**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #42) of 3 (R #31, #42 and #58) residents when they failed to monitor R #42 for signs and symptoms of stroke and to treat R #42 with blood thinning medication as ordered. This deficient practice is likely to result in residents experiencing worsened conditions or death. The findings are: A. Record review of R #42's face sheet revealed an admission date of 10/23/24 and included the following diagnoses: - Cerebral palsy (group of conditions that affect movement and posture caused by brain damage before birth), - Muscle weakness, - Lack of coordination, - Difficulty in walking, - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Reduced mobility, - Peripheral vascular disease (PVD; disorder that causes abnormal narrowing of arteries). B. Record review of R #42's hospital discharge records, dated 10/23/24, revealed the following : - An order for clopidogrel (blood thinning medication) tablet, 75 milligrams (mg) daily. Route: Oral (by mouth). Date first scheduled: 10/11/24. - History of pontine cerebrovascular disease (a life-threatening blockage of blood flow to part of the brainstem). Patient was hospitalized in February 2024 for transient ischemic attack (TIA; when blood flow to part of the brain stops for a brief period of time) in the setting of medication noncompliance (failure to take prescribed medications as directed by a healthcare provider). Continue home medication Lipitor (medication that lowers the amount of fats in the blood), 890 mg daily and Plavix (brand name for clopidogrel) 75 mg daily. - Discharge summary notes: On 09/19/24 [information included on discharge summary from a previous hospitalization] patient was cleared to resume Plavix by gastrointestinal (GI; diseases affecting the stomach and intestines) specialist on 09/18/24 after his recent episode of GI bleed. - During his hospitalization, there were not any reported signs of overt (obvious) GI bleed, and hemoglobin (protein in red blood cells) remained stable around baseline. C. Record review of R #42's history and physical (H&P), dated 10/24/24, revealed the following: - The resident had a history of pontine cerebrovascular accident (CVA; stroke) and TIA. - The record did not mention treatment to prevent another CVA. D. Record review of R #42's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 10/29/24, revealed the following: - Active diagnoses: CVA, TIA, or Stroke. - Medications: The resident did not receive an antiplatelets (medication that prevents blood clots) or anticoagulants (blood thinner). E. Record review of R #42's Medication Administration Records (MAR), dated October 2025 through February 6, 2025, revealed there was no order for or instructions for staff to administer clopidogrel, 75 mg to R #42. F. Record review of R #42's Treatment Administration Records (TAR), dated December 2024 through February 2025, revealed the following: - Diagnoses included unspecified sequelae of cerebral infarction and PVD. - The record did not instruct staff to monitor for signs and symptoms of stroke. G. Record review of R #42's quarterly MDS, dated [DATE], revealed the following: - Active Diagnoses: CVA, TIA or Stroke. - Medications: The resident did not receive an antiplatelet and/or anticoagulant. H. Record review of R #42's current physician orders, dated February 2025, revealed the record did not contain an order for clopidogrel, 75 mg or any other antiplatelet or blood thinner medication. I. On 02/04/25 at 9:28 am during an interview, R #42 stated he needed to be on a blood thinner. He stated he used to be on heparin (blood thinning medication), but when he came to the facility from the hospital, the facility staff did not give him the blood thinner. J. On 02/06/25 at 4:58 pm during an interview with the Medical Director (MD), he stated R #42's hospital discharge records contained an order for clopidogrel 75 mg, and R #42 should have received the medication while at the facility. He verified staff did not administer the clopidogrel to R #42 since his admission to the facility [10/23/24]. He reviewed R #42's medical record and stated someone at the facility dropped the ball. K. On 02/07/25 at 9:18 am during an interview with the Director of Nursing (DON), she confirmed that she was responsible for verifying the admission orders during the post admission resident review, but she missed the order for clopidogrel, therefore it was not ordered and was not being administered to R #42. L. On 02/07/25 at 10:47 am during an interview, the Nurse Practitioner (NP) stated the order for clopidogrel 75 mg was on R #42's admission orders from the hospital, but the orders were not clear about how long the resident should continue to take the medication. She stated staff should have administered the clopidogrel to R #42 based on the admission orders from the hospital. M. On 02/25/25 at 12:47 pm during an interview with the Administrator and the DON, they stated the R #42 had multiple diagnoses, and he had complex medical needs. They stated the resident's stroke occurred over a year ago, and it was not the primary reason for his admission to the facility. The Administrator and the DON stated the resident had an initial care plan meeting on 10/27/25, and he attended the meeting. They stated the resident had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact; but he did not mention that he should take a blood thinning medication. The Administrator and the DON confirmed R #42's medical record did not instruct staff to monitor the resident for signs and symptoms of stroke. They stated they monitor all residents for signs of a change of condition. The Administrator and the DON confirmed they did not treat the resident for his history of CVA. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility Administrator was notified on 02/07/25 at 10:42 am. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 02/07/25 at 3:15 pm. Implementation of the POR was verified onsite on 02/10/25 by conducting record reviews and staff interviews. Scope and Severity was reduced to Level 2, E. Plan of Removal: All residents have the potential to be affected by this alleged deficient practice. The following corrections were completed by 02/07/25: - Audit all residents with a diagnosis of CVA to ensure antiplatelet therapy was in place as ordered. - Audit of recent admissions to ensure accurate medication reconciliation, review, and continuation of medications and treatments. - All licensed staff educated regarding medication transcription, medication reconciliation upon admission, and documentation in the resident's chart. - During morning clinical meetings, medication reconciliation audits occur for new admissions and medication order changes. - Nurse Practice Educator or Designee will begin education on 02/07/25 and continue until all licensed nursing staff have been educated prior to their next shift. Any licensed staff member on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire. - The Director of Nursing (DON) or designee will audit five random residents three times a week to ensure all medications reconciliations have occurred. - The DON or designee will bring results of audits to Quality Assurance and Performance Improvement (QAPI) committee for further recommendations based on tracking and trending. It will be presented monthly for the next two months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer clopidogrel (blood thinning medication used to prevent heart attacks and strokes in persons with heart disease, recent stroke, or blood circulation disease) as ordered by the physician for 1 (R #42) of 3 (R #31, #42 and #58) residents reviewed for medications. This deficient practice is likely to result in a resident failing to obtain maximum wellness or suffer prolonged illness. The findings are: Cross Reference findings from F684. A. Record review of R #42's face sheet revealed an initial admission date of 10/23/24 and included the following diagnoses: - Sequelae of cerebral infarction (long term effects and complications that can occur after a stroke), - Congestive systolic and diastolic heart failure, - Peripheral vascular disease (disorder that causes abnormal narrowing of arteries). B. Record review of R #42's hospital discharge records, dated 10/23/24, revealed the following : - An order for clopidogrel (blood thinning medication) tablet, 75 milligrams (mg) daily. Route: Oral (by mouth). Date first scheduled: 10/11/24. - Continue home medication Lipitor (medication that lowers the amount of fats in the blood), 890 mg daily and Plavix (brand name for clopidogrel) 75 mg daily. C. Record review of R #42's Medication Administration Records (MAR), dated October 2025 through February 6, 2025, revealed staff did not administer clopidogrel, 75 mg to R #42. D. On 02/06/25 at 4:58 pm during an interview with the Medical Director (MD), he stated R #42's hospital discharge records contained an order for clopidogrel 75 mg on admission to the facility. He verified staff missed the order and did not administer clopidogrel to R #42 since the resident's admission to the facility on [DATE]. E. On 02/07/25 at 9:18 am during an interview, the Director of Nursing (DON) stated she missed the resident's order for clopidogrel when she verified R #42's admission orders. F. On 02/07/25 at 10:47 am during an interview, the Nurse Practitioner (NP) stated R #42's hospital discharge orders included an order for clopidogrel. She stated R #42 should have received clopidogrel while at the facility. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility Administrator was notified on 02/07/25 at 10:42 am. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 02/07/25 at 3:15 pm. Implementation of the POR was verified onsite on 02/10/25 by conducting record reviews and staff interviews. Scope and Severity was reduced to Level 2, E. Plan of Removal: All residents have the potential to be affected by this alleged deficient practice. The following corrections were completed by 02/07/25: - Audit all residents with a diagnosis of CVA to ensure antiplatelet therapy was in place as ordered. - Audit of recent admissions to ensure accurate medication reconciliation, review, and continuation of medications and treatments. - All licensed staff educated regarding medication transcription, medication reconciliation upon admission, and documentation in the resident's chart. - During morning clinical meetings, medication reconciliation audits occur for new admissions and medication order changes. - Nurse Practice Educator or Designee will begin education on 02/07/25 and continue until all licensed nursing staff have been educated prior to their next shift. Any licensed staff member on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire. - The Director of Nursing (DON) or designee will audit five random residents three times a week to ensure all medications reconciliation have occurred. - The DON or designee will bring results of audits to Quality Assurance and Performance Improvement (QAPI) committee for further recommendations based on tracking and trending. It will be presented monthly for the next two months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to: 1. Provide oversight of shower sheets to identify wounds, 2. Accurately document new skin impairments on Skin Checks, 3. Update and implement new preventative measures, treatment, and orders when new skin impairments were identified for 1 (R #1) of 3 (R #1, 2, and 3) residents reviewed for pressure wound injuries. This deficient practice could like result in new pressure injuries, pain, or significant decline in health status. The findings are: A. Record review of R #1's current electronic health record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: - Polyosteoarthritis [five or more joints have arthritis (a painful inflammation and stiffness of the joints) at the same time], - Age-related osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue), - Peripheral autonomic neuropathy (damage to the autonomic nervous system, which controls involuntary body functions such as heart rate, perspiration, blood pressure, digestion, loss of bladder control), - Psoriasis (a skin disease that causes a rash with itchy, scaly patches). - These diagnoses are not all-inclusive and do not include all of R #1's diagnoses. B. Record review of R #1's Braden Scale for Predicting Pressure Score Risk (an assessment tool used to assess and document a resident's risk for developing pressure injuries), dated [DATE], showed a score of 11, which indicated a high risk to acquire pressure sores. C. Record review of R #1's care plan, review date [DATE], revealed the following: - R#1 required extensive assistance of one with bed mobility, changing, dressing, and personal hygiene. - R#1 was at risk risk for skin breakdown related to decreased mobility, and frail fragile skin. - Staff to implement the following interventions: - Observe skin for signs and symptoms of skin breakdown, such as redness,cracking, blistering, decrease sensation, and skin that does not blanche (change to white color when pressure is applied) easily. - Evaluate for any localized skin problems, such as dryness, redness,pustules, inflammation. - Assist resident in turning and reposition every two hours. - Pressure redistribution surface to bed, low air loss mattress (a mattresses designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.) - The care plan did not contain interventions related to the resident's refusals of nail care and scratching at wounds. D. Record review of the facility policy, titled NSG236 Skin Integrity and Wound Mangement #6, revision date [DATE], stated, The licensed nurse will perform and document skin inspections .weekly .and with any significant change in condition. E. Record review of R #1's Skin Check forms, dated [DATE], revealed nursing staff documented the following: - On [DATE], the resident had new skin wounds. An open area to the resident's right hip, an abrasion which measured approximately 1 inch (in) by 0.75 in; a scab to the resident's anterior (palm) right hand, which measured 0.5 in by 0.5 in; and redness to the resident's right antecubital space (the space inside the crook of the elbow). - On [DATE], the resident had a previously identified skin wound initially thought to be from self-scratching will now be re-classified as unstageable pressure with new SWIFT (Swift technology - a digital program that visualizes and measures wounds accurately, and automatically tracks wound healing progression and management) photo, located at the right hip and right elbow. A skin tear/bruise was located at the right elbow. F. Record review of R #1's Skin and Wound Evaluations (an evaluation performed to document and determine the appropriate treatment for a wound), dated [DATE], revealed staff documented the following: - On [DATE], the resident had a front right hip abrasion which measured 2.52 cm (centimeters) long, 3.37 cm wide. - On [DATE], the resident had a front right hip wound which measured 1.9 cm length, 3.0 cm width. - On [DATE], the resident had a right hip wound reclassified as pressure injury, unstageable [a full-thickness injury in which the base of the wound is obscured by slough (dead tissue, usually cream or yellow in color) or eschar (dry, black, hard dead tissue)]. G. Record review of R #1's Skin Check forms (a medical form used to track and assess skin issues and conditions), dated [DATE], revealed nursing staff documented the following: - On [DATE], the resident had a Stage 3 pressure ulcer (a pressure sore that has full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) located on the right hip; A skin tear/bruise located at the right elbow. - On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow. - On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow. - On [DATE], the resident had a Stage 3 pressure ulcer on the right hip; and a skin tear/bruise located at the right elbow. H. Record review of R #1's Skin Assessment, dated [DATE], revealed staff documented the resident had a in-house acquired (wound developed after admission to a healthcare facility) right hip pressure wound, stage 3, full thickness skin loss, which measured 0 centimeter (cm) by 0 cm by 0 cm and classified as resolved. Staff noted a foam dressing was placed on the area for protection, and wound care orders were to be discontinued on [DATE]. I. Record review of R #1's physician's orders, dated [DATE], revealed the record did not contain orders for treatment for the hips, shoulder, or sacrum area after [DATE]. J. Record review of a physician progress note for R #1, dated [DATE], MD #1 indicated the Stage 3 pressure was healed and measured 0 cm by 0 cm, with no measurable depth and an area of 0 cm2. K. Record review of R #1's shower sheets, dated [DATE], staff documented the following: - On[DATE], the resident had reddened areas and an open area on R #1's hips, scratches on R #1's lower back, and the resident refused nail care. - On [DATE], the resident had reddened areas, an open area, and a darkened area on both of R #1's hips, scratches on R #1's lower back, and the resident refused nail care. - On [DATE], the resident had reddened areas and an open area on R #1's hips, a wound on the lower back, and the resident needed nail care but refused. The staff also documented that R #1 takes off dressings. L. Record review of R #1's Skin Check forms, dated [DATE], revealed the following: - On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments. - On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments. - On [DATE], a resolved Stage 3 pressure ulcer on the right hip was identified. Staff did not document any other skin impairments. M. Record review of R #1's Skin and Wound Evaluations revealed staff documented the following: - The record did not contain skin and wound evaluations between [DATE] to [DATE]. - On [DATE], the resident had a right shoulder, blister which measured 1.89 cm by 0.89 cm. - On [DATE], the resident had a right shoulder Stage 2 pressure ulcer (an ulcer that has a break in the top two layers of skin, usually open with swelling, discoloration, and pain), which measured 1.63 cm by 1.22 cm. - On [DATE], the resident had a sacrum wound, which was unstageable, with slough and/or eschar, and measured 5.7 cm by 3.3 cm, Staff noted the following interventions: foam dressing, mattress with pump, pillows, repositioning every one to two hours, practitioner notified. - On [DATE], the resident had a unstageable sacrum (the large, triangular bone at the base of the spine) wound, which measured 6.04 cm by 3.07 cm. - On [DATE], the resident had a front left hip, unstageable, deep tissue injury (DTI; persistent non-blanchable deep red, purple, or maroon areas of intact skin, non-intact skin, or blood-filled blisters caused by damage to the underlying soft tissues), unstageable, which measured 3.04 cm length by 3.21 cm. Applied betadine foam (a type of antiseptic). - On [DATE], the resident had a front left hip, unstageable pressure ulcer, slough and/or eschar, which measured 3.24 cm by 2.93 cm. - On [DATE], the resident had an unstageable front right hip pressure wound which measured 6.56 cm by 4.85 cm. - On [DATE], the resident had an unstageable front right hip wound, new, in-house acquired, which measured 8 cm length, 8.9 cm width, with full thickness skin and tissue loss, 100% of the wound is eschar filled, redness, inflammation, warmth, light exudate (a fluid released by a wound), serosanguineous (drainage containing blood), no odor after cleansing. N. Record review of R #1's physician's orders for R #1 revealed the following: - The record did not contain orders for treatment for the hips, shoulder, or sacrum area after [DATE] through [DATE]. - A wound care order, start date [DATE], for unstageable pressure ulcer of the sacrum. Cleanse the wound with Vashe (name brand of a type of a saline based wound cleanser), paint the area around the wound with Betadine (a type of a topical antiseptic that provides infection protection), apply a skin layer of Therahoney (wound healing ointment), cover with Calcium Alginate (wound dressing), and cover the wound with foam dressing. Every day shift and as needed. - A wound care order, start date of [DATE], for unstageable pressure ulcer of the right hip. Cleans the wound with wound cleanser or Vashe, skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to surrounding skin, and place a foam dressing saturated with Betadine over the wound. Every day shift and as needed if the dressing becomes wet, soiled or missing. - A wound care order, start date of [DATE], for unstageable pressure ulcer of the left hip. Cleanse the wound with wound cleanser or Vashe, skin prep to surrounding skin, and place a foam dressing saturated with Betadine over the wound. Every day shift and as needed if the dressing becomes wet, soiled, or missing. - A wound care order, start date of [DATE], for a blister located on the right shoulder. Clean with Vashe, paint the wound with Betadine, skin prep to surrounding area, and cover with foam dressing for protection. Every day shift. - A wound care order, start date of [DATE], to check dressings to right shoulder, bilateral hips, and sacrum to ensure they are intact. If not, provide wound care following as needed orders, every night shift. - An order for doxycycline hyclate oral tablet (an antibiotic used to treat infections), 100 milligrams (mg). Give one tablet by mouth two times a day for wound infection for ten days. O. Record review of R #1's Treatment Administration Record (TAR), dated [DATE], revealed the following: - Wound care unstageable pressure sacrum: Cleanse with wound cleanser or Vashe and pat dry. Paint intact peri-wound with Betadine. Apply thin layer of Therahoney to open area, then cover with Calcium Alginate. Skin prep to surrounding skin. Cover with foam dressing, every day shift for sacral pressure ulcer. Start Date -[DATE] 6:00 am; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Wound care unstageable pressure ulcer right hip: Cleanse with wound cleanser or Vashe and pat dry. Skin prep to surrounding skin. Place foam dressing saturated with Betadine over wound. Every day shift for right hip pressure ulcer. Start Date -[DATE] 6:00; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Wound care unstageable pressure ulcer left hip: Cleanse with wound cleanser or Vashe and pat dry. Skin prep to surrounding skin. Place foam dressing saturated with Betadine over wound. Every day shift for left hip pressure ulcer. Start Date -[DATE] 6:00 am; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Wound care blister right posterior shoulder: Cleanse with wound cleanser or Vashe and pat dry. Generously paint with Betadine. Skin prep to surrounding skin. Cover with foam dressing for protection. As needed (PRN) for right shoulder blister. Start Date -[DATE] 6:15 pm; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Staff to check dressings to right shoulder, bilateral hips, and sacrum to ensure they are intact. If not, provide wound care following night (pm) orders. Every night shift for right shoulder, bilateral hips, and sacrum . Start Date -[DATE] 6:00 pm; discharge date -[DATE] 8:37 am. Staff administered the treatment on [DATE], [DATE], [DATE] and [DATE]. - Doxycycline hyclate oral tablet, 100 mg. Give 1 tablet by mouth two times a day for wound infection for ten days. Start Date -[DATE] 8:00 pm; discharge date -[DATE] 8:37 am. Staff administered the medication on [DATE], [DATE], [DATE]. P. Record review of R #1's nursing progress notes revealed the following: - On [DATE], facility staff notified the on-call provider that R #1 had symptoms of infection in the right hip. A physician's order for Doxycycline (an antibiotic used to treat infections), 100 mg, twice a day was received. - On [DATE] 6:27 pm, staff documented the resident's vitals as: blood pressure 112/56 (normal less than or equal to 120/80) , pulse 94 (normal 60-100), respiratory rate 16 (normal 12 to 18), temperature 99.7 (normal 97 to 99), pulse oximetry [a test used to measure the oxygen level (oxygen saturation) of the blood] 90 percent (%) (normal 95% to 100%). - On [DATE], R #1 developed a wet cough, (a cough that produces mucus or phlegm). - On [DATE] 7:41 am, staff documented the resident's vitals as: blood pressure 146/68, pulse 87, respiratory rate 17.0, temperature 97.7, pulse oximetry 92.0%. - On [DATE], R #1 had a change in condition of vital signs, with a pulse oximetry reading of oxygen 87%, altered levels of consciousness, and labored breathing. R #1 was transported to the emergency room. Q. Record review of R #1's hospital records, admission date [DATE], stated the following: - The resident was admitted with diagnoses of: - Severe sepsis (a serious infection usually caused when bacteria make toxins that cause the immune system to attack the body's own organs and tissues). - Decubitus ulcer (a pressure sore of damage to the skin and tissue underneath in the over the bony region of the very end of the spine) of coccyx. - Decubitus ulcer of hip. - Decubitus ulcer of shoulder blade. - Infection caused by multi-drug resistant bacteria. - Decubitus ulcer with full thickness skin loss involving damage of subcutaneous (beneath, or under, all the layers of the skin) tissue of right hip. - The list is not all inclusive and does not include all of R #1's diagnoses. -R #1 was admitted to the Intensive Care Unit for a septic (infected, or denoting infection) cough, secondary (relating to a medical condition that arises as a result of another disorder, disease process, or injury) to infected decubitus wounds. R #1 underwent incision and drainage [involves cutting and draining purulent (thick, white, and pus-like) contents from an abscess (a pocket of pus)] surgery of her right buttock and sacrum on [DATE]. Right hip and sacral eschars were removed. A culture of the sacral wound was positive for methicillin-sensitive staphylococcus aureus (MSSA; a type of infection, commonly known as a staph infection.) A culture of the fluid removed from R #1's right hip abscess, on [DATE], revealed a heavy growth of staphylococcus aureus (group of spherical bacteria that causes infections). - R #1 did not return to the facility. On [DATE], R #1 was admitted to Hospice. She expired on [DATE] at 6:50 am. R. On [DATE] at 9:22 am, during an interview with the Wound Care Nurse (WCN), she stated she became aware of R #1's wounds on [DATE] after the floor nurse alerted her. She said she was not aware of the resident's wounds between [DATE] and [DATE], because there was not a physician's order to treat them. She said R #1 had the original, right, front hip wound, a resolved Stage 3 pressure, which became unstageable; an unstageable to the sacrum; an unstageable to the left, front hip; and a right posterior (back) shoulder, Stage 2 pressure injury. The WCN stated she reassessed R #1's wounds on [DATE] and saw redness around the right, front hip and the other wounds. She said all the wounds had eschar. S. On [DATE] at 12:47 pm, during an interview, Certified Nursing Assistant (CNA) #1 reviewed and confirmed she completed the shower sheets for R #1, dated [DATE], [DATE], [DATE], and [DATE]. She reported R #1 was getting red, and there were not treatment orders to address the areas of redness or the scratching. She stated R #1 would scratch at the sides of her hips and would remove the dressings that covered the wounds during the month of December. The CNA stated the wounds were scabbed and appeared to look like road rash, prior to healing. The scratched areas then would heal with a scab. The CNA reported R #1 would dig in her back with her long nails. She stated she spoke to the Assistant Director of Nursing (ADON) about her concerns for R #1, but she could not recall the date she reported it to the ADON. The CNA stated one of R #1's hip wounds healed, but then the wound came back. She reported the wound on R #1's right hip was red and healed. The CNA did not recall when the resident's left side got a wound but said it was red and started to become moist. She stated the wound on R #1's back (sacral area) was dark and black. CNA #1 reported she was not aware of any wounds to R #1's shoulder. She stated there was a mark on the resident's shoulder that looked like a pimple, but it would not have been something she would mark on a shower sheet. T. On [DATE] at 2:27 pm, during an interview with Registered Nurse (RN) #1, she stated when a CNA finds a new wound on a resident, the nurse will assess the wound and talk about it with the WCN. RN#1 stated staff should document new areas of redness on the resident. RN #1 stated the wound on R #1's right hip would bleed, and she would put a dressing on it. She said she did this maybe once or twice. She confirmed there were no orders for wound treatment for the resident's right hip wound. She stated the orders for treatments for R #1's right hip were discontinued on [DATE]. She stated R #1 needed orders for any treatments, and the WCN usually puts the orders into the resident's medical record. RN #1 stated she asked the WCN to check on R #1's right hip wound prior to going on leave on [DATE]. RN #1 did not remember seeing any scratches on R #1's left hip. She stated she saw the wound on the resident's back twice, and the wound was dark in the center with a scab and red outside the scab prior. The RN said she verberally reported this to the WCN prior to going on leave on [DATE]. U. On [DATE] at 9:15 am, during an interview, the ADON stated the process for identifying skin care issues for a resident included documenting on the shower sheet and communicating it to the nurse on the floor. He stated staff should document a change in condition (CIC; a sudden, clinically important deviation from a patient's baseline, in physical, cognitive, behavioral, or functional domains). The ADON stated scratches and redness on hips were considered a change in condition, and staff should have created a change in condition record for R #1's skin conditions that staff identified on the shower sheets on [DATE] and [DATE]. The ADON said changes in scabs and open areas are also considered a change in condition He said staff should document a CIC in the resident's medical record, and the doctor will write an order for it. The ADON said CIC documents are reviewed by the unit manager, and staff also document it in a progress note. The ADON said the nurse who completed a CIC assessment was responsible to notify the provider. He said it did not have to be the WCN who notified the provider regarding CICs completed for a change in skin condition. The ADON stated R #1's medical record did not contain skin assessments, documentation of a conversation, or progress notes regarding the skin concerns documented on R #1's shower sheet dated [DATE]. The ADON confirmed he signed off on the shower sheets for R #1, dated [DATE], [DATE], [DATE], and [DATE]; and that indicated the shower task was completed. The ADON stated the CNA was then given direction to follow-up with the nurse. V. On [DATE] at 9:41 am, during an interview, the WCN stated residents with scratches and scabs required skin assessments. She reviewed R #1's shower sheets dated, [DATE], [DATE], [DATE], and [DATE]. She said she was not aware of the changes identified on the resident's shower sheets, but staff should have made her aware, prior to [DATE]. The WCN stated staff can put foam dressing on the areas that are reddened and blanchable (when pressing an area of the body with a finger and releasing, the area should become pale and then return to its normal color). She said, if the area was opened, the granulation (the development of new tissue and blood vessels in a wound during the healing process) of the wound determined the type of protective dressing. She confirmed R #1's medical record did not contain orders for any type of dressings, prior to [DATE]. The WCN stated she expected to see the wounds documented on skin checks, because she reviewed skin checks and not CIC documentation. She stated there was a problem with staff informing her about the wounds. W. On [DATE] at 10:21 am, during an interview with the Director of Nursing (DON), she stated there was not a system to trigger change in condition for skin conditions documented on shower sheets that identified skin concerns. She stated new skin concerns were triggered by the skin check sheets. The DON stated if there was something new on the skin check then the WCN would do an assessment, but if the skin concern was not new then a skin assessment would not be triggered. The DON said the nurses address the skin check concerns the next day and create a CIC document for the skin concerns. The DON reviewed R #1's shower sheets for December, 2023 and stated the CNA should have alerted the WCN. The DON stated staff should have documented the new wound areas on the resident's skin checks. The DON stated R #1's skin checks stated right hip, which suggested there was a current injury to that area. She said the WCN would need to follow-up on that documentation. The DON stated there was a breakdown in communication. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 1:54 pm. Implementation of the POR was onsite on [DATE] by conducting observations, record reviews, and staff interviews. Scope and severity was lowered to D. Plan of removal: On [DATE], the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds, will include change in condition documentation and notification to the provider and family. Any new orders will be followed. Beginning [DATE], the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee: Nurses will be educated on Genesis wound processes which include the DIMES, timely and accurate identification, and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. Center Nurses will be educated on responsibility regarding wound basics, wound evaluation, wound treatments, and documentation. CNA's will be educated on how to minimize pressure, friction and shearing, change in condition process for CNA's (including skin changes), and stop and watch. The Market Skin Team Health Lead will audit the skin integrity process weekly. The Skin Team Health Lead / DON will be responsible for the skin integrity process in the center and to make sure assessments, communications, and treatments are documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the required supervision for 1 (R #74) of 3 (R # 9, 74, and 78) residents reviewed when R #74 ate food from another resident's plate that was not within his ordered diet texture. This deficient practice could likely result in R #74 choking, needing to have the Heimlich maneuver (procedure for dislodging an obstruction from a person's windpipe) performed on him, be resuscitated (revived from unconsciousness), suctioned (removal of food) and could potentially cause death if this resident is not closely monitored by staff. The findings are: A. On 10/04/23 at 8:19 am during a random observation, breakfast was served on the 100 unit and two residents sat at a table. One resident (R #74) tried to take food off of resident (R #78) plate. She (R #78) slapped his (R #74) hand. He (R #74) attempted two more times, R #78 stopped him. Approximately five minutes later, R #78 left the table and exited the dining room. R #74 grabbed the bread off of R #78's plate and began to eat it. R #74 ate all of the remaining bread left on R #78's plate. Staff members that were in the dining room were not aware of R #74's behavior .Two Certified Nurse Assistance (CNA) assisted other residents with eating and the nurse was sitting at a chair working on the computer. B. Record review of the hospital documentation indicated R #74 was admitted to the hospital on [DATE] from a skilled nursing facility (previous facility) where he had choked on a ham sandwich and went into cardiac arrest (heart attack). Resident was on a dysphagia advanced diet (foods that are moist and bite sized) while at the skilled nursing facility (previous facility). It was unclear how R #74 got the ham sandwich. Resident was admitted to the MICU (medical intensive care unit) and was intubated (tube inserted into windpipe to aid in breathing). R #74 failed three swallow studies while in the hospital and a feeding tube (medical device to provide nutrition to people who cannot obtain nutrition by mouth) was placed. He was discharged to the current facility on 12/13/22. C. Record review of the face sheet for R #74 indicated the following: R #74 was admitted to the current facility on 12/13/22. He was admitted as a full code (all necessary interventions) and he had a diagnosis of Dysphagia (difficulty swallowing food or liquid), Feeding Tube, Dementia (decreased ability to think and remember, emotional problems, problems with language, decreased motivation) with behaviors. This is not an all inclusive list of diagnoses. D. Record review of the physician orders dated 06/17/23 indicated R #74 was ordered a regular diet, dysphagia puree texture, thick liquids-nectar consistency (thicker than water but able to be poured or sipped). Double portions and with direct staff supervision on unit . E. Record review of the physician orders dated 06/28/23 indicated that R #74 was to be monitored for behaviors every shift: yelling, profanity, refusal of care, throwing food, eating off of other resident plates, agitation. F. On 10/04/23 at 11:30 am, during an interview, the Speech, Language Pathologist (SLP) stated R #74 was on a puree diet with nectar thick liquids for his regular meals. She stated he is impulsive and they are aware of his behavior of taking food off of other residents' plates. The SLP stated R #74 had a history of choking. He had choked at a previous facility and was admitted to the hospital. After the hospital he came to this facility. She stated she does want R #74 supervised while eating in the dining room. The SLP stated supervised eating to her means as long as someone is in the dining area, not sitting right next to the resident. She stated she had evaluated R #74 a couple of times to take him off of puree food, but she never felt comfortable enough making him dysphagia advanced diet (moist and bite sized) for his meals due to the risk. G. On 10/04/23 at 4:15 pm, during an interview, Registered Nurse (RN) #8 stated R #74 had behaviors. He will cuss and yell out, he will wander around a little bit and he takes food off of other residents' plates. She stated R #74's behavior of taking food off of others plates was last seen a couple of months ago when he first came to that unit. She stated when she is monitoring the dining room she is unable to watch only him because she has to watch everyone in the dining room on the unit. H. On 10/04/23 at 4:19 pm, during an interview, Certified Nursing Assistant (CNA) #12 stated R #74 was on a puree diet only. CNA #12 stated R #74 takes food from others residents' plates almost daily. She stated staff try to manage him by not letting him linger in the dining room very long after he has finished his meal. CNA #12 stated she is not sure if he needs to be directly monitored (which meant having staff sit and watch him eat) but he needs to be watched. I. On 10/05/23 at 11:41 am, during an interview, Unit Director (UD) stated R #74 came into the facility on a feeding tube. Then he was taken off of the feeding tube and had been puree and nectar thick liquid. She was aware that he takes food off of other residents' plates. She stated everyone was keeping their eyes open for residents taking food. She stated they have a couple of residents who require feeding assistance, so they put those residents at one table. She stated if a staff member observed a resident trying to take food off of another resident's plate they should stop and re-direct them. J. On 10/06/23 at 10:21 am, during an interview, CNA #11 stated he was aware that R #74's diet was puree texture. CNA #11 stated R #74 frequently tries to take food off of other residents' plates. He stated that they have to constantly keep an eye on him because of this. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced on 10/05/23 at 5:25 pm to the Center Executive Director/Administrator in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 10/06/23 at 1:05 pm. Implementation of the POR was verified onsite on 10/06/23 by conducting observations, record review and staff interviews. Plan of removal: All staff in the building on 10/05/23 were immediately educated by the Director of Nursing (DON) and Nurse Practice Educator (NPE) regarding the proper monitoring of residents on altered diets. The staff were educated on their responsibility to know the diet of each resident they are monitoring, properly monitor the residents as they eat to ensure that they are only eating their ordered diet, and redirect any residents who attempt to eat food that is not on their own plate. On 10/05/23 the DON and the Dietary Manager completed an audit of all residents in the center in order to identify all residents who are on altered diets and to compare the resident diet orders in our electronic health record (EHR) to the resident meal cards. On 10/06/23 the DON/Designee completed staff interviews to screen residents with altered diets for behaviors of grabbing food from other resident's plates. Resident care plans were updated for individualized behavior. Additional staff will be stationed in the dining rooms for all meals served in the dining rooms to monitor residents on altered diets until the center can ensure that sufficient monitoring is occurring.