/7/25, Resident #130 was observed in the dining room from 10:26 A.M. until 11:57 A.M. Throughout this time Resident #106 was not observed to have either of the two nursing assistants or the nurse working on the floor approach the Resident to check for incontinence or to provide care. At 1:12 P.M., the surveyor returned to the unit and Resident #130 was observed still reclined in the dining room. Review of Resident #130's most recent Norton Pressure Ulcer assessment dated [DATE], indicated the Resident has both bladder and bowel incontinence and is a high risk for pressure ulcer development. Review of Resident #130's ADL care plan indicated the following intervention: -(The Resident) needs dependent care of 1-2 for all of (his/her) ADLs. Review of Resident #130's incontinence care plan, failed to indicate an intervention of a toileting schedule or how often the Resident should be checked/changed. During an interview on 3/5/25 at 1:48 P.M., Certified Nursing Assistant (CNA) #4 said the unit is very short staffed, and because of this it takes a long time to provide care to residents and ensure that all the care is being completed. During an interview on 3/07/25 at 1:12 P.M., CNA #5 and #6 said they provide incontinence care to residents on the floor in the morning and then again in the afternoon. CNA #5 said the staff on the floor know the residents well on the floor and can predict when they go to the bathroom so there is no need to check for incontinence. CNA #5 said Resident #130 is dependent on staff for all care, including toiling and that the Resident is incontinent of both bladder and bowel. CNA #5 said she did not provide care to Resident #130 while the surveyor was off the unit. CNA #5 said she provided care to Resident #130 this morning and because the Resident did not get up from bed until after breakfast, he/she would not receive care again until the afternoon staff starts their shift. During interviews on 3/5/25 at 2:03 P.M., and 3/7/25 at 1:22 P.M., Nurse #1 said all residents should be checked for incontinence and have incontinent care provided to them every 2-3 hours. Nurse #1 said there is not enough staff on the floor for the acuity of the residents and because of this people are often left soaking with incontinence because staff cannot get to the residents on time. Nurse #1 said residents are cared for in the morning and then are often not cared for again until the afternoon when the next shift comes in. Nurse #2 said she and the other staff do not have enough time to complete rounds on residents. During an interview on 3/7/24 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. Refer to F686 and F725. Based on observations, record review and interviews, the facility failed to ensure four Residents (#138, #110, #106, and #130) were free from abuse and neglect out of a total sample of 42 residents. Specifically, 1.) For Resident #138, the facility failed to ensure staff provided necessary care of repositioning and incontinence care resulting in the deterioration of a pressure wound. 2.) For Residents #110, #106 and #130, the facility neglected to provide the necessary care for incontinence management. Findings include: Review of the facility policy titled, Abuse: Prevention, dated revised 3/2022, indicated the following: Purpose: To allow residents freedom of the risk of abuse, neglect, involuntary seclusion, and misappropriation and exploitation of resident property. Policy: - The facility will be proactive with any type of abuse. - The facility Administrator will be the Abuse Prevention Coordinator. - The Administrator or designee has the ability to delegate actions and tasks to other employees, such as gathering of pertinent data, so that a timely resolution of an event and/or alleged event will occur. Procedure: - 3. The Administrator will ensure that residents, families, and staff have information on how to and whom they may report concerns, incidents, and grievances without fear of retribution, and provide feedback regarding concerns that have been expressed. - 6. Facility specific characteristics will be considered when planning for prevention. Such characteristics may include: a. Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility; b. The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs; c. The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds; and d. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. Review of the facility policy titled, Abuse Prohibition, dated 3/2022, indicated the following: Purpose: - Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property, Every resident in the facility will always be treated with respect and dignity, - Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Policy: - Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteer staff, family members, friends, or other individuals, - Staff will refrain from all actions that could be considered abuse, mistreatment, neglect, exploitation, and/or misappropriation. 1.) For Resident #138, the facility failed to ensure staff provided necessary care to reposition and provide incontinence care resulting in the deterioration of a pressure wound. Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. The MDS further indicated Resident #138 had a stage three pressure ulcer, required substantial/maximal assistance to roll in bed, was always incontinent of bowel and bladder, and was dependent of staff for toileting hygiene and transfers. Review of Resident #138's medical record indicated he/she had been transferred to the hospital on 3/4/25 for deteriorating coccyx wound with increased size, drainage, and foul smell. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she does not believe Resident #138 was repositioned every two hours or was receiving incontinence care timely and that this caused his/her pressure ulcer to worsen. During a follow-up telephone interview on 3/10/25 at 8:56 A.M., Resident #138's health care proxy said she was looking for another facility for Resident #138 because he/she was being neglected at the facility. Resident #138's health care proxy said Resident #138's wound worsened to a stage four pressure ulcer with visible bone in the wound bed because he was not being turned and repositioned every two hours which the physician had ordered. Resident #138's health care proxy said Resident #138 also often did not have necessary incontinence care provided. Resident #138's health care proxy said she had told the Administrator, the Director of Nursing (DON), the Unit Manager, and many nurses and certified nurses assistants (CNAs) that Resident #138 was not being repositioned or having necessary incontinence care, but it continued. Review of Resident #138's plan of care related to actual alteration in skin integrity, initiated 11/7/24, indicated: - Turn and reposition every 2-3 hours every shift. Review of Resident #138's plan of care related incontinence of bladder, initiated 6/4/24, indicated: - Check twice a shift and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Review of Resident #138's report titled 'Documentation Survey Report' (a report including certified nursing (CNA) documentation), dated 10/24/24 to 3/4/25, indicated the Resident was always incontinent and always required staff assistance for repositioning. Review of Resident #138's assessment titled 'Skin Observation Tool', dated 10/25/24, indicated the Resident did not have any pressure ulcers on 10/25/24. Review of Resident #138's Wound Nurse Practitioner progress note, dated 10/29/24, indicated initial exams for two new wounds including: - Initial exam: left buttock pressure ulcer, stage 1. - Initial exam: MASD (moisture associated skin damage) coccyx. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 10/29/24, 11/5/24, 11/19/24, 11/26/24, 12/3/24, 12/10/24, 12/17/24, 12/27/24, 12/31/24, 1/7/25, 1/14/25, 1/21/25, 1/28/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25, and 3/4/25, indicated: - Treatment recommendations for left buttock pressure ulcer and MASD coccyx include prompt peri care and frequent repositioning. Review of Resident #138's Wound Nurse Practitioner progress note, dated 11/5/24, indicated: - Deteriorating left buttock pressure ulcer, unstageable. - MASD to coccyx was reclassified as an unstageable pressure ulcer. - Deteriorating pressure ulcer coccyx, unstageable. - New stage three right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from time between new wound was noted and when the wound deteriorated, dated 10/30/24 to 11/5/24, indicated: - Toileting hygiene was not provided on 4 shifts. - Turning and repositioning every 2 hours was not provided 12 times. Review of Resident #138's Wound Nurse Practitioner progress note, dated 12/10/24, indicated: - Deteriorating coccyx pressure ulcer which increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 11/6/24 to 12/10/24, indicated: - Toileting hygiene was not provided on 33 shifts. - Turning and repositioning every 2 hours was not provided 45 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 12/17/24, indicated: - Coccyx pressure wound reclassified to a stage three and increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 12/11/24 to 12/17/24, indicated: - Toileting hygiene was not provided on 7 shifts. - Turning and repositioning every 2 hours was not provided 17 times. Review of Resident #138's nursing progress note, dated 1/27/25, indicated: - (Health care proxy) stated he/she need to be changed right now. The nurse explained that I will notify the nursing aide for you. The resident aide was on break, the nurse was on break, two of the aide was with a resident in shower room. The other one was helping a resident with food. After a couple of minutes, while this writer was verify a dressing order, so that she was going to change when she heard someone was screaming at her: hey you, if you don't want to do your job just (expletive) stay home. This writer reply are you talking to me please do not yelled at me. This family member keep shouting and screaming at the nurse .This writer did not reply, just report it to the aide to change the resident as soon as he returned from break. [sic] Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/11/25, indicated: - Pressure ulcer to coccyx is deteriorating this week. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/1/25 to 2/11/25, indicated: - Toileting hygiene was not provided on 16 shifts. - Turning and repositioning every 2 hours was not provided 31 times. Review of Resident #138's nursing progress note, dated 2/12/25, indicated: - Pressure ulcer to coccyx deteriorating this week. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/18/25, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - New stage two right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/12/25 to 2/18/25, indicated: - Toileting hygiene was not provided on 6 shifts. - Turning and repositioning every 2 hours was not provided 5 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 3/4/25, indicated: - Deteriorating coccyx pressure ulcer. - New left buttock maceration. - Stable right buttock stage two pressure ulcer. Review of Resident #138's nursing progress note, dated 3/4/25, indicated: - Coccyx wound in deteriorating, foul smell noted, with increased size and drainage. NP (nurse practitioner) orders to send patient for ED (emergency department) evaluation. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/19/25 to 3/4/25, indicated: - Toileting hygiene was not provided on 9 shifts. - Turning and repositioning every 2 hours was not provided 9 times. Review of Resident #138's hospitalist progress note, dated 3/7/25, indicated: - No definite sacral osteomyelitis, but the MRI is not adequate for evaluation due to significant motion artifact. - Recommendations for wound care include to change positions regularly. Review of Resident #138's entire medical record, dated 10/24/24 to 3/4/25, failed to indicate the Resident refused repositioning or incontinence care. During a telephone interview on 3/7/25 at 6:29 A.M., Certified Nurse Assistant (CNA) #7 said the facility has been short staffed several days a week for the past few months. CNA #7 said several days a week there was only one CNA on the overnight shift making it physically impossible to turn and reposition all the residents on the unit. CNA #7 said she does not believe Resident #138 was repositioned every two hours consistently over the past three months. During a telephone interview on 3/7/25 at 8:40 A.M., Nurse Practitioner (NP) #1 said she sees that staff isn't always able to reposition and provide toileting/incontinence care. During an interview on 3/7/25 at approximately 1:00 P.M., the Administrator said not providing services or care to residents when needed is considered neglect. During an interview on 3/7/25 at 1:12 P.M., Certified Nurse Assistant (CNA) #8 said leaving a resident in their feces or urine for hours or not turning and repositioning them is neglect. During an interview on 3/7/25 at 1:17 P.M., Nurse #8 said leaving a resident in their feces or urine for hours or not turning and repositioning them is neglect. Nurse #8 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 1:19 P.M., Unit Manager #2 said Resident #138 should have been repositioned every two hours and incontinence care should have been provided promptly. Unit Manager #2 said repositioning and incontinence care should be documented by the CNAs, which is where the information from the report titled 'Documentation Survey' populates, under repositioning and toileting hygiene. Unit Manager #2 said if a Resident refuses repositioning or incontinence care that should be documented accordingly. Unit Manager #2 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 1:58 P.M., the Director of Nursing (DON) said residents who are incontinent should be changed every 2-3 hours. The DON said he would have to defer to the Administrator's definition of neglect and would not answer if not providing care could be considered neglect. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. The Wound NP said 50% of the time during weekly wound visits Resident #138's brief was soiled or full of urine. During an interview on 3/10/25 at 10:11 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant said CNA documentation should be completed by the end of each shift, including repositioning and incontinence care. The DON and Regional Nurse Consultant declined to comment on if not providing frequent repositioning or prompt incontinence care can cause a wound to deteriorate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide necessary treatment, services, and/or interventions to promote healing and prevent new ulcers from developing for four Residents (#138, #30, #167, and #143), who had pressure ulcers, out of 42 total sampled residents. Specifically, 1a.) For Resident #138, the facility failed to implement multiple wound care orders timely, resulting in the deterioration of the wound. 1b.) For Resident #138, the facility failed to ensure staff provided prompt incontinence care and was repositioned every two hours for pressure ulcer care, resulting in the deterioration of the wound. 1c.) For Resident #138, the facility failed to ensure staff implemented an appropriate support surface based on it's therapeutic benefit for the Resident's specific situation when the Resident, who had multiple worsening pressure ulcers and difficulty communicating needs, utilized an air mattress without specified settings. 2a.) For Resident #30, the facility failed to ensure wound care orders were implemented at the correct frequency. 2b.) For Resident #30, the facility failed to ensure staff implemented an appropriate support surface based on it's therapeutic benefit for the Resident's specific situation when the Resident, who had multiple pressure ulcers and incontinence, utilized an air mattress without specified settings. 3.) For Resident #167, the facility failed to ensure wound care recommendations were implemented timely. 4.) For Resident # 143, the facility failed to obtain physician orders for the use of a support surface (air mattress/overlay). Findings include: 1.) Resident #138 was admitted to the facility in June 2024 with diagnoses including functional urinary incontinence and dementia. Resident #138 did not have any pressure ulcers on admission to the facility. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/29/25, indicated Resident #138 had severe cognitive impairment based on a Staff Assessment for Mental Status. This MDS also indicated Resident #138 had a stage three pressure ulcer, required substantial/maximal assistance to roll in bed, and was dependent on staff for toileting hygiene and transfers. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she was concerned that the Resident was not receiving the wound care he/she needs because his/her wounds kept worsening. Review of Resident #138's medical record indicated he/she had been transferred to the hospital on 3/4/25 for deteriorating coccyx wound with increased size, drainage, and foul smell. 1a.) Review of Resident #138's assessment titled 'Skin Observation Tool', dated 10/25/24, indicated the Resident did not have any pressure ulcers on 10/25/24. Review of Resident #138's Wound Nurse Practitioner progress note, dated 10/29/24, indicated initial exams for two new wounds including: - Initial exam: left buttock pressure ulcer, stage 1. - Initial exam: MASD (moisture associated skin damage) coccyx. - Treatment recommendation for left buttock pressure ulcer and MASD coccyx: Wash with soap and water, pat dry. Apply zinc paste to bilateral buttocks and coccyx QD (every day) and PRN (as needed). Review of Resident #138's physician orders indicated: - Wash with soap and water, pat dry, then apply zinc oxide paste to BL (bilateral) buttocks and coccyx QD and PRN, initiated 10/31/24, which was two days after recommendation was made. Review of Resident #138's treatment administration record (TAR), dated October 2024, failed to indicate any treatment for the Resident's left buttock pressure ulcer or MASD on coccyx on 10/29/24 or 10/30/24. This TAR further indicated that on 10/31/24 the treatment order to Wash with soap and water, pat dry, then apply zinc oxide paste to BL (bilateral) buttocks and coccyx QD and PRN was not marked as implemented, but instead not documented by the nurse. This wound order was not implemented until 11/1/24, which was three days after it was recommended. Review of Resident #138's Wound Nurse Practitioner progress note, dated 11/5/24, indicated: - Deteriorating left buttock pressure ulcer, unstageable. - MASD to coccyx was reclassified as an unstageable pressure ulcer. - Deteriorating pressure ulcer coccyx, unstageable. - New stage three right buttock pressure ulcer. - Treatment recommendation for left buttock pressure ulcer and unstageable coccyx pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Santyl to open area, cover with collagen and sacral dressing, QD and PRN. - Treatment recommendation for right buttock pressure ulcer: Wash with wound cleanser, pat dry, skin prep to peri skin, collagen into open area, cover with sacral dressing, QD and PRN. Review of Resident #138's physician orders indicated: - Rt (Right) Buttock: Wash with wound cleanser, pat dry, skin prep to peri skin, collagen into area, cover with sacral dressing QD/PRN, initiated 11/8/24. This wound order was not implemented until three days after the recommendation was made. - Left buttock/coccyx: Wash with wound cleanser, pat dry, skin prep to peri skin. Santyl to open area, cover with collagen and sacral dressing QD and PRN with peri care, initiated 11/8/24. This wound order was not implemented until three days after the recommendation was made. Review of Resident #138's Wound Nurse Practitioner progress note, dated 12/10/24, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - Treatment recommendation for unstageable coccyx pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Collagen with silver to wound bed, cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated: - Wash with wound cleanser, pat dry, skin prep to peri skin. Collagen with silver to wound bed. Cover with sacral dressing QD/PRN and with peri care, initiated 12/17/24. This wound order was not implemented until seven days after the recommendation was made. Review of Resident #138's medication administration record (MAR) indicated santyl ointment was applied to his/her coccyx wound from 12/10/24 to 12/18/24, which was eight days after santyl was no longer recommended by the Wound Nurse Practitioner. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 12/17/24, indicated: - Coccyx pressure wound reclassified to a stage three and increased in size. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/11/25, indicated: - Pressure ulcer to coccyx is deteriorating this week. - Treatment recommendation for stage three coccyx pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Santyl to slough. Collagen to open area and cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated: - Pressure coccyx wound: Wash with WC (wound cleanser), pat dry, skin prep to peri skin. Santyl to slough, collagen to open area and cover with sacral dressing QD/PRN with peri care, initiated 2/14/25. This wound order was not implemented until three days after the recommendation was made. Review of Resident #138's nursing progress note, dated 2/12/25, indicated: - Pressure ulcer to coccyx deteriorating this week. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/18/25, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - New stage two right buttock pressure ulcer. - Treatment recommendation for stage three coccyx pressure ulcer and stage two right buttock pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Santyl to slough. Collagen to open area and cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated: - Pressure coccyx wound: Wash with WC (wound cleanser), pat dry, skin prep to peri skin. Santyl to slough, collagen to open area and cover with sacral dressing QD/PRN with peri care, initiated 2/14/25. - No wound treatment order was implemented for the Resident's new stage two right buttock pressure ulcer until 3/4/25. This wound order was not implemented until 14 days after the recommendation was made. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/25/25, indicated: - Treatment recommendation for stage three coccyx pressure ulcer and stage two right buttock pressure ulcer: Wash with wound cleanser, pat dry. Skin prep to peri skin. Collagen to open area and cover with sacral dressing QD/PRN/with peri care. Review of Resident #138's physician orders indicated the stage three coccyx pressure ulcer treatment recommendation was never implemented prior to the next scheduled weekly Wound Nurse Practitioner's visit on 3/4/25 during which wound deterioration was noted. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 3/4/25, indicated: - Deteriorating coccyx pressure ulcer. - New left buttock maceration. - Stable right buttock stage two pressure ulcer. Review of Resident #138's nursing progress note, dated 3/4/25, indicated: - Coccyx wound in deteriorating, foul smell noted, with increased size and drainage. NP (nurse practitioner) orders to send patient for ED (emergency department) evaluation. Review of Resident #138's hospitalist progress note, dated 3/7/25, indicated: - No definite sacral osteomyelitis, but the MRI is not adequate for evaluation due to significant motion artifact. - Recommendations for wound care include to change positions regularly. During an interview on 3/7/25 at 1:19 P.M., Unit Manager #2 said she usually completes the weekly wound rounds with the Wound Nurse Practitioner. Unit Manager #2 said the Wound Nurse Practitioner verbally communicates wound treatment changes before she leaves the floor. Unit Manager #2 said the Wound Nurse Practitioner always sends the written progress note with the treatment recommendations the next day, and the latest the facility receives it is the next day. Unit Manager #2 said the treatment recommendations should be communicated to the Resident's provider when the recommendation is received and implemented or documented why it was not. Unit Manager #2 said Wound NP treatment recommendations should be addressed and implemented the day they are received. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said she always tells the nurse or unit manager if there are any wound treatment recommendations before she leaves the facility. The Wound NP said she always sends the written progress note with the treatment recommendations the next day. The Wound NP said she expects the treatment recommendation to be implemented or addressed prior to the next scheduled dressing change. The Wound NP said not implementing Resident #138's wound treatment recommendations timely could cause the wound to deteriorate. The Wound NP said santyl is a debriding agent that can damage healthy tissue and applying it when no longer indicated could cause a wound to deteriorate. During an interview on 3/10/25 at 10:11 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant declined to comment on what was an acceptable time frame for Wound NP treatment recommendations to be addressed/implemented. 1b.) Review of the facility policy titled 'Preventative Pressure Ulcer', revised April 2022, indicated: - Prevention: Moisture: Keep skin clean and free of exposure to urine and fecal matter. - Prevention: Mobility/Repositioning: At least every two hours, reposition residents who are reclining and dependent of staff for repositioning. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said she does not believe he/she is repositioned every two hours or is receiving incontinence care timely and that it's caused his/her pressure ulcers to worsen. Resident #138's health care proxy said she believed this was related to the facility not having enough staff. Review of Resident #138's plan of care related to actual alteration in skin integrity, initiated 11/7/24, indicated: - Turn and reposition every 2-3 hours every shift. Review of Resident #138's plan of care related incontinence of bladder, initiated 6/4/24, indicated: - Check twice a shift and as needed for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Review of Resident #138's report titled 'Documentation Survey Report' (a report including certified nursing (CNA) documentation), dated 10/24/24 to 3/4/25, indicated the Resident was always incontinent and always required staff assistance for repositioning. Review of Resident #138's assessment titled 'Skin Observation Tool', dated 10/25/24, indicated the Resident did not have any pressure ulcers on 10/25/24. Review of Resident #138's Wound Nurse Practitioner progress note, dated 10/29/24, indicated initial exams for two new wounds including: - Initial exam: left buttock pressure ulcer, stage 1. - Initial exam: MASD (moisture associated skin damage) coccyx. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 10/29/24, 11/5/24, 11/19/24, 11/26/24, 12/3/24, 12/10/24, 12/17/24, 12/27/24, 12/31/24, 1/7/25, 1/14/25, 1/21/25, 1/28/25, 2/4/25, 2/11/25, 2/18/25, 2/25/25, and 3/4/25, indicated: - Treatment recommendations for left buttock pressure ulcer and MASD coccyx include prompt peri care and frequent repositioning. Review of Resident #138's Wound Nurse Practitioner progress note, dated 11/5/24, indicated: - Deteriorating left buttock pressure ulcer, unstageable. - MASD to coccyx was reclassified as an unstageable pressure ulcer. - Deteriorating pressure ulcer coccyx, unstageable. - New stage three right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from time between new wound was noted and when the wound deteriorated, dated 10/30/24 to 11/5/24, indicated: - Toileting hygiene was not provided on 4 shifts. - Turning and repositioning every 2 hours was not provided 12 times. Review of Resident #138's Wound Nurse Practitioner progress note, dated 12/10/24, indicated: - Deteriorating coccyx pressure ulcer which increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 11/6/24 to 12/10/24, indicated: - Toileting hygiene was not provided on 33 shifts. - Turning and repositioning every 2 hours was not provided 45 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 12/17/24, indicated: - Coccyx pressure wound reclassified to a stage three and increased in size. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 12/11/24 to 12/17/24, indicated: - Toileting hygiene was not provided on 7 shifts. - Turning and repositioning every 2 hours was not provided 17 times. Review of Resident #138's nursing progress note, dated 1/27/25, indicated: - (Health care proxy) stated he/she need to be changed right now. The nurse explained that I will notify the nursing aide for you. The resident aide was on break, the nurse was on break, two of the aide was with a resident in shower room. The other one was helping a resident with food. After a couple of minutes, while this writer was verify a dressing order, so that she was going to change when she heard someone was screaming at her: hey you, if you don't want to do your job just (expletive) stay home. This writer reply are you talking to me please do not yelled at me. This family member keep shouting and screaming at the nurse .This writer did not reply, just report it to the aide to change the resident as soon as he returned from break. [sic] Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/11/25, indicated: - Pressure ulcer to coccyx is deteriorating this week. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/1/25 to 2/11/25, indicated: - Toileting hygiene was not provided on 16 shifts. - Turning and repositioning every 2 hours was not provided 31 times. Review of Resident #138's nursing progress note, dated 2/12/25, indicated: - Pressure ulcer to coccyx deteriorating this week. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 2/18/25, indicated: - Deteriorating coccyx pressure ulcer which increased in size. - New stage two right buttock pressure ulcer. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/12/25 to 2/18/25, indicated: - Toileting hygiene was not provided on 6 shifts. - Turning and repositioning every 2 hours was not provided 5 times. Review of Resident #138's Wound Nurse Practitioner progress notes, dated 3/4/25, indicated: - Deteriorating coccyx pressure ulcer. - New left buttock maceration. - Stable right buttock stage two pressure ulcer. Review of Resident #138's nursing progress note, dated 3/4/25, indicated: - Coccyx wound in deteriorating, foul smell noted, with increased size and drainage. NP (nurse practitioner) orders to send patient for ED (emergency department) evaluation. During a review of Resident #138's 'Documentation Survey Report' from the timeframe before the wound deteriorated, dated 2/19/25 to 3/4/25, indicated: - Toileting hygiene was not provided on 9 shifts. - Turning and repositioning every 2 hours was not provided 9 times. Review of Resident #138's hospitalist progress note, dated 3/7/25, indicated: - No definite sacral osteomyelitis, but the MRI is not adequate for evaluation due to significant motion artifact. - Recommendations for wound care include to change positions regularly. Review of Resident #138's entire medical record, dated 10/24/24 to 3/4/25, failed to indicate the Resident refused repositioning or incontinence care. During a telephone interview on 3/7/25 at 6:29 A.M., Certified Nurse Assistant (CNA) #7 said the facility had been short staffed several days a week for the past few months. CNA #7 said several days a week there is only one CNA on the overnight shift making it physically impossible to turn and reposition all the residents on the unit. CNA #7 said she does not believe Resident #138 was repositioned every two hours consistently over the past three months. During a telephone interview on 3/7/25 at 8:40 A.M., Nurse Practitioner (NP) #1 said she sees that staff isn't always able to reposition and provide toileting/incontinence care. During an interview on 3/7/25 at 1:17 P.M., Nurse #8 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 1:19 P.M., Unit Manager #2 said Resident #138 should have been repositioned every two hours and incontinence care should have been provided promptly. Unit Manager #2 said repositioning and incontinence care should be documented by the CNAs, which is where the information from the report titled 'Documentation Survey' populates, under repositioning and toileting hygiene. Unit Manager #2 said if a Resident refuses repositioning or incontinence care that should be documented accordingly. Unit Manager #2 said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said not providing frequent repositioning or prompt incontinence care could cause a wound to deteriorate. The Wound NP said 50% of the time during weekly wound visits Resident #138's brief was soiled or full of urine. During an interview on 3/10/25 at 10:11 A.M., the Director of Nursing (DON) and the Regional Nurse Consultant said CNA documentation should be completed by the end of each shift, including repositioning and incontinence care. The DON and Regional Nurse Consultant declined to comment on if not providing frequent repositioning or prompt incontinence care can cause a wound to deteriorate. 1c.) Review of the facility policy titled 'Preventative Pressure Ulcer', revised April 2022, indicated: - Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Review of Manufacturer's guidelines for Medline Supra APL Mattress System indicated: - To set the Medline Supra APL, first connect the pump and mattress, then power it on and inflate. Adjust the mattress based on the patient's weight. On 3/4/25 at 9:40 A.M. and at 3:04 P.M., the surveyor observed Resident #138 in bed on a Medline Supra APL air mattress. Resident #138 did not respond to the surveyors questions. During both observations the air mattress pump was set to 180 weight (lbs). Review of Resident #138's 'Monthly Weight Report' indicated the following weights: - December 2024: 160.8 lbs. - January 2025: 149.8 lbs. - February 2025: 142 lbs. - March 2025: 141 lbs. Review of Resident #138's physician order, initiated 10/29/24, indicated: - Pressure air pad and pump, every shift, for Dry Skin and limited bed mobility, initated 10/29/24 and discontinued 3/4/25. - Low airloss mattress to bed set to comfort, initiated 3/4/25 without stop date. Review of Resident #138's plan of care related to actual alteration in skin integrity, initiated 11/7/24, indicated: - Therapeutic air mattress to be applied: Setting: set to resident's preference. Review of Resident #138's medical record indicated he/she had been transferred to the hospital on 3/4/25 for deteriorating coccyx wound with increased size, drainage, and foul smell. During a telephone interview on 3/6/25 at 9:07 A.M., Resident #138's health care proxy said Resident #138 often called out because he/she was uncomfortable in bed during the past few months. During an interview on 3/10/25 at 9:35 A.M., Unit Manager #2 said Resident #138's air mattress did not require specific settings because it can be changed based on his/her comfort. Unit Manager #2 said Resident #138 had difficulty communicating and could not communicate discomfort verbally. During an interview on 3/11/25 at 10:52 A.M., Unit Manager #2 said Resident #138 had a physician's order for an air mattress for pressure ulcer management. During an interview on 3/11/25 at 10:59 A.M., the Regional Nurse Consultant said she changed all the orders for any residents on air mattresses to be set related to resident comfort. The Regional Nurse Consultant said air mattresses should be set according to facility policy. The Regional Nurse Consultant there is no system in place to monitor the effectiveness or comfort of each resident on an air mattress, even if they are not able to communicate their needs, but they expect the nurses to be monitoring for signs of discomfort and adjusting the air mattress settings as necessary based on the nurses assessment of each resident's comfort. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said if air mattresses are used for wounds they require settings usually related to size and weight. If an air mattresses is set too firm or too soft it puts the resident at risk for skin breakdown or worsening wounds. The Wound NP said Resident #138 was on an air mattress to treat his/her pressure ulcers. 2.) Resident #30 was admitted to the facility in December 2020 with diagnoses including diabetes and pressure ulcers. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated Resident #30 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #30 had a stage three pressure ulcer and a stage four pressure ulcer. 2a.) On 3/10/25 at 2:02 P.M., the surveyor observed Nurse #8 and Unit Manager #2 perform a wound dressing change for Resident #30's left buttock stage four pressure ulcer. Nurse #8 said we always change his/her left buttock dressing twice a day. Review of Resident #30's Wound Nurse Practitioner (NP) progress note, dated 3/4/25, indicated: - Stage four pressure ulcer left buttock. - Treatment recommendation for pressure ulcer left buttock: Wash with wound cleanser, pat dry. Skin prep peri skin, Santyl to slough. Pack entire wound with collagen. Cover with silicone foam dressing QD (every day)/PRN (as needed). Review of Resident #30's physician's order, initiated 3/4/25, indicated the following for his/her left buttock: - Wash with WC (wound cleanser), pat dry. skin prep PS (peri skin), santyl to slough, pack entire wound with collagen, then silicone foam dsg (dressing) QD/PRN, every day shift and every evening shift. Review of Resident #30's treatment administration record (TAR), dated 3/4/25 to 3/9/25, indicated the physician's order to Wash with WC (wound cleanser), pat dry. skin prep PS (peri skin), santyl to slough, pack entire wound with collagen, then silicone foam dsg (dressing) QD/PRN was documented as implemented twice daily. During an interview on 3/10/25 at 2:40 P.M., Unit Manager #2 said she reviewed the Wound NP's treatment recommendation and the physician's order for Resident #30's left buttock. Unit Manager #2 said it was transcribed incorrectly and accidentally scheduled to be completed twice a day, instead of once a day. During an interview on 3/11/25 at 9:15 A.M., the Director of Nursing (DON) said Resident #30's physician's order for his/her left buttock should have been transcribed at frequency recommended, and the left buttock treatment being completed twice day was incorrect. 2b.) Review of Manufacturer's guidelines for Selectis Serenity Air Mattress indicated: - The Selectis Serenity alternating low air loss mattress system helps provide prevention therapy and treatment of multiple stage wounds. - By tailoring the pressure based on the patient's weight and specific ailment, optimal comfort and support can be achieved. On 3/4/25 at 9:45 A.M., the surveyor observed Resident #30 in bed on a Selectis Serenity air mattress. The air mattress pump was set to 300 pounds (lbs.) weight. Resident #30 said his/her air mattress is uncomfortable. Resident #30 said it often feels deflated and that when she tells them it takes a long time to fix it. During observations on 3/4/25 at 3:10 P.M., 3/5/25 at 7:01 A.M., and 3/6/25 at 5:34 A.M., Resident #30 was in bed on a Selectis Serenity air mattress with the pump set to 300 pounds weight. Review of Resident #30's 'Monthly Weight Report' indicated the following weights: - December 2024: 190.5 lbs. - January 2025: 194.5 lbs. - February 2025: 195.5 lbs. Review of Resident #30's physician orders indicated: - Low air mattress to bed check every shift/function every shift. Settings are per weight (192.4), initiated 1/29/24 and discontinued 3/4/25. - Air mattress to bed check every shift/function set to resident comfort level, initiated 3/4/25 without stop date. Review of Resident #30's plan of care related to actual alteration in skin integrity, initiated 10/16/24, indicated: - Air mattress, set to patient comfort. During an interview on 3/10/25 at 9:35 A.M., Unit Manager #2 said residents on air mattresses did not require specific settings because it can be changed based on his/her comfort. During an interview on 3/11/25 at 10:52 A.M., Unit Manager #3 said Resident #30 had a physician's order for an air mattress for pressure ulcer management. During an interview on 3/11/25 at 10:59 A.M., the Regional Nurse Consultant said she changed all the orders for any residents on air mattresses to be set related to resident comfort. The Regional Nurse Consultant said air mattresses should be set according to facility policy. The Regional Nurse Consultant there is no system in place to monitor the effectiveness or comfort of each resident on an air mattress, but they expect the nurses to be monitoring for signs of discomfort and adjusting the air mattress settings as necessary based on the nurse's assessment of each resident's comfort. During an interview on 3/7/25 at 2:49 P.M., the Wound Nurse Practitioner (NP) said if air mattresses are used for wounds, they require settings usually related to size and weight. If an air mattress is set too firm or too soft, it puts the resident at risk for skin breakdown or worsening wounds. 3.) Resident #167 was admitted to the facility in December 2024 with diagnoses including diabetes, prostate cancer, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/5/25, indicated that Resident #167 is cognitively intact as evidenced by a Brief Mental Status (BIMS) score of 13 out of 15. The MDS also indicated that he/she was at high risk for pressure ulcers and had two Stage 3 pressure ulcers. Review of Resident #167's Norton Plus Pressure Ulcer Scale, dated, 12/6/24, 12/16/24,12/30/24, 12/31/24, 1/12/25, 1/16/25, and 2/4/25 indicated that he/she was at high risk for pressure ulcers. Review of Resident #167's nursing progress note, dated 12/25/24, indicated Resident sustained a pressure ulcer to coccyx, Nurse Practitioner (NP) #3 notified, area covered pending wound care evaluation. Review of Resident #167's Treatment Administration Record (TAR), dated 12/7/24, indicated Apply triad and DPD to coccyx area daily. Review of Resident #167's Wound care progress note, dated 12/27/24, indicated pressure ulcer coccyx measuring 3 centimeters (cm) x 2.3 cm x 0.1 cm. Treatment Recommendations: wash, dry, apply Med honey to wound bed, cover with dry protective dressing (DPD) daily and as needed. Review of Resident #167's nursing progress note, dated 12/30/24, indicated Resident followed up by wound care consultant on 12/27/24, report on 12/30/24 as follows: evaluated for new area on coccyx, stage 2. Recommended treatment: Wash with wound cleanser, pat dry, apply med [NAME] to wound bed, cover with dry protective dressing (DPD) daily and as needed. NP #3 in agreement. Order in place. Review of Resident #167's plan of care, dated 12/30/24, indicated actual in skin integrity related to stage 3 to coccyx. Interventions include: -wash with wound cleanser, pat dry, skin prep peri skin, apply collagen wafer, then apply silicone border dressing daily and as needed. Review of Resident #167's TAR, dated 12/30/24, indicated Pressure Coccyx wound: wash with wound cleanser, pat dry, apply med honey to wound bed, cover with DPD daily and as needed. Further review of TAR, dated 12/30/24, failed to indicate that treatment was signed as completed on 12/30/24 or 12/31/24. Review of Resident #167's TAR, dated 12/31/24, indicated Pressure Coccyx wound: wash with wound cleanser, pat dry, apply med honey to wound bed, cover with DPD daily and as needed. Further review of TAR, dated 12/31/24, failed to indicate that treatment was signed as completed on 12/31/24 and 1/1/25. During an interview on 3/11/25 at 9:15 A.M., the Director of Nursing (DON) said he would expect wound care recommendations to be followed. 4.) Resident #143 was admitted to the facility in January 2025 with diagnoses including osteomyelitis (bone infection) of right tibia and fibula, diabetes, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/7/25, indicated that Resident #143 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS indicated Resident #143 was at risk for pressure ulcer, required maximum assist for bed mobility, and had two deep tissue injuries (DTIs). On 3/04/25 at 8:35 A.M., the surveyor observed Resident # 143 sleeping in bed with a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent abuse for 1 Resident (#157) out of a total sample of 41 residents. Specifically, Resident #157 was physically restrained to a chair by a staff member, causing emotional distress and weepiness. Findings include: Review of the facility policy titled Abuse Prohibition, dated 10/24/22, indicated the following: -Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. -The center will implement an abuse prohibition program through the following: * Prevention of occurrences * Identification of possible incidents or allegations which need investigation * Investigation of all incidents and allegations * Protection of patients during investigation * Reporting of incidents, investigations, and center response to the results of their investigation. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with the resulting physical harm, injury, or mental anguish. Resident #157 was admitted in April 2022 with diagnoses including dementia and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #157 did not score on the Brief Interview for Mental Status (BIMS), but is severely cognitively impaired. Review of the MDS indicated that Resident #157 requires supervision with mobility. Review of the Incident Report investigation, dated 3/8/24, indicated the following: At about 6:45am today, pt was found by nurse from a different department crying upon examination, pt restrained by clothing on a chair in the common area. Review of a witness statement, dated 3/8/24, indicated the following: Approximately 6:45 AM, I was helping a resident in his/her wheelchair to get to the common area on the unit. After he was set, I noticed Resident #157 sitting in a chair crying, behind me. I walked over to him/her and saw that there was a blanket covering the back of the chair. I pulled the blanket back, and noted that his/her shirt was pulled over the back of the chair he/she was sitting on. It was so far down that I had a hard time pulling it off the back of the chair . During an interview on 3/21/24 at 10:08 A.M., the Director of Nursing said that she was told of the incident by the MDS nurse, who noticed that Resident #157's shirt was up and over the back of the chair and tucked under. The Director of Nursing said that the shirt being tucked under was preventing the Resident from rising and the Resident was teary and whining. The Director of Nursing said that she interviewed the certified nursing aide and nurse that were on the unit, but neither admitted to restraining the Resident. The Director of Nursing said that there was no way the Resident could have tucked his/her shirt behind him/her in the chair. The Director of Nursing notified the Resident's family, police, and terminated both employees. She said that they are doing education shiftly and initiated a quality assurance performance improvement (QAPI) program. On 3/21/24, the facility provided the surveyor with a plan of correction that addressed the areas of concern identified during this survey. The plan of correction is as follows: -Investigation of the circumstances leading up to and including the restraint -Education of restraints and abuse to all employees on every shift, before the beginning of their shift daily for 14 days, then weekly for two weeks, then monthly for 2 months until 3/25/24. -Audit of each unit on 3/12/24 for restraints -The Director of Nursing, Assistant Director of Nursing, Unit Manager, Supervisors, and Facility Educator are responsible for completion of the education. REF to F604.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent 1 Resident (#157) from being free from restraints, out of a total of 41 residents. Specifically, Resident #157 was physically restrained to a chair by a staff member. Findings include: Review of the facility policy titled Restraints: Use of, dated 6/15/22, indicated the following: -Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms. -Physical restraint is defined as any manual method, physical or mechanical device, equipment, or materials that meets all of the following criteria: -Is attached or adjacent to the patient's body -Cannot be removed easily by the patient -Restricts the patients freedom of movement or normal access to their body Resident #157 was admitted in April 2022 with diagnoses including dementia and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #157 did not score on the Brief Interview for Mental Status (BIMS), but is severely cognitively impaired. Review of the MDS indicated that Resident #157 requires supervision with mobility. Review of the Incident Report investigation, dated 3/8/24, indicated the following: At about 6:45am today, pt was found by nurse from a different department crying upon examination, pt restrained by clothing on a chair in the common area. Review of a witness statement, dated 3/8/24, indicated the following: Approximately 6:45 AM, I was helping a resident in his/her wheelchair to get to the common area on the unit. After he was set, I noticed Resident #157 sitting in a chair crying, behind me. I walked over to him/her and saw that there was a blanket covering the back of the chair. I pulled the blanket back, and noted that his/her shirt was pulled over the back of the chair he/she was sitting on. It was so far down that I had a hard time pulling it off the back of the chair . During an interview on 3/21/24 at 10:08 A.M., the Director of Nursing said that she was told of the incident by the MDS nurse, who noticed that Resident #157's shirt was up and over the back of the chair and tucked under. The Director of Nursing said that the shirt being tucked under was preventing the Resident from rising and the Resident was teary and whining. The Director of Nursing said that she interviewed the certified nursing aide and nurse that were on the unit, but neither admitted to restraining the Resident. The Director of Nursing said that there was no way the Resident could have tucked his/her shirt behind him/her in the chair. The Director of Nursing notified the Resident's family and police and terminated both employees. She said that they are doing education shiftly and initiated a quality assurance performance improvement (QAPI) program. On 3/21/24, the facility provided the surveyor with a plan of correction that addressed the areas of concern identified during this survey. The plan of correction is as follows: -Investigation of the circumstances leading up to and including the restraint -Education of restraints and abuse to all employees on every shift, before the beginning of their shift daily for 14 days, then weekly for two weeks, then monthly for 2 months until 3/25/24. -Audit of each unit on 3/12/24 for restraints -The Director of Nursing, Assistant Director of Nursing, Unit Manager, Supervisors, and Facility Educator are responsible for completion of the education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was newly admitted to the facility after undergoing surgical repair of left hip fracture due do a fall, had severe cognitive impairment with poor safety awareness, and was noted upon admission by nursing to be at increased risk for falls, the Facility failed to ensure he/she was provided with adequate safety measures and supervision to meet his/her immediate safety care needs in an effort to prevent a fall with injury. Resident #1 was in the facility less than 24 hours when he/she had an unwitnessed fall, was found on the floor in his/her room beside the bed, and required emergent transfer to the Hospital Emergency Department for evaluation. Resident #1 was diagnosed with a right hip fracture and subarachnoid hemorrhage (brain bleed), was admitted to the Intensive Care Unit, and required surgical intervention to repair his/her right hip fracture. Findings include: Review of the Facility's Policy titled, Fall Management, dated as revised 6/15/22, indicated all patients (residents) will be assessed for risk of falls upon admission. The Policy indicated that the Facility would implement and document patient-centered interventions according to individual risk factors in the patient's (resident's) plan of care. The Policy indicated that the Facility would educate staff and the patient (resident) as appropriate to increase awareness of at risk patients and to provide possible strategies to minimize risk for falls. Review of Resident #1's Hospital History and Physical, dated 11/15/22, indicated Resident #1 had been admitted to the ED for left hip pain after he/she fell. The History and Physical indicated Resident #1 was diagnosed with a left femoral neck (hip) fracture, and his/her head computerized tomography (CT) scan was negative for intracranial (inside the skull) findings. Review of the Hospitalist's Note, dated 11/18/22, indicated Resident #1 underwent left hip surgery to repair his/her left hip fracture. Resident #1 was admitted to the Facility in November 2022, diagnoses included dementia, and left femur (hip) fracture, secondary to a fall on same level from slipping, tripping, and stumbling without subsequent striking against an object. Review of Nurse #1's admission Nursing Note, dated 11/19/22, indicated Resident #1 was admitted to the Facility following a left femur (hip) fracture with subsequent surgical repair. The Note indicated Resident #1 required the assistance of two staff members for mobility and he/she had experienced a fall in the last two to six months prior to admission. The Note indicated Resident #1 had a history of dementia, was confused, and was not oriented to place or time. The Note indicated Resident #1's decision making skills were severely impaired and staff needed to anticipate and meet resident's needs. During an interview on 12/21/22 at 2:24 P.M., Nurse #1 said she completed the admission assessments on Resident #1 to help Nurse #2. Nurse #1 said she assessed Resident #1 as being a high fall risk. Nurse #1 said after completing the assessments, she passed care of Resident #1 back to Nurse #2. Nurse #1 said she told Nurse #2 that Resident #1 was a high fall risk. Nurse #1 said typically, an intervention such as an alarm would be added once a resident was determined to be a high fall risk, but said she just helped Nurse #2 by doing the admission assessments. Nurse #1 said she did not know if the Certified Nurse Aides (CNAs) were made aware that Resident #1 was a high fall risk. During an interview on 12/21/22 at 2:44 P.M., Nurse #2 said nurses should add fall prevention interventions to the residents' Falls Care Plan upon admission, but said he did not initiate an admissions care plan or interventions related Resident #1's fall risk or safety concerns. Review of Resident #1's Bed Rail Evaluation, dated 11/19/22, indicated he/she was at high risk for falls. Further review of Resident #1's medical record indicated there was no documentation to support that the CNA Care [NAME] (which is were each residents specific care needs are identified and communicated to the CNAs) was updated to indicate he/she was at increased risk for falls and that there were safety concerns. Review of a Nurse's Note, dated 11/20/22, indicated Resident #1 was found (on the floor in his/her room beside the bed) lying on his/her right side with a laceration on the right side of his/her head. The Note indicated Resident #1 was transferred to the Hospital's ED for evaluation. Review of a Nurse's Note, dated 11/20/22, indicated Resident #1 suffered a subarachnoid hemorrhage (brain bleed) and was admitted to the Hospital's ICU. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/25/22, indicated Resident #1 had an unwitnessed fall with a head strike in his/her room on 11/20/22 at approximately 11:15 A.M. The Report indicated a nurse responded to the sound of a loud bang and found Resident #1 lying on the ground (floor) with bleeding from his/her face, and a laceration on his/her right eyebrow. The Report indicated it appeared that Resident #1 had attempted to walk by him/herself. The Report indicated Resident #1 was sent to the Hospital's Emergency Department (ED) evaluated, diagnosed with a right hip fracture and subarachnoid hemorrhage (brain bleed) and subsequently admitted to the Intensive Care Unit (ICU) for further care. The Report indicated Resident #1 required surgical repair of his/her right femur (hip) fracture. During an interview on 12/22/22 at 10:15 A.M., Nursing Supervisor #1 said the nurse completing the resident admission, is required to develop a Falls Care Plan upon admission and add appropriate fall prevention interventions to the Care Plan. Nursing Supervisor #1 said Resident #1's Care Plan for Falls and safety concerns was not developed or put into place upon admission. Nursing Supervisor #1 said she developed Resident #1's Falls Care Plan, which is dated 11/20/22, and included interventions to help maintain his/her safety, but said she did so after Resident #1 had already fallen at the Facility and had been transferred to the Hospital's ED. During an interview on 12/21/22 at 11:45 A.M., the Assistant Director of Nurses (ADON) said he had been the acting Director of Nurses (DON) on 11/19/22 when Resident #1 was admitted to the Facility, and when he/she fell the following day. The ADON said there was a breakdown in communication and he was not made aware that Resident #1 was being admitted over the weekend. The ADON said, based on Resident #1's recent fall with a left hip fracture prior to admission, he/she should have been considered a high fall risk, and nursing staff should have implemented a Falls Care Plan upon admission to the Facility, but did not. The ADON said he was unable to locate any documentation to support fall prevention interventions had been put into place upon admission or prior to Resident #1's fall on 11/20/22. The ADON said had he been aware Resident #1 was being admitted over the weekend, based on his/her history of falls, and most recent fall with a left hip fracture, he would have made sure Resident #1's room was located closer to the Nurses' Station if possible, and that he/she was provided with a bed alarm, if needed. The ADON said CNAs refer to the CNA Care [NAME] for each resident to determine fall risk and level of staff assistance needed to care for the resident. The ADON said this information does not appear on the CNA Care [NAME] until after the nurse adds it to the resident's care plan. The ADON said Resident #1's Falls Care Plan and safety interventions were not initiated until after Resident #1 fell in the facility on 11/20/22. During an interview on 01/04/22 at 10:10 A.M., the Administrator said every resident that is admitted to the Facility should be considered a fall risk. Review of Resident #1's Summary of Hospital Course, dated 11/20/22, indicated Resident #1 presented to the Hospital's ED following a fall at the Facility on 11/20/22, and was found to have a right frontal lobe subarachnoid hemorrhage. The Summary also indicated Resident #1 was found to have a right femoral neck (hip) fracture which required surgical repair.