**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made for 4 of 5 (Resident #1, #24, #47, and #209) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, with revision date 2/1/2023 revealed, .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect .must report the event immediately .it is the policy of this facility that abuse allegation .are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made . 2. Review of the medical record revealed Resident #1 admitted to the facility on [DATE], with diagnoses that included Epilepsy, Muscle Weakness, and Mild Cognitive impairment. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status score of 7 which indicated severe cognitive impairment. Review of Resident #1's Progress Notes dated 1/12/2025 revealed, .nurse alerted to resident's room by cnas (Certified Nursing Assistants) and weekend manager. Resident has laceration to rt [right] eye brow. Noted swelling around eye and bruising where the eye meets his nose. Noted blood in sclera. Resident states he has a mild headache. Denies hitting head on any objects. This nurse initiated neurochecks. Notified NP [Nurse Practitioner], POA [Power of Attorney] and DON [Director of Nursing]. Site was cleansed and covered with bandage. Ice applied to eye to attempt to reduce swelling and bruising. Resident given one time dose of Tylenol 325mg [milligram] 2 tabs . Review of the medical record revealed Resident #209 was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Unspecified mood disorder, Anxiety disorder, and Homelessness. Review of the Quarterly MDS dated [DATE], revealed Resident #209 had a BIMS score of 15, which indicated no cognitive impairment. Review of Resident #209's Progress Notes dated 1/13/2025, revealed Resident oriented to new room, without complaint or issues reported. Resident has baseline confusion with words .Resident ate meals x 3 and ambulated unit without issues noted . 3. Review of the Quarterly MDS dated [DATE], revealed Resident #24 had a BIMS score of 8, which indicated moderate cognitive impairment. Review of the medical record revealed Resident #47 admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia with psychotic disturbance, Delusional Disorders, Anxiety disorder, and Restlessness and Agitation. Review of the Quarterly MDS dated [DATE], revealed Resident #47 had poor short term and long-term memory. Review of Resident #47's comprehensive care plan with edit date 3/6/2025 revealed, .I have hx [history] of yellout [yelling out] toward others and disrupting environment. I have a hx of throwing objects at others .I do talk to myself and imagine objects . 4. During an interview on 3/11/2025 at 10:32 AM, Certified Nursing Assistant (CNA) C was asked if she ever witnessed resident to resident abuse. CNA stated, .I know of some residents that hit each other, [Named Resident #209] hit [Named Resident #1], he got hit in the eye, [Named Resident #47] hit [Named Resident #24]. [Named Resident #24] got hit in the back of her head because she was trying to get [Named Resident #47]'s lunch tray . During an interview on 3/11/2025 at 10:50 AM, the Administrator was notified staff reported to this surveyor Resident #209 hit Resident #1 and Resident #47 hit Resident #24. The Administrator stated, Who told you that, I think I may have a file on [Named Resident #209] and [Named Resident #1] but I don't know anything about [Named Resident #24] hitting [Named Resident #47] . After the Administrator was informed of the allegation of abuse between Resident #1 and Resident #209, the Administrator provided the following investigation: Review of a typed statement signed by Assisted Director of Nursing (ADON) E dated 1/12/2025 revealed, .Resident has laceration to rt eye brow. Noted swelling around eye and bruising where the eye meets his nose. Noted blood in sclera .Denies hitting head on any objects .Room was assessed for items that resident may have hit head on .Nightstand is on the left side of bed had some blood on corner of nightstand. Resident tends to roll over to grab stuff out of his night stand which would correlate where the cut would hit if he had rolled to grab something . Review of a typed statement signed by DON dated 1/12/2025 revealed, On 1/12/2025 at approx. [approximately] 16:45 [4:45 PM] I was notified of a laceration to [Named Resident #1] .R [right] eyebrow. ADON was charge nurse on this day and she was instructed on steps for investigation. Investigation revealed that [Named Resident #1] was attempting to retrieve something from his table which caused the laceration to his R eye . Review of an email provided by the Administrator revealed the Administrator had emailed himself a typed statement. The email was dated 1/13/2025 which revealed, .I [Administrator] spoke with both [Named Resident #209 and Resident #1] today. [Named Resident #1] said a tall, dark, [NAME] looking [AGE] year-old looking kid decided he needed a black eye on Friday 1/10/25 [2025]. He said he was doing good ever since the incident with his eye and that the staff and other residents are good to him .[Resident #209] said he knew about his roommate's eye but that he was in the common area when this all happened as staff rushed into the room to respond to [Resident #1]. He denies ever touching [Resident #1] and reassured he'd never do anything like that. There were no other witnesses . Review of the email revealed the Administrator was aware of the allegation of abuse when Resident #1 told the Administrator someone blacked his eye. During an interview on 3/11/2025 at 10:59 AM, the Administrator was asked if he reported Resident #1's allegation of abuse to the state agency. The Administrator stated, .[Named Resident #1] had the dates mixed up .the day before I knew he had the injury. He has Dementia I was looking at the big picture, the fact he had an injury, we had an investigation about the injury .In this case looking at the facts related to the day prior. I used deductive reasoning. I felt I had the information I needed to have . After the Administrator was informed of the allegation of abuse between Resident #24 and Resident #47, the Administrator provided the following investigation: Review of a typed statement signed by the Administrator and DON dated 3/11/2025 revealed, .2:30pm Admin [Administrator] and DON spoke with [Named CNA C] in DON office. [Named CNA C] explained that she had witnessed [Named Resident #47] hit [Named Resident #24] on the head with her hand. She stated that the nurse witnessed the event as well and assumed that the nurse being her supervisor was aware . Review of a typed statement signed by the Administrator dated 3/11/2025 revealed, 2:50 PM .Admin and DON called [Named Licensed Practical Nurse LPN Q] on the phone and was asked about the event between [Named Resident #47 and Named Resident #24]. [Named LPN Q] was asked if she had witnessed the event in question. She recalled that she saw [Named Resident #47] playing with [Named Resident #24]'s hair in a non-aggressive manner. [Named LPN Q] stated that she asked [Named Resident #24] if she wanted to have [Named Resident #47] moved away from her to which [Named Resident #24] said that she didn't mind [Named Resident #47] playing with her hair . The written statement was completed 4 hours after this Surveyor reported the allegation of resident-to-resident abuse and this was not reported to the state agency. Review of a typed statement signed by the Administrator dated 3/11/2025 revealed, .Admin [Administrator] interviewed .[Named Resident #24] and she reported no concerns of care regarding other staff members nor issues with other resident in the facility. She stated that she feels safe here when asked . During an interview on 3/13/2025 at 11:00 AM, CNA K stated, .we were passing out trays around January. I had just taken [Named Resident #1]'s tray and he asked me who is that man over there referring to his roommate [Named Resident #209]. I told him it was his roommate, and he is on his side of the bed. I went down the hall and when I came back [Named Resident #1] was in the bed and he was bleeding around his eye, and it immediately started swelling up and getting red. His roommate [Named Resident #209] was the only person in the room. [Named Resident #1] said he hit me with his fist. The ADON knew about it he told her the same thing. They moved [Named Resident #209] to another room. During an interview on 3/13/2025 at 11:15 AM, CNA D stated, .the next morning [1/13/2025] [Named Resident #1] was saying some guy punched him in the face . The facility failed to report the abuse incident between Resident #1 and Resident #209, and the abuse incident between Resident #24 and Resident #47 to the State Survey Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments Section GG (Functional Abilities) were incomplete for 2 of 16 (Resident #20 and #21) MDS assessments reviewed. The findings include: 1. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Insomnia, Sleep Apnea, Cardiomyopathy, and Chronic Pain Syndrome. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact and Section GG was dashed and not completed. 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hypertension, Seizure Disorder, and Dysphagia, pharyngoesophageal phase. Review of the quarterly MDS dated [DATE], revealed Resident #21 had a BIMS score of 9, which indicated the resident was moderately cognitively impaired and Section GG was dashed and not completed. 3. During a telephone interview on 3/12/2025 at 4:10 PM, the MDS Coordinator confirmed she was on vacation the week of 2/10/2025 to 2/18/2025, Resident #21's assessment date was due to be completed on 2/13/202. MDS Coordinator confirmed Resident #21's assessment was completed by the ADON on 2/18/2025 which was done outside of the assessment period. The MDS Coordinator confirmed section GG for Resident #21 should have been completed by the Assessment Reference Date (ARD) Date of 2/13/2025. MDS coordinator confirmed no assessment was done for Resident #21 during the ARD period of 2/11/2025 and 2/13/2025 and section GG was blank and incomplete. During an interview on 3/12/25 at 4:43 PM, the MDS Coordinator confirmed she was on vacation the week of 2/10/2025 to 2/18/2025 and when she returned she realized the assessment for Resident #20 was incomplete. MDS Coordinator confirmed the assessment was due to be completed on 2/12/2025 and the facility had appointed someone to complete section GG in her absence. MDS Coordinator confirmed the Director of Nursing and herself had a video meeting and a list of assessments with due dates had been given to the DON with a list of completion dates. The MDS Coordinator confirmed that Section GG for Resident #20 was on the list and should have been completed between 2/10/2025 and 2/12/2025 and it was not completed until 2/18/2025. The MDS Coordinator confirmed that the annual MDS assessment dated [DATE] is incomplete and inaccurate if it was not completed at least 2 days prior to the Assessment Reference Date (ARD) of 2/2/2025. The MDS Coordinator confirmed if the section is dashed, it is incomplete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interview, the facility failed to provide scheduled showers/baths for 1 of 28 (Resident #28) sampled residents reviewed for bathing. The findings include: 1. Review of the undated policy titled, Bathing Policy, revealed .As a standard, residents are placed on a 3x [time]/week shower/full bed bath schedule. However, if a resident asks for a shower/full bed bath in addition to the schedule, every attempt is made to accommodate .Shower schedules are placed in the reference book at the nurse's stations. Documentation is by exception only, meaning that refusals of shower/full bed baths be documented . 2. Review of the shower schedule provided by the facility revealed Resident #28 was scheduled to receive a shower on night shift from 6:00 PM to 6:00 AM on Monday, Wednesday, and Friday. 3. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses which included Traumatic Subdural Hemorrhage, Diabetes Mellitus, Orthostatic Hypotension, and Chronic Pain. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. Continued review revealed Resident #28 was dependent for shower/bath, substantial assistance with upper body dressing, and dependent for lower body dressing and toileting hygiene. During an observation and interview on 3/10/2025 at 10:59 AM, Resident #28 was dressed in a blue shirt and red/black checked pajama pants. Family Member (FM) P stated, .we have had issues with him [Resident #28] getting a shower since he admitted . The facility has told us he is scheduled to get a shower on night shift 3 days a week. Since 2/15/2025 he has only had 4 showers, we ask about the showers when we come in because we are here every day from around 7 [7:00 AM] to around 7:30 [7:30 PM] .We mentioned it in his care meeting with the social worker and nurse management and nothing has improved .[Named Certified Nursing Assistant (CNA) N] has provided him 3 of his showers on day shift . During an observation and interview on 3/11/2025 at 10:22 AM, Resident #28 continued to have on the same blue shirt and red/black checked pajama pants he had on 3/10/2025. FM P stated, .yes he still has on the same clothes this morning and his shower was scheduled last night . During an observation and interview on 3/11/2025 at 3:00 PM, Resident #28 had on a blue short sleeve shirt and gray jogging pants. FM P stated, .still no shower, I helped him change his shirt and pants today . During an observation and interview on 3/12/2025 at 9:00 AM, Resident #28 continued to have on the same blue shirt and gray jogging pants he had on 3/11/2025. During an observation and interview on 3/13/2025 at 8:30 AM, Resident #28 continued to have on the same blue shirt and gray jogging pants he had on 3/11/2025. FM P confirmed Resident #28 continued to have on the same clothes. FM P stated, .I was here until 8:00 PM last night and he didn't get a bath . During an observation and interview on 3/13/2025 at 10:00 AM, Resident #28 was up in his wheelchair dressed in different clothes. FM P stated, .[NAME] gave him a shower this morning .she is so good . During an interview on 3/13/2025 at 10:15 AM, CNA P was asked why she gave resident #28 a shower. CNA P stated, .I gave him his bath. He asked me for it . The CNA was asked how she would chart his shower. CNA P stated, .we have no way to chart showers .if a resident refuses a shower, then we report it to the nurse and she would document the refusal . CNA P was asked if she routinely cares for Resident #28 and she stated, yes. CNA P was asked if it was common for Resident #28 to have on the same clothes with no evidence of shower being given on night shift and she stated, .all I can say is I try to do the best I can for him and the family . During an interview on 3/13/2025 at 10:30 AM, License Practical Nurse (LPN) O stated, .the CNAs should fill out a shower sheet if a resident gets a shower and we keep it at the nurses desk .I have some shower sheets for February and March but I don't see any shower sheets for [Named Resident #28] .he is scheduled to receive a shower on night shift .I don't see any refusals charted for his shower . During an interview on 3/13/2025 at 11:37 AM, the Director of Nursing (DON) was asked to review Point of Care History for Resident #28's bathing from 2/22/2025 to 3/12/2025. The DON was asked if a resident refused a bath or shower would it be charted on the Point of Care History and she stated, yes, it would be charted if he refused. The DON verified no refusals were charted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to follow physician orders for 2 of 28 sampled residents (Resident #8 and Resident #207) reviewed. The findings include: 1. Review of the undated facility policy titled, PHYSICIAN ORDER RECAP PROCESS [Named Electronic] SOFTWARE revealed When the nurse receives the order, she will review the physician orders for any changes and obtain any clarifications or additional orders necessary. The nurse confirmation of this order attests that she has completed this review process. When the physician makes the required visit, he will review .make any changes he/she deems necessary and sign this order. This will serve as documentation that he has reviewed and renewed the orders . Review of the facility policy titled, LAB AND X-RAY SERVICES, dated 3/2024 revealed, The center maintains agreements/contracts for .laboratory .services. These studies will be obtained only upon the written order of the patient's physician .The center ensures that the patient's physician or physician extender is made aware of test results that fall outside the clinical reference ranges within a reasonable timeframe after receiving the results. If the study cannot be done in the center, administration shall assist in arranging adequate and safe transportation of the patient to the office or laboratory where the test will be performed . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Osteoarthritis, and Chronic Diastolic Heart Failure. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of Resident #8's Resident Orders dated 3/1/2025-3/12/2025 revealed a physician's order for Breo Ellipta (inhaler that treats asthma and Chronic Obstructive Pulmonary Disease) 100-25 mcg (microgram)/dose 1 inhalation once a day at 7:00 AM - 11:00 AM. During a medication observation Licensed Practical Nurse (LPN) A prepared Resident #8's medication. During the preparation LPN A looked for Resident #8's Breo Ellipta and was unable to find the inhaler in the medication cart. LPN A stated, I will put in an order to the pharmacy. During a telephone interview on 3/12/2025 at 11:37 AM, [Named Pharmacy #1]'s Certified Technician stated, the inhaler was delivered on 2/13/2025 it is a one-month supply so the facility should have the medication to give. During an interview on 3/13/2025 at 12:00 PM, LPN A was asked if Resident #8 received her Breo Ellipta inhaler from the pharmacy. LPN A stated, .She still doesn't have any . 3. Review of Hospital #1's History of Present Illness dated 2/25/2025 for Resident #207 revealed .History of present illness .presents complaint of knee pain. The patient had multiple previous surgeries on her right knee .she had a revision last on the right side in 2023. She tells me she has had drainage from the wound since about Christmas time. She also felt weak and feverish. This grew mixed organisms. Due to the patient's continue drainage she wants to proceed with resection surgery. She has history of coronary artery disease. She has undergone balloon angioplasty as well as stent placement-this is noted in previous record . Review of the medical record revealed Resident #207 admitted to the facility on [DATE], with diagnoses which included Infection and Inflammatory reaction due to internal Right Knee Prostheses, Type 2 Diabetes Mellitus without complications, and Atherosclerotic Heart Disease. Review of Resident #207's Resident Orders dated 3/9/2025-3/11/2025 revealed a physician's order to administer Vancomycin 1000mg intravenous every 12 hours at 8:00 AM and 8:00 PM which started on 3/7/2025. Continued review revealed a physician's order to draw Vancomycin Trough on 3/11/2025. Review of the Medication Administration History (MAH) dated 3/1/2025-3/12/2025 revealed an order for Vancomycin 1,000 mg every 12 hours through 3/25/2025 at 8:00 AM and 8:00 PM. Further review of the MAH dated 3/11/2025 revealed the 8:00 AM dosage of Vancomycin 1000 mg was .Not administered: On Hold . Further review revealed the Vancomycin was charted as given on 3/11/2025 at 1:59 PM, 5 hours and 59 minutes past the scheduled administration time. Review of Resident #207's Progress Notes dated on 3/11/2025 at 1:26 PM revealed, .MD [Medical Doctor] contacted regarding vanc [Vancomycin] being held due to waiting on trough draw for morning dose. Orders to hold morning dose and resume PM dose after trough results . The Progress Notes revealed the MD was not contacted until 5 hours 36 minutes pass the time of the Vancomycin to be administered. Review of the Progress Notes revealed no nurse tried to obtain the lab work for the trough and did not notify the MD until 5 hours and 36 minutes past the time for the medication administration. During a medication observation on 3/12/2025 at 9:05 AM, Assistive Director of Nursing (ADON) B was observed administering Vancomycin 1,000 mg per Resident #207's PICC (Peripherally Inserted Central Catheter) line. During an observation and interview on 3/10/2025 at 11:22 AM, Resident #207 stated, .I got here yesterday evening around 5:00 PM .I had to have surgery on my leg .I am supposed to get some IV [intravenous] medication . Resident #207 was noted to have a single lumen IV site to her left arm. Observation on 3/11/2025 at 8:00 AM, 9:00 AM, and 10:00 AM in Resident #207's room revealed no Vancomycin was being administered for her AM dose of IV therapy. During an interview on 3/11/2025 at 4:30 PM, the Assistant Director of Nursing (ADON) was asked about Resident #207's AM dose of Vancomycin. The ADON stated, .the nurse notified the lab of the trough to be drawn when she admitted on [DATE] they usually come out at 3:00 AM .the nurse called at 3:00 AM this morning but the lab never came out . The ADON was asked if a Registered Nurse (RN) could have drawn the lab. The ADON stated, .I don't think you can draw from the midline .I guess we could have got a peripheral stick for the trough, but the lab would still need to pick the lab work up .she didn't get a dose this morning but the lab is still supposed to come out and get the trough so she can get the evening dose . During a medication observation and interview on 3/12/2025 at 9:05 AM, ADON was observed starting the infusion of Vancomycin 1000 mg for Resident #207 through her PICC (peripherally inserted central catheter) line. The ADON was asked about Resident #207's lab for her trough level. The ADON stated, .the trough was obtained around 7:30 PM last night. She got her dose last night . During a telephone interview on 3/12/2025 at 11:54 AM, the Pharmacist was asked at what time a trough should be performed for a resident receiving Vancomycin Intravenously. The Pharmacist stated, it should be drawn 30 minutes before the Vancomycin is due to be given. The Pharmacist was asked why Resident #207's trough was ordered to be completed at 3:00 AM and she stated, I don't know why the trough would be scheduled at 3:00 AM. The lab does normally draw the lab work. The trough would be more accurate if done 30 minutes before the next dose. I know they did obtain the trough, and the Vancomycin dosage was increased for the evening dose today. I do not do the dosing it is done by the IV consultant. The trough must have been low . During a telephone interview on 3/12/2025 at 2:05 PM, the Pharmacist Consultant stated, .I wasn't surprised her trough was low with her weight and the dosage she was on I recommended Vancomycin 1500 mg every 12 hours .I was not aware the lab was drawing troughs at 3:00 AM .It is not really a trough, needs to be closer to the time it is due to be done .I assumed the level was drawn at a normal time. I wasn't aware that it was not being done at an appropriate time .I would expect a nurse to draw the lab at the appropriate time and wait on the lab to pick it up . During an interview on 3/12/2025 at 4:15 PM, Licensed Practical Nurse (LPN) O stated, .the lab comes and obtains our lab . LPN O was asked how the facility notifies lab work needs to be completed. LPN O stated, .we put it in the computer hit stat and it goes straight to the lab . During an interview on 3/13/2025 at 4:20 PM, the MD was asked about Resident #207's trough not being completed until after she missed her morning IV Vancomycin. The MD stated, .I was notified about it not being done, labs are a problem in all these facilities .If you can find a lab that will work with us that would be good . During an interview on 3/13/2025 at 6:30 PM, the DON was asked if she would expect her nursing staff to follow Physician orders. The DON stated, .yes, I would expect the nurses to follow the orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services for a resident with a percutaneous endoscopic gastrostomy (PEG) tube (tube inserted into the stomach to administer medications, supplements and liquid food) when staff failed to notify physician and resident representative of a change in status resident weight loss, and refusal of peg tube feedings for 1 of 3 (Resident #6) sampled residents reviewed for enteral feedings. The findings include: 1. Review of the facility policy titled, Patient Care Policies -Policies and Procedure Regarding Change in Patient Status, revised on 3/2024, revealed .The patient or patient representative is encouraged to be involved in all decision-making regarding changes in the plan of care .Notification of Patient Representative .The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's representative . Review of the facility policy titled, Patient Care Policies Nutrition Support - Enteral/Total Parenteral Nutrition (TPN), revised 3/2024, revealed .Nutrition support will be provided according to physician orders and assessed nutritional needs. Patients who receive tube feeding or TPN will be routinely assessed and recommendations made when appropriate . Review of the facility policy titled, Medication Administration - General Guidelines, revised on 2/25/2025, revealed .Consistent medication refusal must be reported to the prescriber and there must be documentation of prescriber notification of such. Refusal of anticoagulants .and any narrow therapeutic index medication should be closely monitored and reported to the physician as needed . Review of the facility policy titled, Weight Monitoring, revised 3/2021, revealed .Patients weights will be monitored to maintain acceptable nutritional parameters .Weights will be monitored and evaluated for significant changes, 5% in 30 days and 10% in 180 days . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included Encounter for surgical after care following surgery on digestive system, unspecified Dementia, unspecified severity, without behavioral disturbance, psychotropic disturbance, mood disturbance, and anxiety, other Specified Eating Disorder, Chronic embolism (an obstruction or blockage in a blood vessel) and thrombosis (a blood clot within blood vessels that limits the flow of blood) of right popliteal (back of the knee) vein, Dysphagia Oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), and Gastrostomy (a surgical opening (gastrostomy) into the stomach) status. Review of the Vitals Report for Resident #6 revealed the following weights: On 10/03/2024 at 2:55 PM Weight: 151.8 pounds (lbs) and Routine BMI (Body Mass Index) (a calculated measure of body weight relative to height): 27.76. On 10/08/2024 at 4:17 PM - Weight: 148.7 lbs and BMI: 27.19. On 11/07/2024 at 3:41 PM - Weight: 145.1 lbs and BMI: 26.54. On 12/02/2024 at 2:32 PM - Weight: 144.2 lbs and BMI: 26.37. On 01/07/2025 at 12:02 PM - Weight: 150.4 lbs and BMI: 27.51. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Further review revealed Resident #6 was dependent on staff for all Activities of Daily Living (ADL) care, always incontinent of bowel and bladder, Non-Alzheimer's Dementia, Dysphagia, oropharyngeal phase, had a recent surgery involving the gastrointestinal tract (The organs that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces), had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months not on physician-prescribed weight-loss regimen, had a feeding tube while a resident, 51% or more of total calories the resident received through parenteral or tube feeding, 501 CC/day or more average fluid intake per day by tube feeding, and received anticoagulant medication, and diuretic medication. Review of the Comprehensive Care Plan dated 1/17/2025, for Resident #6 revealed a plan of care with problems and interventions to include Enhanced Barrier Precautions, Tube Feeding with interventions to include assess for complications, NPO Status, provide frequent oral care, Lubricate lips, Dysphagia, cognitive deficits related to Dementia with interventions to include involve my representative in medical and financial matters as needed/requested, at risk for complications, Nutrition/Hydration with interventions to include medication as ordered, observe for signs and symptoms of dehydration and notify medical doctor, Provide tube feeding as ordered, weigh monthly if stable and monitor for significant changes, with no problems or interventions for refusal of medications or refusal of tube feedings. Review of the Vitals Report for Resident #6 dated 1/23/2025 at 5:32 PM revealed a weight of 149.8 lbs. Review of the progress notes for Resident #6 dated 1/26/2025 revealed, .Resident refused 3rd bolus for today . Review of the progress notes for Resident #6 dated 1/31/2025 at 6:00 PM, revealed Resident refused total of 3 bolus feed this shift. She did let this nurse flush her tube with H20 total 600 mL H20 for this shift ADON [Assistant Director of Nursing] aware . Review of the Vitals Report for Resident #6 dated 2/10/2025 at 1:29 PM revealed a weight of 146.8 lbs. Review of the Medication Administration Record (MAR) dated 2/1/2025 to 2/28/2025, for Resident #6 included furosemide 80 mg tablet 1 tablet one a day with 2 scheduled doses documented as not administered refused, Tube feeding formula Jevity 1.5 240 ml bolus with 120 ml flush before and after at 5 AM, 9 AM, 1 PM, and 9 PM with 36 scheduled bolus tube feedings documented not administered refused, Tube feeding medication flush every shift flush with 30 ml of water before and after meds. Flush with 15 ml of water between meds with 4 medication flushes documented not administered refused, Tube feeding shift total every shift with 13 shift totals documented as not administered refused, Tube flush shift total every shift flush total with 7 shift totals documented as not administered refused, tube residual check every shift. Check residuals. If greater than 100 mL, hold feeding until physician is notified. Record amount of residual in vitals with 9 shift residuals documented as not administered refused. On 2/1/2025 through 2/28/2025 it was documented on the MAR that Resident #6 refused 3 consecutive bolus tube feedings on 2/17/202, 2/18/2025. 2/23/2025, 2/26/2025 and 2/27/2025. On 2/28/2025 Resident #6 refused 4 consecutive bolus tube feedings. There was no documentation in the medical record of notification of physician and/or responsible party. Review of the Food & Nutrition Service progress note dated 2/28/2025 revealed, Nutrition Monthly enteral review - Resident continues on tube feedings of Jevity 1.5 240 ml bolus 5 x per day at 5 A, 9 A, 1 P, 6 P, and 9 P .she is NPO, but could not eat, but has refused ever since she had a tooth problem and refused to eat after that and has refused all offers of being seen by SLP. She seems very content with present feeding. She has lost quite a bit of weight which was therapeutic for her as she had gained up to 204 # [pounds] in April 2023 with BMI of 37.3 which is close to being morbidly obese. WEIGHTS: HT: 62 CBW:146.8# BMI: 26.85 in optimal range IWR:99-121# Weight up 2.6# 1.8% X 30 days. P: continue with current POC. RD [Registered Dietitian] to follow . Review of the Vitals Report for Resident #6 dated 3/04/2025 at 5:10 PM revealed a weight: 146.0 lbs. Review of the Vitals Report for Resident #6 dated 3/10/2025 at 8:35 AM revealed a weight: 130 lbs. Review of the physician orders for Resident #6 dated 2/12/2025 through 3/11/2025, revealed .NPO [nothing by mouth] .Tube feeding formula Jevity 1.5, 240 ml [milliliter] bolus [a single large dose] with 120 ml flush before and after at 5 AM, 9 AM, 1 PM, 5 PM, and 9 PM .furosemide [given to treat fluid retention] tablet 20 mg [milligram] 1 tab [tablet] .Twice A Day .furosemide tablet .80 mg 1 tab .Once A Day .Enhanced Barrier Precautions [using gown and gloves during specific high-contact resident care activities] r/t [related to] tube feeding q [every] shift . Resident #6's daily source of nutritional intake per physician's orders via peg tube was Jevity 1.5 calorie and 240 ml given 5 times a day with a total of 1200 ml/day or 1800 calories, with a Water flush intake total of 1200 ml per day. A Weight Calculation revealed on 2/10/2025 a weight of 146.8 and 3/12/2025 a weight of 135.4 for Resident #6 which resulted in a significant and severe weight loss of 7.77% (11.4 lbs) in 30 days. A 5% body weight loss in 30 days is considered a significant weight loss. A greater than 5% body weight loss in 30 days is considered severe weight loss. Review of the MAR dated 3/1/2025 to 3/12/2025 for Resident #6 revealed tube feeding formula Jevity 1.5 240 ml bolus with 120 ml flush before and after at 5 AM, 9 AM, 1 PM, 5 PM, 9 PM, with 17 scheduled bolus tube feedings documented not administered refused, Tube feeding medication flush every shift flush with 30 ml of water before and after meds. Flush with 15 mL of water between meds with 4 medication flushes documented as not administered refused, Tube feeding shift totals every shift with 9 shift totals documented as refused, Tube flush shift totals with 4 shift totals documented as refused, Tube residual check every shift with 5 residual checks documented as refused. On 3/1/2025 through 3/12/2025 it was documented on the MAR that Resident #6 refused 3 consecutive bolus feedings on 3/9/2025 and refused 4 consecutive bolus feedings on 3/8/2025 with no documentation in the medical record of notification of physician and/or responsible party. Review of the progress notes for Resident #6 dated 12/31/2024 to 3/12/2025 revealed there was no documentation the physician, practitioner, or POA was notified of the resident's refusal of tube feedings and weight loss. During observation on 3/10/2025 at 12:05 PM, 3/11/2025 at 8:14 AM, and 3/12/2025 at 8:30 AM, Resident #6 was lying in bed with dry chapped lips. During a telephone interview on 3/12/2025 at 11:39 AM, the POA T was asked if the facility had notified her of Resident #6's weight loss. POA T stated, .No, they haven't called me . The POA T was asked if she had been notified that Resident #6 had 28 refusals in the last 30 days of her bolus tube feedings. POA stated, .No, but I will be calling them . During an interview on 3/12/2025, at 2:09 PM the RD was asked about Resident #6. RD confirmed she was not notified of Resident #6's consistent refusals of bolus tube feedings and that Resident #6 had a body weight loss of 7.77% in 30 days. During an interview on 3/12/2025 at 5:05 PM, LPN O was asked about Resident #6's bolus tube feeding and medication refusals. LPN O stated Resident #6 had refused her 1:00 PM and 5:00 PM bolus tube feeding today. LPN was asked if the provider was notified. LPN O stated, No, the NP is aware [named Resident #6] has been refusing feedings. During a telephone interview on 3/12/2025 at 6:30 PM, the Nurse Practitioner (NP) was asked about Resident #6. The NP stated she was familiar with Resident #6, did not have access to her computer. To the best of her knowledge Resident #6 was a long-term care resident with a peg tube receiving Jevity 1.5 calorie bolus tube feedings with H20 flushes. The NP was asked if she had been notified by the nursing staff that Resident #6 had refused bolus tube feedings. The NP stated, Not to my knowledge. The NP was asked what the expectation of nursing staff is when a resident refuses bolus tube feedings and/or medication. The NP stated the expectation is for the staff to notify the provider if a resident refuses 3 bolus tube feedings in a shift, if a resident refuses medications, and if medication is not given especially critical medications. Review of the Vitals Report for Resident #6 dated 3/12/2025 at 6:34 PM revealed a weight: 135.4 lbs. Review of physician orders for Resident #6 dated 3/13/2025, revealed orders for CBC (complete blood count) w/differential (the number of different types of white blood cells) one time, CMP (Comprehensive Metabolic Panel a routine blood test measuring 14 different substances in the blood sample)-Comp Metabolic Panel one time, Tube feeding formula - Jevity 1.5 @ (at) 55 ml continuous 22 hours per day 4PM to 2AM and flush with 55ml H2O (water) 22 hours per day from 4 AM to 2 AM and Flush with 55ml H2O time 22 hours 4 AM to 2 AM. Everyday. Can hold for ADL Care. The physician's order revealed Resident #6 had 1815 calories via peg tube per day and 1210 ml of water. During an observation and interview on 3/13/2025 at 8:29 AM, revealed Resident #6 was lying in bed, lips dry chapped, head of bed elevated, kangaroo feeding pump at bedside with Jevity 1.5 formula infusing at 55 mL/hour. Resident #6 was asked when the tube feeding pump was started. Resident #6 stated this morning a nurse brought it in. Resident #6 was asked if she remembered refusing bolus tube feedings and or medications. Resident #6 stated Yes. Can you tell me a reason you would refuse tube feedings and /or medications. Resident #6 stated not time yet. Resident #6 was asked how you know it is not time yet. Resident #6 stated, I don't know. During an interview on 3/13/2025 at 11:45 AM, ADON E was asked about the initiation of Resident #6's continuous tube feeding per pump. ADON E stated she initiated the order for Resident #6 to be placed on continuous tube feeding with H20 flush per pump this morning around 7:30 AM. ADON E stated the orders were initiated through the RD that wanted the tube feedings adjusted due to Resident #6's weight loss. ADON E was asked about Resident #6's refusal of tube feedings and how she knew Resident #6 did not refuse the continuous tube feeding. ADON E stated Resident #6 had a BIMS score of 11 or 12 and usually understands what is said to her. ADON E stated Resident #6 was told the continuous tube feeding was ordered due to Resident #6 was refusing the bolus tube feedings and losing weight. ADON E stated Resident #6 when asked about starting the continuous feeding said 'OK'. ADON E was asked if a change in the diet order of a resident receiving tube feedings would be considered a change in condition. ADON E stated I think it would be. ADON E was asked what the facility policy is when a resident has a change in condition. ADON E stated the responsible party or POA should be notified. ADON E was asked when should staff notify the provider if a resident receiving tube feedings is refusing the feedings. ADON E stated if the resident refuses feedings 2 to 3 times in a shift the nurse should notify the provider, and the responsible party should be notified. ADON E was asked if she notified Resident #6's POA about the tube feeding order change. ADON E stated No, the RD put in the new order and usually notifies the responsible party or POA. During an interview on 3/13/2025 at 3:45 PM The ADON B was asked when should staff report bolus tube feeding refusals. ADON B stated that more than one tube feeding refusal in a shift should be reported to the supervisor. ADON B confirmed that staff was not communicating Resident #6's refusals of bolus tube feedings and medications to him. ADON B was asked if notified of a resident's refusal of tube feedings and/or medication what would he do? ADON B stated he would speak to the resident to investigate the refusals, call the Nurse Practitioner (NP), and notify the family or responsible party. ADON B was asked what can happen if a resident consistently refuses tube feedings? ADON B stated if refusals are consistent, it can cause dehydration, malnutrition, and weight loss. ADON B stated that Resident #6's refusals definitely should have been caught sooner. During an interview on 3/13/2025 at 4:30 PM, the Director of Social Services was asked if she was aware of Resident #6 refusing tube feedings and medications. Social Services Director stated I heard in the last two days she was refusing her tube feeding. That was new to me I would try my best to follow up. The Social Services Director was asked who notifies families and/or RP of resident change in condition. Social Services Director stated nursing should notify family and/or RP of resident changes in condition. During an interview on 03/13/2025 at 6:30 PM, The Director of Nursing (DON) stated Resident #6 was re-weighed DON on 3/12/2025 due to the weight was wonky The scales were calibrated by Medical Equipment Services on 3/6/2025. DON was asked when staff should notify the provider of tube feeding refusals and medication refusals. DON stated staff should notify the provider if a resident refuses medications and if a resident is consistently refusing tube feedings. DON was asked if the resident's representative should be notified of refusals of tube feedings and medications. DON stated resident representatives should be notified of resident changes in condition.

Based on policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 8 of 13 CNAs (CNA F, G, H, I, J, K, L, and M) employed for a full year received at least 12 hours of in-service training. The findings include: 1. Review of the facility's policy titled Patient Care Policies, dated 2024, revealed .The center's in-service training program will provide additional partner training based on individual partner's assessed needs and in compliance with NHC, State and federal regulations . 2. Review of the Inservice Training Hours revealed: a. CNA F had a hire date of 10/17/2023, and had only competed 5.76 in-service hours from 1/2/2024 -present. b. CNA G had a hire date of 6/6/2023, and had only completed 10.26 in-service hours from 1/2/2024 -present. c. CNA H had a hire date of 12/5/2023, and had only completed 3.50 in-service hours from 1/2/2024 -present. d. CNA I had a hire date of 6/20/2023, and had only completed 3.25 in-service hours from 1/2/2024 -present. e. CNA J had a hire date of 7/10/2024, and had only completed 11.60 in-service hours from 1/2/2024 -present. f. CNA K had a hire date of 9/12/2023, and had only completed 9.26 in-service hours from 1/2/2024 -present. g. CNA L had a hire date of 9/12/2023, and had only completed 10.46 in-service hours from 1/2/2024 -present. h. CNA M had a hire date of 1/2/2024, and had only completed 11.96 in-service hours from 1/2/2024 -present. 3. During an interview on 3/13/2025 at 3:31 PM, the Facility Educator was asked how many CNA in-service hours are required for a year. The Facility Educator confirmed 12 hours yearly. The Facility Educator was asked who is responsible to ensure they are completed as required. The Facility Educator stated, Mine and theirs because they know to complete those .every month from the time they are hired there is a report of who has not completed them .I have given verbal warnings and I have written them up and some don't even care and the 2 that are highlighted are habitual for not doing what they are supposed to get done .has been reported to the Director of Nursing (DON) and the Administrator .the DON has taken them off the schedule and has suspended them for noncompliance and they still don't get it done .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medication review, observation, and interview, revealed the facility failed to ensure medications were properly stored and secured for 2 of 16 (Resident #20 and #36) residents when medications were found unattended and unsecured in resident rooms. The findings include: 1. Review of the facility's policy titled, STORAGE OF MEDICATION, with a revision date of 2/25/2025, revealed .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of supplier. The medication is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorize to administer medications . Review of the facility's policy titled, SELF-ADMINISTRATION OF MEDICATIONS, with a revision date of 2/25/2025, revealed .residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer .a physician order should be obtained then an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive .physical, and visual ability to carry out this responsibility . 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Insomnia, Sleep Apnea, Cardiomyopathy, and Chronic Pain Syndrome. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact. Review of the Care Plan reviewed on 2/12/2025, revealed .Cognitive Deficit not related to Dementia .I have forgetfulness at times and am at risk for poor decision making and poor safety awareness . and no care plan for self-administration of medications. Observations in Resident #20's room on 3/10/25 at 11:32 AM and at 4:02 PM, revealed 1 bottle Tums Antacid on the Resident's bedside stand, unsecured and unattended. The resident did not have a physician's order for the use of the Antacid. Review of the medical record revealed Resident #20 had no Self-Administration of Medication assessment completed until 3/11/2025. Review of the Physician's Orders dated 3/12/2025, revealed .Tums (medication used for heart burn) (antacid) .chewable .200 mg [milligram] .2 tabs [tablets] .Three times a day . Review of the medical record revealed Resident #20 had no order for the use of the antacid until 3/12/2025. During an interview in Resident #20's room on 3/10/2025 at 4:02 PM, Licensed Practical Nurse (LPN) R was asked are residents supposed to keep medications at their bedside. LPN R confirmed all medication should be securely locked on the medication cart. LPN R confirmed she was unaware if Resident #20 had been assessed for self-administration of medications and was unsure if the resident had an order for the use of the medication. During an interview on 3/13/25 at 6:27 PM, the Director of Nursing (DON) confirmed that Resident #20 was not assessed for self-administration of medications until 3/12/2025 and the medications should not have been at bedside but should have been stored in the locked and secured medication cart. 3. Review of the medical record revealed Resident #36 admitted to the facility on [DATE], with diagnoses which included Chronic Pain, Generalized Osteoarthritis, Anxiety disorder, and History of falling. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #36 had Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. Continued review revealed Resident #36 required substantial assistance to maximal assistance with ADL (Activities of Daily Living) care. Review of the Medication Administration History dated 3/1/2025-3/12/2025 revealed Resident #36 had an order for Asper Creme (Lidocaine Hydrochloride) liquid roll-on, 4% as needed for pain. During a medication observation on 3/12/2025 8:25 AM, Licensed Practical Nurse (LPN) A prepared Resident #36's medications and goes into the resident's room. We arrived in the room and Resident #36 stated, .will you put my Asper Crème [topical pain relief product] on . and opened a roll-on applicator of Asper Creme that was sitting on her overbed table. The nurse left the room and told Resident #36 let me look and make sure you have an order for it. At 8:34 AM, Resident #36 took the lid off the Asper Crème and self-applied it to her left side above her waistline and stated, .silly they can't rub this on me . LPN A stated, .she has never done that, it is normal for her to have it in her room. I don't see where she can self-administer the medication, but she does have an order for it . During an interview on 3/12/2025 at 9:00 AM, the Director of Nursing (DON) was asked if Resident #36 should have Asper Creme in her room and self-administer the medication. The DON stated, No, the Asper Crème should not be in her room, and she should not be self-administering the medication.

Based on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 6 of 22 (Residents #23 and #26's room, Residents #9 and #20's room, Resident #13 and #37's room, Residents #1 and #41's room, Residents #7 and #24's room, and Resident #53's room) resident occupied rooms and bathrooms observed. The findings include: 1. Observations in the shared bathroom for Resident #23 and #26 on 3/10/2025 at 12:06 PM, and 4:09 PM, and on 3/11/2025 at 10:00 AM, revealed 2 teal wash basins stacked inside of each other in the bathroom floor, unlabeled and uncontained. 2. Observations in the shared room for Resident #9 and Resident #20 on 3/10/2025 at 11:32 AM, revealed 1 bottle of Sea Breeze facial astringent (facial cleanser) on top of the dresser uncontained, and unsecured. 3. Observations in the shared room for Resident #13 and #37 on 3/10/25 at 11:55 AM, revealed the following: a. a bottle of sterile water opened and uncontained sitting on the bedside stand next to the refrigerator. b. a 16.9 oz (ounce) bottle of California Mango shampoo on top of the refrigerator c. a 12 oz bottle of California Cleansing gel on top of the refrigerator d. 2 graduate dispensers on back of the toilet, unlabeled and uncontained e. a teal wash basin in the bathtub, unlabeled and uncontained f. a 7.5 oz bottle of Dial hand soap on the dresser near the window g. 3 aerosol bottles of Febreze air freshener on the dresser near the window Observations in the shared bathroom for Resident #13 and #37 on 3/10/25 at 12:01 PM, revealed the following: a. a teal wash basin on the toilet seat, unlabeled and uncontained b. a blue denture cup on back of the toilet, unlabeled and uncontained c. a teal wash basin in the bathtub, unlabeled and uncontained d. a 7.5 oz bottle of Dial hand soap on the sink, unsecured e. a 28 oz bottle of Suave shampoo and conditioner on the sink, unsecured. 4. Observations in the shared Room and bathroom for Resident #1 and #41 on 3/10/25 at 11:50 AM, revealed the following: a. a 7.5 oz bottle of foaming bodywash on the nightstand near the television. b. a teal bath basin on floor in bathroom, a graduate dispenser on back of toilet in the bathroom, a denture cup with a silver toothbrush and white toothbrush resting on the inside, and 2 teal wash basins in the bathtub, all unlabeled and uncontained. 5. Observations in the shared room and bathroom for Resident #7 and #24 on 3/10/25 at 11:45 AM, revealed the following: a. a bottle of Glade Air Freshener sitting on the window seal. b. a teal bed pain on the grab bar next to the toilet, unlabeled and uncontained. c. a 7.5 oz bottle of skin cleanser. d. a 7.5 oz bottle of foaming body wash. e. a white and a blue toothbrush inside of a clear plastic cup on top of the sink. 6. Observation in Resident #53's room on 3/10/25 at 4:13 PM, revealed a clear plastic spray bottle sitting in the window seal of the room labeled White Powder 7. During an interview on 3/10/2025 at 4:09 PM, Licensed Practical Nurse (LPN) R confirmed that no chemicals such as air fresheners should be left out in resident rooms, they should be secured in the nurses' medication cart or the medication room. LPN R confirmed that all personal items such as denture cups, bed pans, urinals, graduate dispensers, wash basins should be cleaned, labeled with their name and then stored in a plastic bag and put in the resident's drawer until they are needed. During an interview on 3/10/2025 at 3/12/25 at 5:24 PM, the Director of Nursing (DON) confirmed that all medical personal items such as bed pans, wash basins, urinals, graduate dispensers, denture cups, should be labeled, covered, and stored in the bottom drawer of the residents bedside night stand or left in the bathroom but they must be labeled and contained, and items such as air fresheners, facial cleansers, should not be left in resident's room unsecured but should be locked on the medication cart or in the medication room until they are needed. The DON confirmed the facility does have residents who wander into other resident's room and that some residents have a STOP sign across their doorway to deter wandering residents from entering their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to develop and implement a person-centered care plan for 4 of 7 (Resident #1, #2, #4, and #7) sampled residents reviewed. The facility failed to designate the number of staff required to provide physical assistance which resulted in inconsistent care and negative outcomes. The findings include: Review of the facility policy titled, Patient Rights, revised February 2023, revealed, .Your plan of care will be developed to address physical and psychosocial areas where you and your health care team have concerns .The ultimate goal is to assist you to achieve and/or maintain the highest level of functioning possible within the limits set by your medical condition . A written plan of care is developed for you individually . Review of the facility's policy titled, Falls Assessment Process, dated October 2022, revealed .Care plan should include appropriate interventions, proactive approaches to prevent falls, and be individualized to the patient . Review of the medical record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Pressure Ulcer of sacral region Stage 3, encounter for Palliative care, unspecified Atrial fibrillation, Long term (current) use of anticoagulants, Osteoarthritis, and presence of cardiac pacemaker. Review of the Current Comprehensive Care Plan dated 10/24/2022 for Resident #1 revealed, .Terminal Diagnosis/Hospice .notify Hospice of any changes in their condition .I have left sided Hemiplegia .assist with daily cares as needed .at risk for falling R/T [related to] HX [history] of hemiplegia of the left side, weakness, decreased mobility and stiffness .at risk for skin breakdown .MAY HAVE A PRESSURE REDUCING DEVICE IN BED AS TOLERATED .Activities of Daily Living limited ability to perform self-care .I NEED TOTAL ASSIST X 1-2 WITH MY ADLS .Edited by [MDS Coordinator] .Side rails for mobility ¼ x2 .Created : 5/8/2023 .' Resident #1's Care Plan dated 10/24/2022 did not specify how/when to determine if 1- or 2 -person TOTAL ASSISTANCE with ADLS was required. On 9/3/2023, Resident #1 fell out of bed and sustained a compression fracture of T5- Thoracic Vertebrae while receiving one-person assistance with personal care from CNA #10. Review of MDS Progress Note dated 7/14/2023 for Resident #1 revealed, .DURING RESIDENT LOOK BACK PERIOD FOR ASSESSMENT, STAFF INTERVIEW WAS PERFORMED, RESIDENT IS NOT ABLE TO AMBULATE. RESIDENT STAYS IN BED PER CHOICE. RESIDENT DOES NEED TOTAL ASSIT x1 WITH HER ADLS Now . signed by MDS Coordinator. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated Resident #1 was cognitively intact. Total dependence with one-person assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. Review of the Nursing Progress Note dated 9/3/2023 at 7:55 PM for Resident #1 revealed, the Assistant Director of Nursing (ADON) #1 phoned Family Member #1 .about concerns r/t [related to] to [sic] resident's fall earlier this shift. Resident will be a 2 person [assist] for all ADLs [Activities of Daily Living] going forward. During a phone interview on 9/19/2023 at 8:10 PM, CNA #10 stated she was .never shown how .to look up resident care plans on the computer. During an interview on 9/26/2023 at 3:00PM, Resident #1 was asked since your fall how many staff come in to assist with your care? Resident #1 stated One. Resident #1 asked since your fall have two staff members assisted with your care? Resident #1 stated Sometimes Resident #1 was asked do you feel safe. Resident#1 stated, No I don't feel safe Resident was asked to explain why she didn't feel safe? Resident replied, still one person helping. Review of the medical record revealed Resident #2 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included diseases of the gallbladder, unspecified Dementia, unspecified Diastolic (congestive) Heart Failure, Paroxysmal Atrial Fibrillation, disorder of adrenal gland, unspecified convulsions, Muscle weakness (generalized), Difficulty in Walking, and Depression. Resident #2 was discharged on 6/30/2023. Review of the Care Plan dated 6/12/2023 for Resident #2 revealed, .I am at risk for falling R/T Muscle weakness .ADLs Functional Status/Rehabilitation Potential .Assist with bath, shower as needed .assist with personal items for hygiene .assist with transfers, bed mobility .I NEED . EXTENSIVE ASSIST X1-2 WITH BED MOBILITY, DRESSING, TOILETING, AND HYGIENE, TOTAL ASSIST X1-2 WITH BATHING . Resident #2's Care Plan dated 6/12/2023 did not specify how/when to determine if 1-or 2-person EXTENSIVE ASSISTANCE or TOTAL ASSISTANCE was required. Review of Discharge MDS assessment dated [DATE] for Resident #2 revealed a BIMS score of four (4) which indicated severe cognitive impairment. Resident #2 required total dependence with bathing, extensive assistance with toilet use, personal hygiene, limited assistance with bed mobility, transfer, dressing, toileting, supervision with eating, and a history of two or more falls without injuries. Review of the Medical Record revealed Resident #4 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Hypertensive Heart Disease, Urinary Tract Infection, Old Myocardial Infarction, Atherosclerotic Heart Disease, Paroxysmal Atrial Fibrillation, History of falling, and personal history of Transient Ischemic Attack. Review of he Quarterly MDS assessment dated [DATE] for Resident #4 revealed a BIMS score of fifteen (15) which indicated resident was cognitively intact. Resident #4 required total dependence with one-person physical assist for transfer, bathing, extensive assistance with one-person physical assist for bed mobility, dressing, toilet use, personal hygiene, and supervision with eating. Review of the Care Plan dated 8/17/2023 for Resident #4 revealed, .I am at risk for falling R/T Muscle weakness, hx [history]of falls .Activities of Daily Living: Limited ability to perform self-care .May use Hoyer lift as tolerated .I NEED EXTENSIVE ASSIST X1-2 WITH MY ADLS .TOTAL ASSIST X1-2 WITH BATHING AND TRANSFERS . Resident #4's Care Plan dated 8/17/2023 did not specify how/when to determine if 1-or 2-person EXTENSIVE ASSISTANCE or TOTAL ASSISTANCE was required. During an observation and interview on 9/12/2023 at 1:40 PM, Resident #4 was asked how many staff assist with her care. Resident #4 stated It depends usually it is one, sometimes two. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic neuropathy, Alcohol dependence, other symptoms and signs involving the Musculoskeletal System, Chronic pain, Essential (primary) Hypertension, Benign Paroxysmal Vertigo, other Lack of coordination, Ataxic Gait, Muscle Weakness (generalized), and history of falling. Review of the Annual MDS assessment dated [DATE] for Resident #7 revealed a BIMS score of fourteen (14) which indicated cognitively intact. Resident #7 required Extensive assistance with two plus person physical assist for bed mobility, transfer, total dependence with one-person physical assist for toilet use, bathing, extensive assistance with one-person physical assist for dressing, personal hygiene, supervision setup help only for eating, and no history of falls since admission. Review of the Care Plan for Resident #7 dated 8/7/2023, revealed a plan of care developed to address .at risk for falling R/T Muscle weakness .which included interventions .fall mats .Keep bed in lowest position with brakes locked .low bed . a plan of care developed to address .TRANSFERS, AND DRESSING X1 .TOTAL ASSIST X1-2 WITH TOILETING AND BATHING . Resident #7's Care Plan dated 8/7/2023 did not specify how/when to determine if 1-or 2-person EXTENSIVE ASSISTANCE or TOTAL ASSISTANCE was required. During an interview on 9/27/2023 at 12:30 PM, Resident #7 was asked how many staff assist with care and transfers. Resident 7 stated . I am supposed to be a two person assist .most of the time it is one-person assisting . During a phone interview on 9/15/2023 at 9:09 AM, the MDS Coordinator stated she has worked at the facility for approximately seven (7) years. The MDS Coordinator was asked how to determine the amount of assistance a resident requires with ADL care. The MDS Coordinator stated, I do a 7-day look back period, review CNA documentation of ADL Care, review the medical record, interview the staff, and interview the resident. If I find a discrepancy, I will assess the resident . During a phone interview on 9/19/2023 at 8:10 PM, CNA #10 stated she was .never shown how . to look up resident care plans on the computer. During an interview on 9/27/2023 at 10:30 AM, the Physical Therapy [PT] Assistant was asked how you determine if a resident needs one (1) or two (2) person assistance with ADL care. The PT Assistant responded it is determined on an individual case-by-case basis taking into consideration staff strength, size, resident strength, size, what activity is about to happen, how has the resident been feeling that day, and if resident is a large person .I would ask for help. The PT assistant stated, .The first consideration is patient and staff safety based on the individual activity and can vary from minute to minute . During an interview on 9/28/2023 at 3:05 PM, The DON was asked how CNAs determine whether to use one or two staff during ADL care when the care plan intervention states 1-2 person assist. The DON stated .The CNA is going to go on how the resident is feeling, acting, if in pain, if sick, if acute illness, if the resident is unable to help them turn, struggling with movements, and increased pain with movements. My expectation is the CNA is to observe and ask questions of the resident or other staff to determine if assistance is needed with ADL care . When asked how you know that the appropriate number of staff are used during resident ADL care for example if a resident is a 2 person assist. The DON answered, .For residents requiring 2-persons assist the staff usually uses the mechanical lifts and two persons are required to use a mechanical lift per manufacture's recommendation . The DON was asked is there evidence to show that one- or two-person assist was provided with ADL care. The DON responded, .The only evidence we have would be the CNA documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to assess, and document fall risk factors for 3 of 7 (Resident #1, #6, and #7) residents reviewed. The facility failed to provide seventy-two (72) hour post fall assessment and monitoring documentation for 4 of 7 (Resident #1, #2, #3, and #4) residents reviewed. The findings include: Review of facility's policy titled, Fall Prevention Program, reviewed May 2021, revealed .[Named Facility Corporation] is committed to eradicating falls when possible and reducing all injury related to falls .takes person-centered approach to falls prevention. Comprehensive assessment and root cause analysis are two very important tools in the prevention of falls and the recurrence of falls .Each center has a Falls Committee which monitors falls .utilizes data to systemically address falls . Review of facility's policy titled, Fall Response (After a Fall) dated October 2022, revealed .Evaluate and Observe Patient for 72 hours After the Fall .monitor the patient for 72 hours after the fall .This begins with the nurse completing the Fall Event in the EHR .Record circumstance and patient outcome .This can be captured in the falls event or in a progress note .Implement immediate intervention .an immediate intervention should be put in place by the nurse ideally during the same shift that the fall occurred. Ideally, focused on the root cause of the fall .Complete Falls Assessment .during the immediate patient evaluation (Falls Event) and increased observation (progress note), it may be relevant for a more in-depth assessment .Develop Plan of Care .Results of the Falls Assessment, along with any orders, interventions, should be used by the interdisciplinary team to develop/revise the falls care plan .Observe for Staff Compliance and Patient Response .While the falls care plan may include potentially effective interventions, it is staff compliance that will reduce fall risk. Observing for staff follow-through on the unit is necessary one the care plan has been developed/revised . Review of the facility's policy titled, Falls Assessment Process, dated October 2022, revealed .Patients are assessed based on risk factors and history .assessment begins prior to the patient being admitted .Patient assessed via [Named Fall Assessment] in EHR [Electronic Health Record] on admission, quarterly, and with significant change of status to ensure current risk has not changed and that individualized interventions are meeting the goal . Review of the facility's policy titled, Culture of Safety, dated October 2022, .The term culture of safety is used to describe how the behavior of the center partners affects the safety of patients. The development of a culture of safety is an important step to ensure that fall prevention is the center is effective and integrated into the culture .Developing a culture of safety requires strong center leadership, effective communication across all disciplines and all shifts, fall prevention process accountability, and the development of a multidisciplinary Fall Prevention Team to manage the program and address area for improvement. Educate partners on Fall Management Process .An open style of communication indicates that the center leadership team supports discussion about patient safety, and direct are partners are encouraged to report full details of unsafe conditions without fear of punishment. Communication should be built on trust and clear expectation of performance .Partners should not be blamed or shamed when a patient falls; but rather the system failure should be examined using a team approach . Review of the facility policy titled, Patient Rights, revised February 2023, revealed, .we support the patient/resident's right to live in an environment which is individualized for them .We strive to create a health promotion environment supporting the adoption of attitudes that contribute to positive well-being and providing information, activities and services designed to support healthy lifestyle choices for our patient .The Center agrees to offer services including but not limited to .professional nursing services . Review of facility's policy titled, Incident and Accident Process, reviewed March 2023, revealed .An incident or accident is defined as any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient .All patient incidents should be documented in the EHR [Electronic Health Record] .When any incident results in injury .they must be reported to clinical risk management .The DON [Director of Nursing] should review all incidents for accuracy and complete documentation .Review EHR documentation for all patient incidents . Review of the medical record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Hypertensive chronic kidney disease, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Pressure Ulcer of sacral region Stage 3, encounter for Palliative care, unspecified Atrial fibrillation, Long term (current) use of anticoagulants, Osteoarthritis, and presence of cardiac pacemaker. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated resident was cognitively intact. Resident #1 required extensive assistance with 2- person assist for bed mobility, extensive assistance with one-person physical assistance for dressing, toilet use, personal hygiene, total dependence with one-person assist for bathing, no history of falls since admission, and on hospice care while a resident. There was no documentation in the medical record to show a Significant Change Fall Risk Assessment was completed for Resident #1. Review of Quarterly MDS assessment dated [DATE] for Resident #1 revealed a BIMS score of thirteen (13), which indicated resident was cognitively intact. Resident #1 total dependence with one-person assistance with bed mobility, dressing, eating, toilet use, personal hygiene, bathing, no history of falls since admission, and on hospice care while a resident. Review of the Nursing Progress Note dated 9/3/2023 at 4:00 PM (Recorded as late Entry on 9/3/2023 4:35 PM) for Resident #1 revealed, .around 1015am .resident's [Resident #1] assigned CNA[Certified Nursing Assistant] [CNA #10] said .resident [Resident #1] rolled out of bed, fell on the floor .[named Medical Doctor (MD)] ordered to send resident to hospital .Called ambulance for transport .Transported resident to stretcher and taken her out by 1130am . There was no documentation in the Medical Record to show Quarterly Fall Assessments were completed prior to Resident #1's Fall on 9/3/2023. There was no documentation in the Medical Record to show Resident #1 returned from the hospital after a fall on 9/3/2023. During an interview on 9/19/2023 at 1:30 PM, the Business Office Manager (BOM) stated Resident #1 was discharged on 9/3/2023 at 11:30 AM and re-admitted on [DATE] at 9:22 PM when Resident #1 returned from hospital ER visit. There was no documentation in the Medical Record to show Resident #1 was evaluated and observed post fall on 9/4/2023. During an interview on 9/11/2023 at 12:25 PM, the Director of Nursing (DON) was asked to provide the documentation of Resident #1's return from the hospital on 9/3/2023 and 9/4/2023 post fall documentation. The DON stated the documentation was not there. Review of the medical record revealed Resident #2 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included diseases of the gallbladder, unspecified Dementia, unspecified Diastolic (congestive) Heart Failure, Paroxysmal Atrial Fibrillation, disorder of adrenal gland, unspecified convulsions, Muscle weakness (generalized), Difficulty in Walking, and Depression. Resident #2 was discharged on 6/30/2023. Review of Nursing Progress Note dated 6/6/2023 AT 3:26 AM for Resident #2 revealed, .DURING ROUNDS CNA FOUND RESIDENT SITTING ON THE FLOOR OUTSIDE OF RESIDENTS BATHROOM . Review of Safety Events - Fall Report dated 6/6/2023 for Resident #2 revealed, .Event date 6/6/2023 at 3:42 AM .Fall .Type of Fall .found on floor .Location .Patient Room .The activity during the event was .Ambulating to/from bathroom .Was Fall Witnessed .No . Review of Nursing Progress Note dated 6/9/2023 at 9:41 AM for Resident #2 revealed, .Resident was noted to be yelling hey from her room. Upon entering room, CNA noted resident was sitting on the floor next to her bed . Review of Safety Events - Fall Report dated 6/9/2023 for Resident #2 revealed, .Event date 6/9/2023 at 9:48 AM .Fall .Type of Fall .self reported fall .Location .Patient Room .What was the patient doing just prior to fall .trying to get up to go to the bathroom .The activity during the event was .Ambulating to/from bathroom .Was Fall Witnessed .No . There was no documentation to show Resident #2 was evaluated and observed post fall (6/9/2023) from 6/10/2023 at 2:23 PM to 6/11/2023 at 3:38 PM. There was no documentation to show Resident #2 was evaluated and observed post fall (on 6/9/2023) from 6/11/2023 at 3:38 PM to 6/12/2023 at 5:14 PM. Review of Discharge MDS assessment dated [DATE] for Resident #2 revealed a BIMS score of four (4) which indicated severe cognitive impairment. Resident #2 required total dependence with bathing, extensive assistance with toilet use, personal hygiene, limited assistance with bed mobility, transfer, dressing, toileting, supervision with eating, and a history of two or more falls without injuries. Review of the Medical Record revealed Resident #3 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Chronic Systolic (congestive) Heart Failure, Type 2 Diabetes Mellitus with diabetic neuropathy, Myocardial Infarction type 2, Muscle Weakness (generalized), Paroxysmal Atrial Fibrillation, History of falling, and Depression. Review of Nursing Progress Note dated 7/22/2023 at 3:28 AM for Resident #3 revealed .Per resident report .[Resident #3] was attempting to get up from bed and held on to the bedside table .states [Resident #3] lost her balance, and pulled the bedside table with her . Review of Safety Events - Fall Report dated 7/22/2023 for Resident #3 revealed, .Event date 7/22/2023 at 10:20 PM .Fall .Type of Fall .Interrupted/stabilized Fall .What was the patient doing just prior to fall .reports to this RN [Registered Nurse] that she was attempting to get up .The activity during the event was .Transferring in/out of bed with wheels unlocked .Was Fall Witnessed .No . There was no documentation to show Resident #3 was evaluated and observed post fall (7/22/2023) from 7/23/2023 at 3:43 PM to 7/24/2023 at 10:59 PM. There was no documentation to show Resident #3 was evaluated and observed post fall (7/22/2023) from 7/24/2023 at 8:43 PM to 7/25/2023 at 10:40 PM. Review of the Medical Record revealed Resident #4 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Hypertensive Heart Disease, Urinary Tract Infection, Old Myocardial Infarction, Atherosclerotic Heart Disease, Paroxysmal Atrial Fibrillation, History of falling, and personal history of Transient Ischemic Attack. Review of the Quarterly MDS assessment dated [DATE] for Resident #4, revealed a BIMS score of fifteen (15) which indicated resident was cognitively intact. Resident #4 required total dependence with one-person physical assist for transfer, bathing, extensive assistance with one-person physical assist for bed mobility, dressing, toilet use, personal hygiene, and supervision with eating. Review of Nursing Progress Note dated 7/21/2023 at 7:15 PM for Resident #4 revealed, .At 6:05pm, resident yelling help .CNA checked .resident lying on the floor with her back on the floor beside the left side of bed .skin tear sustained on right elbow approx. [approximately] 2.5cm [centimeter] X [by] 1cm . Review of the Safety Events - Fall Report dated 7/21/2023 at 6:46 PM for Resident #4 revealed, .Event date 7/2/2023 at 6:46 PM .Fall from bed with right elbow skin tear .Type of Fall .Found on floor .Location of Fall .Patient Room .Was Fall Witnessed .No . There was no documentation to show Resident #4 was evaluated and observed post fall (7/21/2023) from 7/22/2023 at 3:33 PM to 7/26/2023 at 3:16 PM. Review of the medical record revealed Resident #6 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included Hydrocephalus, Malignant neoplasm of Cerebral Meninges, Cerebrovascular Disease, Other speech, and language deficits following Cerebral Infarction, Epilepsy, Encounter for Palliative Care, Muscle Weakness, Atrial Fibrillation, Depression, Anxiety Disorder, and History of falling. Review of the Safety Events - Fall Report dated 8/7/2023 for Resident #6 revealed, .Event date 8/7/2023 at 6:41 PM .fall hit head .Type of Fall .Found on floor .Location of Fall .Patient Room .What was the patient doing just prior to fall .GOING TO BATHROOM UNASSISTED .Was Fall Witnessed .No . Review of the Nursing Progress Note dated 8/7/2023 at 6:47 PM for Resident #6 revealed, .[Resident #6] .fell .trying to ambulate to the bathroom unassisted .hit her head on the dresser . Review of the Safety Events - Fall Report dated 8/14/2023 for Resident #6 revealed, .Event date 8/14/2023 at 1:48 PM .fall hit head .Type of Fall .Found on floor .Location of Fall .Patient Room .What was the patient doing just prior to fall .GOING TO BATHROOM UNASSISTED .Was Fall Witnessed .No . Review of Nursing Progress Note dated 8/14/2023 for Resident #6 revealed, .at 12:00 AM resident was calling out for help .nurse entered her room .observed resident sitting up on the floor at the end of her [Resident #6] bed . Review of admission MDS assessment dated [DATE] for Resident #6 revealed a BIMS score of fourteen (14) which indicated resident was cognitively intact. Resident #6 required total dependence with two plus person assist with bathing, extensive assistance with two plus person assist with bed mobility dressing, toileting, personal hygiene, limited assistance with one-person assist with transfer, supervision with set up only for eating. There was no documentation to show an admission Fall Assessment was completed for Resident #6 in the medical record. Review of Nursing Note dated 8/18/2023 at 10:00 PM for Resident #6 revealed, .Resident found .on floor in [Resident #6] room .Injury was quickly established .Resident was bleeding . Review of the Safety Events - Fall Report dated 8/18/2023 for Resident #6 revealed, .Event date 8/18/2023 at 9:10 PM .unwitnessed fall w[with]injury .fall hit head .Type of Fall .Found on floor .Location of Fall .Patient Room .he activity during the event was .getting up from bed .Was Fall Witnessed .No . Review of Significant Change MDS assessment dated [DATE] for Resident #6 revealed a BIMS score of twelve (12) which indicated resident was cognitively impaired. Resident #6 required total dependence with one-person assist for bathing, extensive assistance with one-person assist for bed mobility, limited assist with one-person assist for transfer, Extensive assistance with one-person assist for bed mobility dressing, toileting, personal hygiene, supervision with one-person assist for eating, and hospice care while a resident. There was no documentation to show a Significant Change Fall Assessment was completed for Resident #6. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with diabetic neuropathy, Alcohol dependence, other symptoms and signs involving the Musculoskeletal System, Chronic pain, Essential (primary) Hypertension, Benign Paroxysmal Vertigo, Lack of coordination, Ataxic Gait, Muscle Weakness (generalized), and History of falling. Review of the Annual MDS assessment dated [DATE] for Resident #7 revealed a BIMS score of fourteen (14) which indicated cognitively intact. Resident #7 required Extensive assistance with two plus person physical assist for bed mobility, transfer, total dependence with one-person physical assist for toilet use, bathing, extensive assistance with one-person physical assist for dressing, personal hygiene. Review of admission [Named Fall Assessment] dated 10/6/2021 for Resident #7 revealed, .High Risk for Falls . Review of the [Named Fall Assessment] dated 9/22/2023 for Resident #7 revealed, .Low Risk for Falls . There was no documentation to show Quarterly Fall Assessments were completed between 10/6/2021 and 9/22/2023. During an interview on 9/11/2023 at 12:25 PM, the DON was asked what is the expectation for incident documentation post falls? The DON stated the expectation is that the nurse documents a progress note or skilled nursing note, assessing the residents' pain, injury, and if applicable appearance of delayed injury every shift for 3 days after a fall. A fall event report must be completed. The DON was asked when are fall risk assessments completed for residents. The DON stated per policy on admission, when there is a change in the resident's condition, and quarterly. The DON stated the [Named Fall Risk Assessment] tool is used. The DON was asked where in the medical record are Quarterly Fall Assessments for Resident #1 and Resident #7. The DON stated the documentation was not there. During an interview on 9/19/2023 at 9:30 AM, the Assistant Director of Nursing (ADON) #1 was asked to provide the requested fall risk assessments for Residents #1, #6, and #7. The ADON #1 stated .I brought you what we had .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, document review, medical record review, observation, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 (Resident #5) residents reviewed. The findings include: Review of facility policy titled, Behavioral Health Services, revised 2/2023, revealed .The center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders . Review of facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 8/1/2001, revised on 2/1/2023, revealed .Abuse, Neglect, Misappropriation of Patient property and exploitation .will not be tolerated by anyone, including staff, patients .The patient has the right to be free from abuse, neglect .The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority .Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Physical Abuse: includes hitting, slapping, pinching and kicking .Neglect: the failure of the facility, its employees, or service providers to provided goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress .The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors. partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors .Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team with interventions and follow through designed to minimize the risk of conflict. Procedure The interventions .will include .Identification of patients whose personal histories render them at risk for abusing other patients or partners .Monitoring the patient for any changes that would trigger abusive behavior .Any patient event that is reported to any partner .will be considered an allegation of either abuse, neglect, misappropriation of patient property or exploitation if it meets any of the following criteria .Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others .Any complaint of the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or families or within their hearing distance .Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior .including room or staffing changes .Medical and emotional support will be made immediately available to any individual suffering either alleged abuse, neglect . Review of the facility policy titled, Patient Rights, revised February 2023, revealed, .we support the patient/resident's right to live in an environment which is individualized for them .honoring and supporting each patient's preferences, choices, values and beliefs. We strive to create a health promotion environment supporting the adoption of attitudes that contribute to positive well-being and providing information, activities and services designed to support healthy lifestyle choices for our patient .The Center agrees to offer services including but not limited to: room accommodations, food services, professional nursing services, social services, activities, physical therapy, occupational therapy, speech therapy, beauty and barber services, housekeeping and laundry services .Treatments ordered by the attending physician will be provided for patients in need of physical, speech, or occupational therapy, etc., provided proper reimbursement for charges is made. If a service needed is not available, the patient is not admitted to the facility or is transferred to a facility where the treatment or service is provided .Your plan of care will be developed to address physical and psychosocial areas where you and your health care team have concerns .The ultimate goal is to assist you to achieve and/or maintain the highest level of functioning possible within the limits set by your medical condition and your wishes regarding the plan. A written plan of care is developed for you individually .Behavior Issues: Patients are treated with courtesy and with respect for underlying causes that sometimes prompt unusual behavior. Neither psychoactive drug nor physical restraints will ever be used except as required to treat medical symptoms .upon physician's order and with the agreement of the patient .In an emergency consent may be waived for a short period of time .In the event you believe the Center is not meeting your needs, and efforts to remedy service concerns are unsuccessful, you agree to see relocation either to your home or other facility. Under certain circumstances, the center may initiate involuntary discharge planning .the center will assist in accomplishing relocation of the patient as smoothly as possible .the center may initiate involuntary discharge planning only under the following circumstances .the welfare of the patient cannot be met in the center .Non-payment by the patient or the appropriate third party payor .the health or safety of individuals in the center is threatened or endangered .Under these circumstances, the center will give the patient 30 days written notice except when the health or safety of individuals is endangered or when the transfer or discharge is required by the patient's urgent medical need or the patient has not resided in the center for at least 30 days .A patient is responsible for following the treatment plan recommended by the primary health practitioner .Refusal of Treatment The patient is responsible for consequences of refusal to follow recommended or the practitioner's instructions .If the patient chooses to refuse treatment it may be necessary for the patient and legal representative to document their understanding of the consequences of the refusal .the patient is responsible for following center rules and regulations affecting patient care and conduct .The patient is responsible for being considerate of the rights of other patients and center personnel, and for assisting in the control of noise, smoking . Review of facility document titled, JOB TITLE: Director of Social Services, dated 7/2/2008, revealed .Directly responsible to administrator .DUTIES .Specific duties are assigned at the discretion of the center administrator .Directly or indirectly responsible fo .Obtain accurate, relevant information to be used in determining appropriateness of placement .Serve as liaison with hospital, family and patient in coordinating admission or in assisting with alternative placement .Work as a member of an interdisciplinary team .Participate in patient care planning conference .Coordinate discharge planning as agreed upon by patient, family and care plan team .Maintain relationship with patient and family in order to facilitate early identification of potential problems .Identify and report trends or patterns of complaints to administrator and/or director of nurses .Keep appropriate written records of grievances, to whom reported, and how resolved .Manage difficult emotional customer situation . Review of an undated facility document titled, admission and Financial Agreement, revealed .AGREEMENT TERMINATION: This agreement can be terminated by Patient upon the giving of notice to the Center and this agreement can be terminated by Center upon the giving of 30 days' written notice to Patient, in accordance with the licensure laws of this state and applicable Medicare/Medicaid regulations . Review of facility document titled, Nursing Home Notice of Involuntary Transfer or Discharge, revised 4/2023, revealed .Reason for discharge or transfer .The nursing home says it cannot care for you. Your needs are too High .You make the nursing home unsafe for other people .You may endanger the health of other people in the nursing home .doctor must agree if the nursing home checks this box . Review of the facility's policy titled, TRANSFER/DISCHARGE, revised 2/2023, revealed .The center shall seek transfer or involuntary discharge of the patient only under circumstances allowed by State and Federal law. Involuntary transfers will follow guidelines provided by the State for assuring adequate patient protection . Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses which included Unspecified injury at C5 (Cervical Vertebrae) level of the cervical spinal cord, Unspecified injury at C6 level of cervical spinal cord, Fracture of neck, Hemiplegia, unspecified affecting left nondominant side, Depression, unspecified, Alcohol dependence, anxiety disorder, and Acute pain due to trauma. Review of the Level I Form Pre-admission screening and Resident Review dated 2/8/2023 for Resident #5 revealed, .mental health conditions that are diagnosed or suspected for this individual now or in the past .Major Depression .Anxiety Disorder .Trauma/Stress Related disorder .] Depression - mild or situational .Insomnia , combative and disruptive behavior .Does the Individual have a substance related disorder (abuse or dependency) Yes Alcohol .Summary of Findings Report .Recommendations for consideration by provider .you [Resident #5] were involved in a motor vehicle accident which resulted in multiple injuries .being in the hospital for 2 months .diagnosed with depression, anxiety, and post-traumatic stress disorder .No history of mental illness until after the accident in 2022 .recent symptoms and/or behaviors include excessive worry, fixation, aggression/verbal threats to others, and restlessness, and you recently struck a staff member .SYMPTOMS / BEHAVIORS .Interpersonal Behaviors .Serious difficulty interacting with others .current or within the past 30 days .Mental Health Symptoms .Physical threats with potential for harm) .current or within the past 30 days . Review of the Physician Order Report dated 7/21/2023-9/15/2023 for Resident #5 revealed, .7/21/2023 .Consult psych [psychiatric] .as needed . 8/24/2023 .gabapentin [nerve pain medication] .capsule .300 mg .2 caps [capsule] .Twice A Day .gabapentin capsule .300 mg .3 caps [capsule] .At Bedtime .oxycodone [Narcotic Pain Medication .tablet .5 mg .1 TAB .ADMINISTER 1 TAB EVERY 6 HOURS AS NEEDED FOR PAIN . Review of the Care Plan dated 7/21/2023 for Resident #5 revealed .Psychosocial Well-Being .Assist .with in-room services set-up (Internet Access, phone, cable .) .Follow Up visits with me [Social Services] to ensure adjustment .Behaviors; At risk for complications : I have a hx [history] of refusing medications .Approach at later time .assess behavior and try to determine cause .Assess for stressors in .environment .Mood Indicators and/or Changes in Mood evidenced by: PTSD .Offer mental health services / talk therapy / grief counseling Pain/Discomfort .MD referral as ordered . Review of the PL-C (PTSD [Post-Traumatic Stress Disorder] Checklist -Civilian Version dated 7/25/2023 for Resident #5 revealed .individual is considered to have screened positive if the sum of these items is 4 or greater .Score .6 .Level .Positiv . Review of Social Services Progress Note dated 7/25/2023 at 11:30 AM revealed .BIMS 15 .Visited with [named Resident #6] who was guarded .questioning why I wanted to see him . [Resident #5] stated I get it .I trust no one.[Resident #5] states .has PTSD from an extreme wreck .still has flashbacks or something .gets worked up .I asked .if [Resident #5 would] like to speak with a mental health professional .he said yes, I think that would help a lot .shared that with SW [Social Work] Director who will set up services . Review of the admission MDS assessment dated [DATE] for Resident #5 revealed a BIMS score of fifteen (15) which indicated resident was cognitively intact. Resident #5 with active diagnoses of Anxiety Disorder, Depression. Review of Social Services Progress Note dated 7/31/2023 at 12:03 PM for Resident #5 revealed, . [Named Resident #5] voiced interested in Psych [Psychiatric] Services .signed the consent .Referral emailed . Review of PATIENT CONSENT dated 7/31/2023 for Resident #5 revealed, .Consent for Mental Health Treatment: I have been fully informed and understand the nature of the mental health care serves provided by [Named Provider] . signed by Resident #5 and Director of Social Services on 7/31/2023. Review of Physician's Order for Psychological Services dated 7/31/2023 for Resident #5 revealed, .REQUESTED SERVICES .Psychological Evaluation .Counseling/Psychotherapy/Behavioral Tx [treatment] .REASONS FOR REFERRAL .Adjustment Difficulties .Loss of physical function or Independence .Change in self Image/worth .Difficulty adapting to placement signed by Medical Doctor (MD) on 7/31/2023. Review of Nursing Progress Note dated 8/7/2023 at 5:00 AM for Resident #5 revealed, .Resident throws water pitcher and personal items at Techs before care. Resident refused care X2. Resident yells at Techs . Review of the Social Services Progress Note dated 8/9/2023 at 4:48 PM for Resident #5 revealed, .[Named Resident #5] .said I'm not happy here. SS [Social Services] asked why .[Named Resident #5] said lots of things .offered to send referrals to other centers . Review of the Nursing Progress Note dated 8/12/2023 at 5:23 PM for Resident #5 revealed, .around 0915 [9:15 AM], CNT [Certified Nursing Tech] reported .[Resident #5] was sitting on the floor demanding her [CNT] to get [Resident #5] up then started being verbally abusive and kicking his room door closed. Upon entering the resident's room, he was sitting on the floor .when asked if he fell, the resident began cursing and demanding to just get him up .telling .how he wanted to be picked up .to do it right now .Once .assisted resident to wc [wheelchair] .resident kicked his room door closed . Review of the Nursing Progress Noted date 8/13/2023 at 7:45 PM for Resident #5 revealed, .LPN enters resident's room to give .medications. Resident instantly curses indirectly to LPN [Licensed Practical Nurse] Resident angry because .wasn't picked up yet .Resident cursed and yelled at her [LPN] .Resident cont [continued] to yell loudly and curse indirectly to LPN .Resident anxiety increase as he yells and curses . Review of the Nursing Progress Note dated 8/20/2023 at 2:28 PM for Resident #5 revealed, .The pills were placed in [Resident #5's] hand .he threw the cup .the nurse picked up the pills .Resident then yells What is wrong with you, you fucking bitch? You are the one that was talking crazy to my girlfriend. You don't fucking talk that way to my girlfriend, I will have come up here and spit in your face . Review of the Social Services Progress Note dated 8/22/2023 at 10:37 AM (Recorded as Last Entry on 8/22/2023 at 9:51 AM for Resident #5 revealed, .SS/DON/Administrator need to follow-up on multiple staff concerns regarding [Named Resident #5] .Other patients/residents, family members have also voiced complaints about [Named Resident #5's] behavior, as he tends to move around the center in his wheelchair, loudly yelling/screaming at and cursing staff . Review of the Nursing Progress Note dated 8/21/2023 at 5:19 PM for Resident #5 revealed, . Pt came out of room stating loudly demanding to talk to the administrator immediately because the tech was not doing his range of motion correctly .he again became agitated and shouted over me .this is not ROM [Range of Motion] he then grabbed my wrist and began trying to reposition it on his am . Review of the Social Services Progress Note dated 8/22/2023 at 10:10 AM for Resident #5 revealed, .Per DON [Named Resident #5] had more instances of poor treatment of staff overnight. Administrator made aware . Review of Nursing Progress Note dated 8/22/2023 at 10:13 AM for Resident #5 revealed, .AT APPROXIMATELY 935 AM YESTERDAY, THIS WRITER [ADON#2] ACCOMPANIED BY THE ADMINISTRATOR AND SS MET WITH [Named Resident #5] .REGARDING HIS BEHAVIOR AND HOW HE IS ESCALATING NOW WITH THREATENING THE STAFF AND PHYSICALLY PUTTING HIS HANDS ON A NURSE. HE WAS INFORMED THAT NONE OF HIS BEHAVIORS WERE ACCEPTABLE AND IF SUCH BEHAVIORS CONTINUED, THAT HE WOULD HAVE TO LOOK FOR ALTERNATE PLACEMENT AS HE IS NOT APPROPRIATE IN THIS SETTING IF HE IS GOING TO CONTINUE TO BE VERBALLY AND PHYSICALLY ABUSIVE TOWARDS THE STAFF . Review of Nursing Progress Note dated 9/8/2023 at 2:39 PM for Resident #5 revealed, .Resident had two positive covid tests this morning at 8am . Review of Social Services Progress Note dated 9/8/2023 for Resident #5 revealed, .SS [Social Services] was informed around 4:10 PM that [Named Resident #5] was in the hallway near the DON's office, yelling at staff .[named staff] had been successful getting [named Resident #5] to his room, he was refusing to close his door .[named staff] wrote up a statement saying that [Resident #5 threw the PPE [Personal Protective Equipment] at her [named staff] . Review of Nursing Progress Note dated 9/11/2023 at 11:30 PM for Resident #5 revealed, AROUND 1940 (7:40 PM) .NURSE ENTERED RESIDENT ROOM. RESIDENT BEGAN YELLING .RESIDENT CONTINUED TO YELL, THREAENING TO PUNCH HOLES IN THE WALLS CURSING AT THIS NURSE TO FUCKING CALL THE DON . Review of facility email communication between Social Services Director and Mental Health provider dated 9/15/2023 at 9:47 AM revealed, Hey - I need to chat about [Named Resident #5]. He's the one who you mentioned doesn't have insurance coverage for Psych Services. Would you be willing to do one Pro bono visit with him? He is a VERY difficult man .Ombudsman and the state are involved .We think he has undiagnosed PDs [Personality Disorders] - narcissistic/borderline-something .State is asking for psych notes. Please let me know your thoughts . Response from Mental Health Provider revealed, .I will do an interview on Wednesday when I am in .If we need to chat about [Named Resident #5], just call me . Review of the Nursing Progress Note dated 9/15/2023 at 9:47 PM for Resident #5 revealed, An officer entered the premises stated that he was responding to a call made from the facility. He was requesting to speak with [Resident #5] regarding his call to 911 . Review of the Psychiatric Evaluation dated 9/20/2023 for Resident #5 revealed, .Reason for Visit loss of Independence, Oppositional, Non-Compliant .Diagnosis .Major Depression, unspecified .Anxiety Disorder, unspecified .Paranoid Personality Disorder with narcissistic features .Treatment Recommendations .Individual Psychotherapy .Rationale for Treatment selection: Problems w[with]/social interactions .Prognosis .fair . During an Observation and interview on 9/7/2023 at 4:45 PM, Resident #5 was asked to describe his care at the facility. Resident #5 stated It's terrible look at this fucking room it needs cleaned, I found roaches, there is no fucking clean linens, I am about to go crazy staying in this fucking room. Resident #5 voice became louder as he became more agitated talking about multiple complaints in staff, care, and Administration. Review of the medical record revealed Resident #11 was admitted on [DATE] with diagnoses which included Epilepsy, Generalized Anxiety Disorder, Pseudobulbar Affect, Tinnitus, bilateral, Neurofibromatosis, and Essential (primary) Hypertension. Review of the Quarterly MDS assessment dated [DATE] for Resident #11 revealed, a BIMS score of 8 which indicated cognitive impairment. During observation and interview on 9/18/23 at 5:30 PM, at the fourth-floor nurses desk observed Resident #11 dressed sitting next to nurses' desk. Resident #11 motioned for this surveyor to come closer. Resident #11 stated Can I talk to you? The Surveyor replied yes and Resident #1 ambulated with walker to his room. (Resident #11's room is next to Resident #5's room on the same side of the hall.) Loud rock music can be heard coming from Resident #5's room. Resident #11 stated Hear that? It happens a lot and late into the night. [Resident #5] yells bad words at the staff and does not belong here. (Resident #5) is crazy and needs the mental hospital. Resident #11 asked if he has reported it to Administration It won't do no good. The police have been out here. Resident #11 asked if he was afraid. Resident #11 said no. When asked if he wanted another room that is quieter Resident #11 stated No I will be leaving here soon. Provided resident with Ombudsman contact information, encouraged Resident #11 to report any further issues to the nurse and administration . Review of the medical record revealed Resident #8 was admitted to on 8/11/2023 with diagnoses which included Urinary Tract Infection, spastic quadriplegic cerebral palsy, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, and Type 2 Diabetes Mellitus. Review of admission MDS assessment dated [DATE] for Resident #8 revealed, a BIMS score of 14, which indicated cognitively intact. During an observation and interview on 9/26/2023 at 10:01 AM on the 4th floor, Resident #8 stated .Can't you do anything about [Named Resident #5]? [Resident #5] treats the nurses here awful and cusses them like dogs, plays loud rock music, always yelling and cussing. Some of the staff and residents are afraid of [Resident #5] Resident #8 was asked if she reported this to anyone. Resident #8 stated I don't have to report it they all know about it the other night he had the police up here. Something needs to be done. Resident #8 asked if she felt safe. Resident #8 stated I am not afraid of him (Resident #5). Resident #8 encouraged to report concerns to administration and staff and surveyor would investigate the matter. During an interview on 9/20/23 at 9:00 AM the Interim Administrator was asked about Resident #5 phone call to the police. The Interim Administrator stated Around 10:00 PM I called the facility asked where the police were in the building. I asked to speak with the police. I said I understand we had a resident call the police. The office stated [Resident #5] was just angry with no specific complaint. During an interview on 9/26/2023 at 12:13 PM the Social Services Director with the DON present was asked about Resident #5 mental health services request. The Social Services Director stated [Named Resident #5] signed a consent for psychological services on 7/31/2023 .the MD signed an order .I faxed the consent, order, and resident's face sheet to [Named Mental Health Provider] .I talked to [Named Mental Health Provider] on approximately 8/9/2023 in reference to Resident #5 .[Named Mental Health Provider] stated he had not seen the resident due to not having a payer source .I told [Named Mental Health Provider] patient had Medicaid . The DON stated Last week when [Named Mental Health Provider] was at the facility he stated he did not have a Medicaid number for [Named Resident #5] and that [Named Resident #5] had not been seen sooner because he [Mental Health Provider] didn't think he had insurance . The Social Services Director was asked why the request for Resident #5 to receive mental health services was not followed up on sooner. The Social Services Director stated, I think because we have been busy in survival mode addressing behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on hospice agreement review, facility document review, medical record review, observation, and interview, the facility failed to notify hospice of a fall with injuries and hospital transfer for 1 of 2 (Resident #1) hospice residents reviewed. The finding include: Review of the document titled [Named Hospice Agency] Annual Review of Agreement dated 9/4/2023 revealed .Facility shall immediately notify Hospice (1) in the event of significant changes, (physical , Mental, social, emotional changes) in the Hospice Patient's condition), (2) a clinical complication suggesting a need to alter the plan of care; (3) a need to transfer the patient .Facility agrees not to transfer any Hospice Patent to another care setting, including arranging for an ambulance or other transportation, without prior approval of Hospice .Hospice and Facility shall communicate with each other and document such communications to ensure that the needs of patients are addressed and met 24 hours a day.` There was no documentation of hospice notification by the facility of Resident #1's 9/3/2023 fall with injury and hospital transfer to the emergency room by ambulance. Review of facility's investigation document titled, Manager Investigation Sheet, for Resident #1 dated 9/3/2023, revealed .Fall w/ [with] injury Date: 9/3/2023 Time: 10:15 AM Location: Residnt's [sic, Resident's] room .Resident rolled off bed during care by agency cna .Witness .CNA: [Named CNA #10 .CONTRIBUTING FACTORS: DX [diagnoses] .Hemiplegia [paralysis] .Meds: hydrocodone [narcotic pain medication], metoprolol [high blood pressure medication .Plavix [blood thinner] .], BIMS[Brief Interview for Mental Status]: 13/15 [13 of 15 indicated cognitively intact] PREVIOUS FALL SCORE: 15 NEW FALL SCORE: 15 .CONCLUSION .: Resident rolled off side of bed when CNA stepped away from the bed to grab a care item from resident's dresser, Resident [sic] has zero control of body and fell off side of bed .Residnt [sic] was sent to [Named Hospital] Medical for eval. [ Noted fx [fracture] to back . Review of medical record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included hypertensive chronic kidney disease Stage 1 through stage 4 chronic kidney disease, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pressure ulcer of sacral region Stage 3, encounter for palliative care, unspecified Atrial fibrillation, long term (current) use of anticoagulants, Osteoarthritis, and presence of cardiac pacemaker. Review of the Care Plan dated 10/24/2022 for Resident #1 revealed a plan of care developed to address .Terminal Diagnosis/Hospice . which included interventions .notify Hospice of any changes in their condition . a plan of care developed to address at risk for complications I have left sided Hemiplegia with interventions to include assist with daily cares as needed . Review of Quarterly MDS assessment dated [DATE] for Resident #1 revealed, a BIMS score of thirteen (13) which indicated cognitively intact. Review of the Nursing Progress Note dated 9/3/2023 at 4:00 PM (Recorded as late Entry on 9/3/2023 4:35 PM) for Resident #1 revealed, .around 1015am .resident's [Resident #1] assigned CNA [CNA #10] said when she placed [Resident #1] on left side lying during cares and CNA [CNA] #10 went away to grab something on the dresser . [Resident #1]rolled out of bed, fell on the floor .found [Resident #1]on her back on the floor on the left side of the bed .Resident [Resident #1] alert saying she is hurt on her head, shoulder and back. Skin tear on right wrist 11cmx5cm and left calf 5cmx4cm. Resident said she hit the right side of her head on the floor, no injury on head seen immediately .few minutes after small blood oozing on an open wound approximately 0.5cmx0.5cm .some redness where [Resident#1] was lying .[Resident #1] hoyered [Hoyer lift used] CNAX2 back in bed .[Named MD] ordered to send resident to hospital .Called ambulance for transport .Ambulance EMT [Emergency Medical Technician] X2 arrived within 20 min. Transported resident to stretcher and taken her out by 1130am .Given [Resident #1] hydrocodone as per order .pain . Review of document titled [Named] County EMS Physician Certification Statement, dated 9/3/2023 revealed, .[Named Resident #1] .TRANSPORT DATE: 9/3/2023 .Back to Facility .why being transported by other is contraindicated by the patient's condition: Bed-ridden .Is the patient Bed Confined .YES .If the patient is on Hospice, is this transport related to their terminal illness .No .Contractures fractures .Bed ridden . Review of [Named Hospital] Emergency Provider Report dated 9/3/2023 at 12:25 PM for Resident #1 revealed, .HPI [History of Present Illness] .Fall XXX[AGE] year-old female history of Hypertension, CVA [Cerebral Vascular Accident (Stroke)] with residual left-sided deficits who was rolled accidently out of bed by staff onto her right side, complaining of head injury, neck pain, upper back pain. Takes Plavix .COMPUTERIZED TOMOGRAPHY [CT] .edema [swelling] .CT .IMPRESSION: Acute appearing compression [breaks/cracks] forming of the T5 [Thoracic Vertebrae #5] .new in comparison to the prior study .partial trauma given bruising to the head .complaints of back pain .Discussed with patient, family given her age .status post stroke, bed-bound status .I do not believe she would be a good surgical candidate .patient is already on Hospice . During a phone interview on 9/7/2023 at 11:47 AM Family Member #1 stated that on 9/3/2023 Resident #1 fell from the bed when a CNA turned her during care. Family Member #1 stated she received a call around 10:30 AM from the facility stating [named Resident #1] had fallen out of bed .Family Member #1 stated Resident #1 has been on hospice a couple years now. Family Member #1 stated she called Hospice and was told since Resident #1 hit her head she should go to the hospital to get checked out. Family Member #1 requested Resident #1 be transported to [named Emergency Room] . During an observation and interview on 9/7/2023 at 4:00 PM in Resident #1's room, Resident #1 was observed lying on an alternating air pressure mattress, facial bruising noted around right eye, black and blue in color, dressing noted on Resident #1's right forearm and wrist .Resident #1 was asked what happened to her right eye and arm. Resident #1 replied I fell out of bed when a girl was giving me a bath . During an interview on 9/11/2023 at 4:45 PM, the DON was asked when the facility notified hospice of Resident #1's fall and transfer to the hospital. The DON stated Resident #1's POA notified hospice. During a phone interview on 9/12/2023 at 3:45 PM, the Hospice RN requested the Hospice RN Supervisor be added to the phone interview call. The Hospice RN stated no call was received from the facility staff about Resident #1's fall. The Hospice RN was asked if there was any documentation of facility notifying hospice of Resident #1's fall or transfer to the hospital. The Hospice RN stated no documented record of facility calling hospice about the incident and no hospital records shared with hospice. The Hospice Nurse Supervisor stated facilities are told to contact us with any situation involving a hospice resident, hospice should be called anytime anything is going on even after hours, the hospice after hours number is at the nurses desks, it is unusual to send a resident on hospice to the hospital, hospice residents are sent to the hospital if family requests it or in the case of an adverse event we will follow facility policy, an example would be a resident on blood thinners hits their head and facility policy is to send resident out for evaluation and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure the care plan was revised for 1 of 7 (Resident #1) sampled residents reviewed. The findings include: Review of the facility policy titled, Patient Care Policies, reviewed/revised 2/2023, revealed, The patient care plan process involves the entire inter-disciplinary team, including the patient and/or patient representative .The center will include the attending physician in the development of the patient's plan of care by incorporating the physician's plan of care (orders) into the care plan .The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side, and Vascular Dementia. Review of the progress notes for Resident #1, revealed, .1/26/2023 12:13 PM A SKIN ASSESSMENT WAS PERFORMED ON THE PATIENT THIS MORNING. RESIDENT NOTED TO HAVE ABRASION TO UPPER LEFT BUTTOCK, BILATERAL HEELS ARE RED BUT BLANCHABLE, AND THICK LAYERS OF SCABBED SKIN TO BILATERAL ANKLES. NP AND FAMILY WERE MADE AWARE WITH THE TREATMENT PLAN STARTED. THE PATIENT WAS admitted TO [NAME] HOSPICE LAST NIGHT AND A REQUEST WAS MADE FOR THE RESIDENT TO RECEIVE A SPECIALIZED MATTRESS. EDUCATED STAFF ON HOW TO MAINTAIN THE RESIDENT'S SKIN INTEGRITY . Review of the care plan revised on 1/26/2023 revealed there was no documentation in the care plan which addressed the abrasion to the upper left buttock. During a telephone interview on 5/10/2023 at 3:41 PM, the Minimum Data Set (MDS) Coordinator stated, I do a daily order check to see if any orders for wound care were written. I do not always attend the morning meetings, but the Wound Care Nurse would let me know about any new wounds for residents. An abrasion would not be included on the resident's MDS assessment. There was an MDS assessment dated [DATE] for significant change related to admission to hospice and the care plan was updated. The MDS Coordinator reviewed Resident #1's care plan and confirmed the actual abrasion wound was not care planned. The MDS Coordinator stated an abrasion would not be included on a MDS assessment but should be included in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to notify the resident's physician and/or the resident representative with changes in status for 4 of 6 (Resident #1, #2, #3, and #4) sampled residents reviewed for skin integrity/wounds. The findings include: Review of the facility policy titled, Patient Care Policies, reviewed/revised 2/2023, revealed, .The charge nurse on duty is notified immediately of any change in a patient's condition .The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's representative . Review of the facility policy titled, Communication, Skin Integrity Manual, reviewed 8/2021, revealed, .Physician .Notify on admission if new pressure ulcer is present and notify promptly of in-house development .Notify for lack of progress in wound healing . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side, and Vascular Dementia. Review of the Physician Order Report for Resident #1 revealed, .10/19/2022 .Barrier cream to buttocks BID [twice a day] for prevention .1/26/2023-2/28/2023 .Abrasion to left buttock: Cleanse area with wound cleanser, pat dry, apply skin barrier to peri wound, apply medihoney and cover with foam/hydrocolloid dressing once weekly and as needed until healed .1/26/2023-2/28/2023 .Bilateral Red Blanchable heels: Cleanse heels with soap and water, pat dry. Apply skin barrier cover with foam/hydrocolloid dressing and wrap with Coban [self-adhesive wrap] or kerlix [bandage roll]. Change weekly and as needed for protection . Continued review revealed wound treatment orders for abrasion to left buttock, and bilateral red blanchable heels were discontinued on 2/28/2023, and orders were added for Proheal Critical Care [protein supplement]. A stage 2 (pressure injury which is an open wound which expands to the deeper layers of the skin) to left buttock, unstageable (pressure injury which is covered by a layer of dead tissue) to right buttock, unstageable to bilateral heels, unstageable to right medial ankle, and unstageable left ankle. Review of the Medication Administration Record (MAR) for Resident #1, dated 1/1/2023-1/31/2023, revealed an order for barrier cream to buttocks BID [twice daily] was documented as administered twice a day as ordered without exception. Review of the progress notes for Resident #1 revealed, .1/26/2023 12:13 PM A SKIN ASSESSMENT WAS PERFORMED ON THE PATIENT THIS MORNING. RESIDENT NOTED TO HAVE ABRASION TO UPPER LEFT BUTTOCK, BILATERAL HEELS ARE RED BUT BLANCHABLE, AND THICK LAYERS OF SCABBED SKIN TO BILATERAL ANKLES. NP [Nurse Practitioner] AND FAMILY WERE MADE AWARE WITH THE TREATMENT PLAN STARTED. THE PATIENT WAS admitted TO [NAME] HOSPICE LAST NIGHT AND A REQUEST WAS MADE FOR THE RESIDENT TO RECEIVE A SPECIALIZED MATTRESS. EDUCATED STAFF ON HOW TO MAINTAIN THE RESIDENT'S SKIN INTEGRITY .02/17/2023 02:43 PM Nutrition .She [Resident #1] is noted to have an abrasion to her L [left] buttock that is stable .Food & Nutrition Service .3/2/2023 11:03 PM .Nutrition- Resident is noted to have multiple pressure injuries- Unstageable to L [left] ankle that is 5 x 5 [length by width] cm [centimeter] with slough [yellow/white material which consists of dead cells that accumulate in the wound bed], Stage 2 to R [right] heel up to lateral ankle 5 x 5 cm, unstageable to L heel 3 x 2.5 cm with slough, unstageable to R buttocks 7 x 3 cm with slough, and stage 2 to L buttock 1 x 1 cm. During an interview on 5/9/2023 at 11:10 AM, the Social Services Director (SSD) stated, A family member complained about not getting notified about [Resident #1]'s wounds . During an interview on 5/9/2023 at 12:36 PM, the Director of Nursing (DON) stated, Sometime around 2/20/2023 [Family Member #2] called and wanted to know why she wasn't told about [Resident #1]'s wound on her bottom .I did not go and put eyes on the wound at the time .Later [Family Member #2] wanted a meeting to look at the wound. I went and assessed the wound the day of the meeting [2/28/2023]. I found five wounds, one stage 2 [wound] and and one unstageable [wound] on the buttocks, one unstageable [wound] on the left ankle, a stage 2 [wound] on the right heel, and a stage 2 [wound] on the right ankle . The NP confirmed she was not aware of the wounds on [Resident #1]. During a telephone interview on 5/9/2023 at 1:58 PM, Family Member #1 stated, [ADON] told me [Resident #1] had a lot of dead skin on her heels .no one told me she [Resident #1] had all those wounds . During a telephone interview on 5/9/2023 at 2:37 PM, Family Member #2 stated, I came to the facility on 2/19/2023 .During my visit .I saw the wound on her bottom. I called [DON] the next day [2/20/2023] to find out why they had not told me about the wound .I wanted to see the wounds for myself. [Administrator] asked me if he could set up a meeting with [DON] on 2/28/2023 when she returned to work. I agreed to the meeting .It wasn't until the day of the meeting that anyone looked at [Resident #1]'s wounds. On 2/28/2023 [DON] started the meeting by saying that she had assessed [Resident #1]'s skin that day. During an interview on 5/9/2023 at 5:11 PM, the Administrator stated, [Family Member #2] came to the facility on 2/24/2023 and voiced concerns about [Resident #1] having a wound that she was not aware of, and she thought it was more than what she had been told. She wanted to see the wound. [Family Member #2] wanted to meet with the Wound Care Nurse and DON about [Resident #1]'s care. I told her that [DON] would not be back until 2/28/2023. I did not have anyone else look into the wound on [Resident #1]. I waited for [DON]. During a telephone interview on 5/10/2023 at 11:08 AM, Licensed Practical Nurse (LPN) #5 stated, I work for [Hospice Provider #1] and was assigned to [Resident #1]. I never provided wound care for [Resident #1], I got updates on [Resident #1]'s wounds from the nurse during my weekly visits. I did not see the wounds because someone had already completed wound care. The only orders for wound care were for an abrasion on her buttock and both heels as a preventative measure. I wasn't told about the open areas until [Family Member #2] told me she had seen the wound on [Resident #1] during incontinent care. During an interview on 5/10/2023 at 2:55 PM, Registered Nurse [RN] #2 reviewed a Certified Nursing Assistant [CNA] shower sheet skin assessment for Resident #1 dated 1/25/2023. RN #2 confirmed a CNA had documented an open area to Resident #1's right buttocks. RN #2 stated, I did not report the area to the wound care nurse or the NP . I know I did not document any changes or notifications. I never talked to the family about any changes . RN #2 confirmed that Professional Standards of Practice for nursing included proper assessment of wounds, with documentation of wound care or wound changes and notification of changes to the provider and family. During a telephone interview on 5/10/2023 at 2:31 PM, Hospice (Hospice Provider #1) CNA #2 stated, I was assigned to [Resident #1] in the facility. I provided bed baths to [Resident #1] during visits as part of care. There was a dressing on her bottom and both of her heels. The dressing was always in place, and I did not see skin area under the dressings .The dressings were dirty with foul smelling drainage on her bottom and heels. I reported [the dressings] to the hospice nurse and to the facility Wound Care Nurse that day. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease and Type 2 Diabetes Mellitus. Review of the Weekly Skin Assessment for Resident #2 revealed Licensed Practical Nurse [LPN] #6 documented a skin assessment on 1/31/2023 which included an open wound and red areas to the bilateral under arms, and excoriated, red and raw areas to the buttocks, thighs, and peri-area. LPN #6 documented a referral to wound care on 1/31/2023. LPN #1 documented a skin assessment on 2/8/2023 which included open wounds and red areas to the buttocks, under both arms, groin, and face. LPN #3 documented a skin assessment on 2/14/2023 which included open wounds and red areas to the buttocks, under both arms, groin, and face. Review of the progress notes for Resident #2, revealed, .01/31/2023 .Resident referred to Wound care nurse/ADON [Assistant Director of Nursing] to address alteration in skin integrity. Review of the Wound Management Detail Report for Resident #2, revealed on 3/1/2023 a stage 2 wound was noted on the left buttock which measured 1.5 cm long x 0.5 cm wide with bloody exudate (drainage) and another stage 2 wound on the left buttock which measured 0.4 cm long x 0.4 cm wide with bloody exudate (drainage). A stage 2 wound was noted on the right buttock which measured 2.5 cm long x 1.5 cm wide with no exudate. During an interview on 5/17/2023 at 11:25 AM, Family Member #3 stated, [DON] called me about the wound on [Resident #2] a few days before she died [ 3/8/2023]. [DON] said that she was going to change the treatment from the one the nurses had been doing. I told her I didn't even know about a wound. [Resident #2] complained about hurting on her bottom and I was told there would be an air mattress put in place to prevent wounds from forming. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction. Review of the Wound Management Detail Report for Resident #3, revealed, .3/1/2023 .Length 7 cm width 7 cm .exudate amount .moderate .exudate color and consistency .seropurulent [yellow or tan, cloudy, thick] .wound odor .FOUL .stage .Unstageable-Slough [dead cells], and/or Eschar [black, necrotic tissue] . During a telephone interview on 5/16/2023 at 5:20 PM, Family Member #4 stated, On 2/18/2023 I was visiting [Resident #3], and she complained about her bottom hurting. I called for the CNA [unable to recall the CNA's name] and assisted in holding [Resident #3] over on her side while the CNA changed her. I saw an open area on [Resident #3's] backside, and the CNA said there was a dressing, but it came off. I went to talk to the nurse about it, and she said she would replace the dressing. I talked to [previous ADON] about the area, and she did not have any knowledge of the wound. Someone had been putting a dressing on the wound, so someone knew about it. The next time I talked to anyone about the wound was when [DON] called and talked to me about changing the treatment for the wound, I believe that was in March [2023]. During an interview on 5/16/2023 at 5:40 PM, CNA #3 stated, I first started taking care of [Resident #3] when she moved to the 3rd floor in January [2023] or early February [2023]. [Resident #3] had a dressing on her bottom at that time. In February [2023] I was giving her a bath and the dressing on her bottom came off and had blood on it. I talked to [RN #2] about the blood on the dressing and [RN #2] told [previous ADON]. [previous ADON] came to the room and looked at the wound then put a dressing back on it. During a telephone interview on 5/22/2023 at 8:10 AM, CNA #6 stated, I started working here [Facility #1] on January 10, 2023, and [Resident #3] had a dressing on her bottom at that time. The area on [Resident #3]'s bottom was red, but it wasn't open. When the area opened in February [unable to recall exact date], I let [RN #7] know and she looked at it. During a telephone interview on 5/22/2023 at 8:18 AM, CNA #4 stated, I notified [RN #2] and [RN #7] about a wound on [Resident #3]'s bottom being open in February [2023] and was told they were aware of it. I also put the open area on a shower sheet, had the nurses sign it and turned it in to [previous ADON]. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Adult Failure to Thrive, and Muscle Weakness. Review of the Quarterly MDS assessment dated [DATE] Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Physician Order Report revealed Resident #4 did not have orders for intervention of dry flaky skin. RN #2 stated he would get a physician's order for interventions if skin issues were found during an assessment. Review of the Weekly Skin Assessment for Resident #4 revealed LPN #6 documented a skin assessment on 4/29/2023 which included dry, flaky skin on the bilateral lower extremities. RN #2 documented a skin assessment on 5/10/2023 which included dry, flaky skin on the bilateral lower extremities. Review of the progress notes for Resident #4, dated 4/29/2023-5/17/2023, revealed no documentation of notification to the NP/MD related to dry, flaky skin. During an interview on 5/17/2023 at 3:50 PM, the DON reviewed Resident #4's skin assessment dated [DATE] and Resident #4's Physician Order Report. The DON stated, I would expect the nurse to contact the NP and obtain an order for dry skin treatment if the skin assessment noted dry flaky skin. During an interview on 5/9/2023 at 12:36 PM, the DON stated, .I conducted facility wide skin sweep [audit] and found two other residents with wounds that were being treated without orders. The NP confirmed she was not aware of the wounds on [Resident #1, #2, and #3]. I looked at documentation and did not find any documents that identified the wounds on Resident #1, Resident #2, and Resident #3. I looked at orders, skin assessments, and progress notes and did not find any notes related to the wounds on the Residents [#1, #2, and #3] . During an interview on 5/16/2023 at 1:20 PM, NP #1 stated, .[DON] requested a consult for [Resident #1, #2, and #3]'s wounds on 3/6/2023, and that was the first time I was aware of the wounds on those residents. I do not consult for wounds unless nursing requests an evaluation. During a telephone interview on 5/16/2023 at 3:28 PM, the Medical Director stated, There is a NP in the facility for nursing to consult .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, personnel file review, and interview, the facility failed to ensure care and treatment consistent with professional standards of practice to promote healing and prevent new ulcers from developing for 3 of 3 (Resident #1, #2, and #3) sampled residents reviewed for pressure ulcers. The findings include: Review of the facility policy titled, Communication, Skin Integrity Manual, reviewed 8/2021, revealed, .Physician .Notify on admission if new pressure ulcer is present and notify promptly of in-house development .Notify for lack of progress in wound healing .Weekly Skin And Wound Assessments-Weekly assessments include type, stage or depth of tissue injury, location, and measurement of site (length, width, and depth) .Daily Pressure Ulcer Monitoring-when a pressure ulcer is present, daily monitoring will include .evaluation of ulcer if not dressing present .evaluation of status of dressing if present .status of the area surrounding the ulcer .presence of possible complications such as signs of increasing of area of ulceration .Weekly Wound Documentation .When a wound is present on a patient, the status of the wound should be documented weekly via the Wound Management or other process as designated by the regional nurse . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side, and Vascular Dementia. Review of the Physician Order Report for Resident #1 revealed, .10/19/2022 .Barrier cream to buttocks BID [twice a day] for prevention .1/26/2023-2/28/2023 .Abrasion to left buttock: Cleanse area with wound cleanser, pat dry, apply skin barrier to peri wound, apply medihoney and cover with foam/hydrocolloid dressing once weekly and as needed until healed .1/26/2023-2/28/2023 .Bilateral Red Blanchable heels: Cleanse heels with soap and water, pat dry. Apply skin barrier cover with foam/hydrocolloid dressing and wrap with Coban [self-adhesive wrap] or kerlix [bandage roll]. Change weekly and as needed for protection . Continued review revealed wound treatment orders for abrasion to left buttock, and bilateral red blanchable heels were discontinued on 2/28/2023, and orders were added for Proheal Critical Care [protein supplement]. A stage 2 (pressure injury which is an open wound which expands to the deeper layers of the skin) to left buttock, unstageable (pressure injury which is covered by a layer of dead tissue) to right buttock, unstageable to bilateral heels, unstageable to right medial ankle, and unstageable left ankle. Review of the Medication Administration Record (MAR) for Resident #1, dated 1/1/2023-1/31/2023, revealed an order for barrier cream to buttocks BID [twice daily] was documented as administered twice a day as ordered without exception. Review of the progress notes for Resident #1 revealed, .1/26/2023 12:13 PM A SKIN ASSESSMENT WAS PERFORMED ON THE PATIENT THIS MORNING. RESIDENT NOTED TO HAVE ABRASION TO UPPER LEFT BUTTOCK, BILATERAL HEELS ARE RED BUT BLANCHABLE, AND THICK LAYERS OF SCABBED SKIN TO BILATERAL ANKLES. NP [Nurse Practitioner] AND FAMILY WERE MADE AWARE WITH THE TREATMENT PLAN STARTED. THE PATIENT WAS admitted TO [NAME] HOSPICE LAST NIGHT AND A REQUEST WAS MADE FOR THE RESIDENT TO RECEIVE A SPECIALIZED MATTRESS. EDUCATED STAFF ON HOW TO MAINTAIN THE RESIDENT'S SKIN INTEGRITY .02/17/2023 02:43 PM Nutrition .She [Resident #1] is noted to have an abrasion to her L [left] buttock that is stable .Food & Nutrition Service .3/2/2023 11:03 PM .Nutrition- Resident is noted to have multiple pressure injuries- Unstageable to L [left] ankle that is 5 x 5 [length by width] cm [centimeter] with slough [yellow/white material which consists of dead cells that accumulate in the wound bed], Stage 2 to R [right] heel up to lateral ankle 5 x 5 cm, unstageable to L heel 3 x 2.5 cm with slough, unstageable to R buttocks 7 x 3 cm with slough, and stage 2 to L buttock 1 x 1 cm. There was no documentation for wound characteristics, changes, progress, and additional wounds in the progress notes dated 1/27/2023-2/27/2023 or any documentation provided by the facility (facility policy required weekly documentation of wounds). During an interview on 5/9/2023 at 12:36 PM, the Director of Nursing (DON) stated, Sometime around [2/20/2023] [Family Member #2] called and wanted to know why she wasn't told about [Resident #1]'s wound on her bottom. During that phone call, I called [ADON, also the Wound Care Nurse] and she assured me the wound was only an abrasion, and there was a treatment in place. I totally trusted [ADON], and I did not go and put eyes on the wound at the time. Later [Family Member #2] wanted a meeting to look at the wound. I went and assessed the wound the day of the meeting [2/28/2023]. I found 5 wounds, [1] a stage 2 and [2] an unstageable on the buttocks, [3] an unstageable on the left ankle, [4] a stage 2 on the right heel and [5] a stage 2 right ankle. There were treatment orders in place for the left buttocks and the heels. The treatments were prophylactic [intended to prevent disease] to prevent worsening of the wounds. Nurses were using the same order for all the wounds, no new orders existed for the other wounds. I investigated immediately and notified the Nurse Practitioner [NP] and obtained orders to treat the wounds. The Nurse Practitioner confirmed she was not aware of the wounds on [Resident #1] .The DON stated, [Family Member #1] admitted he knew about the abrasion [upper left buttock] on [Resident #1] during the 2/28/2023 meeting. He didn't understand that the abrasion was a wound. Review of the employee file for the previous ADON revealed, .Supervisory Adverse Action Notice .Employee Name [previous ADON] .Supervisor's Name [DON] .Date 3/1/23 .Supervisor's Statement of Incident: Multiple wounds on multiple patients identified [without] documentation and orders .Supervisor's Response to Employee's Correction Plan Above: Termination re: [re: concerning] failure to assess timely, failure to initiate treatments, treating without a physicians [physician's] order, failure to notify family and MD of wounds, failure to document timely . The document was signed by the DON and the previous ADON on 3/1/2023. During a telephone interview on 5/9/2023 at 1:58 PM, Family Member #1 stated, [ADON] told me [Resident #1] had alot of dead skin on her heels and had orders for ointment. [ADON] said there was an abrasion on one side of [Resident #1]'s bottom. I asked [ADON] if by abrasion she meant scratch, and [ADON] said no it was like something from laying still all the time. [ADON] told me there was a special mattress to help prevent the area from getting worse. No one told me she had all those wounds or that the abrasion was worse until my wife insisted she wasn't getting told the truth about the wounds. During a telephone interview on 5/9/2023 at 2:37 PM, Family Member #2 stated, I came to the facility on 2/19/2023. During my visit the tech took the brief off [Resident #1], and I saw the wound on her bottom. There wasn't a dressing on the wound so I went and asked the nurse if something should be on the wound. The nurse was an agency nurse and didn't know anything about the wound but said she would put something on it. I called [DON] the next day [2/20/2023] to find out why they had not told me about the wound. [DON] told me she spoke to the Wound Care Nurse and assured me it was an abrasion, and there was already a treatment in place. [DON] told me the Wound Care Nurse spoke to [Family Member #1] about the abrasion. After thinking about that conversation I tried to call [DON] back multiple times to question what I saw on [2/19/2023]. On [2/24/2023] I just went up to the facility to speak to the Administrator. I told him I felt like I had been lied to about [Resident #1]'s wound because what I saw was not just an abrasion. I told him that I wanted to see the wounds for myself. [Administrator] asked me if he could set up a meeting with [DON] on [2/28/2023] when she returned to work. I agreed to the meeting and assumed he would check to see if I was being told the truth before the meeting. In fact it wasn't until the day of the meeting that anyone looked at [Resident #1]'s wounds. On [2/28/2023] [DON] started the meeting by saying that she had assessed [Resident #1]'s skin that day. [DON] started crying and said, 'If you think her bottom looks bad, you should see her heels and ankles, they are horrific.' During an interview on 5/9/2023 at 5:11 PM, the Administrator stated, [Family Member #2] came to the facility on 2/24/2023 and voiced concerns about [Resident #1] having a wound that she was not aware of, and she thought it was more than what she had been told. She wanted to see the wound. [Family Member #2] wanted to meet with the Wound Care Nurse and DON about [Resident #1]'s care. I told her that [DON] would not be back until 2/29/2023. I did not have anyone else look into the wound on [Resident #1]. I waited for [DON]. During a telephone interview on 5/10/2023 at 8:15 AM, the previous ADON/Wound Care Nurse stated, I wrote the order for treatment for the left buttock abrasion and both heels when [Resident #1] was admitted to hospice [1/25/2023]. The hospice nurse [Registered Nurse-RN #8] notified the floor nurse [Licensed Practical Nurse-LPN #2] that there was a stage 2 on [Resident #1]'s bottom and needed skin prep to both heels. There was an order for barrier cream every day, twice a day, someone saw the change in [Resident #1]'s buttocks and did not report the change to me. I saw [Resident #1] the next day [1/26/2023] and wrote orders for a treatment for an abrasion on the left buttocks and preventative treatments for both heels. During a telephone interview on 5/10/2023 at 11:08 AM, LPN #5 stated, I work for [Hospice Provider #1] and was assigned to [Resident #1]. I never provided wound care for [Resident #1]. I got updates on [Resident #1]'s wounds from the nurse during my weekly visits. I did not see the wounds because someone had already completed wound care. The only orders for wound care were for an abrasion on her buttock and both heels as a preventative. I wasn't told about the open areas until [Family Member #2] told me she had seen the wound on [Resident #1] during incontinent care. Family Member #2 showed me pictures she took of the wounds on 2/19/2023. During a telephone interview on 5/10/2023 at 12:15 PM, Hospice (Hospice Provider #1) RN #8 stated, I admitted [Resident #1] to hospice services the evening of 1/25/2023. I completed a skin assessment as part of the admission process. I notified the floor nurse about a Stage 2 wound on the left buttocks and Deep Tissue Injuries [DTI]s on heels. I requested barrier cream on Stage 2 and skin prep for heels pending an evaluation by the facility Wound Care Nurse. The facility accepted full responsibility for the wound care. During a telephone interview on 5/10/2023 at 2:31 PM, Hospice (Hospice Provider #1) CNA #2 stated, I was assigned to [Resident #1] in the facility. I provided bed baths to [Resident #1] during visits as part of care. There was a dressing on her bottom and both of her heels. The dressings were always in place, and I did not see skin area under the dressings. I do not recall the exact date in February of the visit, but I came in, and there was a strong odor like feces in [Resident #1]'s room. I checked to see if [Resident #1] had a bowel movement, and she was clean. The dressings were dirty with foul smelling drainage on her bottom and heels. I reported the dirty dressings and foul odor to the hospice nurse and to the facility Wound Care Nurse that day. During an interview on 5/10/2023 at 2:55 PM, RN #2 reviewed a CNA shower sheet skin assessment for Resident #1 dated 1/25/2023. RN #2 confirmed the CNA #7 had documented an open area to Resident #1's right buttocks and the document was signed by him. RN #2 stated, I did not report the area to the Wound Care Nurse or the NP because there was already a treatment in place. RN #2 then reviewed Resident #1's MAR dated 1/2023 and confirmed the order on the MAR had a start date of 1/26/2023. RN #2 confirmed the MAR specified the left buttock abrasion, but there was not an order for a right buttock wound. During a telephone interview on 5/10/2023 at 3:30 PM, the facility Registered Dietitian (RD) stated, During the morning meetings the team discussed [Resident #1]'s weight loss and put interventions in place. I was unaware of any worsening wound issues for [Resident #1] until [DON] reported the new wounds [2/28/2023]. When I am notified of a resident's wounds worsening, I put orders in place for Proheal [protein supplement to promote wound healing]. During a telephone interview on 5/10/2023 at 3:41 PM, the Minimum Data Set (MDS) Coordinator stated, I do a daily order check to see if any orders for wound care were written. I do not always attend the morning meetings, but the Wound Care Nurse would let me know about any new wounds for residents. An abrasion would not be included on the resident's MDS assessment. There was an MDS assessment dated [DATE] for significant change related to admission to hospice and the care plan was updated. The MDS Coordinator reviewed Resident #1's care plan and confirmed the actual abrasion wound was not care planned. The MDS Coordinator stated an abrasion would not be included on a MDS assessment but should be included in the care plan. During an interview on 5/10/2023 at 6:31 PM, RN #7 stated, I did not ever see the wounds on [Resident #1] another nurse told me about the wounds. I did not have to do any dressing changes on her at night. Wound care is usually done on day shift by the nurse. Skin assessments are due to be completed by the nurse weekly and when CNAs report new issues. During an interview on 5/16/2023 at 6:00 PM, LPN #3 stated, I have worked in this facility for 3 years. Nurses were responsible for providing wound care and notifying the Wound Care Nurse [previous ADON] of any changes or new areas of concern. [previous ADON] looked at new areas and wrote orders for treatments, then the nurses reported any changes found during care or weekly skin assessments. I am not sure why I did not note the wounds on [Resident #1]'s skin assessments. LPN #3 reviewed the Weekly Skin Assessments he completed for Resident #1 and stated the assessments were probably not accurate. Review of Weekly Skin Assessment LPN #3 completed on 5/8/2023 for Resident #1 revealed LPN #3 documented there was not a wound on the assessment which had been identified by the Wound Care Nurse on 5/5/2023. LPN #3 confirmed the skin assessment he documented on 5/8/2023 was inaccurate. During an interview on 5/16/2023 at 6:32 PM, CNA #1 stated, I got a write up [dated 1/25/2023, signed 2/1/2023] by [previous ADON] that said I did not report an area on [Resident #1] that had opened up. I reported that area and another area later on [Resident #1]'s bottom. I told [RN #7, RN #2, previous ADON] about the two wounds on [Resident #1]'s bottom. I marked all of my shower sheets with both areas and turned them in to the nurses like I was supposed to do and put the signed sheet in [previous ADON]'s bin. I told [DON] that I didn't feel like I should sign the write up because they knew about the wounds on [Resident #1]. All of them did [RN #7, RN #2, previous ADON]. During a telephone interview on 5/22/2023 at 7:48 AM, LPN #2 stated, On 1/25/2023 [Hospice RN #8] told me that [Resident #1] had a wound on her buttocks and blanchable soft heels. The hospice nurse suggested barrier cream for the buttocks and skin prep for the heels pending evaluation by [previous ADON]. I called [previous ADON] and was told she would be in the next day to look at [Resident #1]'s wounds and write orders. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease and Type 2 Diabetes Mellitus. Review of the Physician Order Report for Resident #2 revealed, .APPLY THICK LAYER OF BARRIER CREAM TO BILATERAL BUTTOCKS EVERY SHIFT AND AFTER EVERY INCONTINENT EPISODE .7/23/2021 .Barrier cream to buttocks BID for prevention .06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM .10/19/2022 . Continued review revealed the only wound treatment orders noted were dated 3/1/2023 and 3/6/2023. Review of the Weekly Skin Assessment for Resident #2 revealed LPN #6 documented a skin assessment on 1/31/2023 which included an open wound and red areas to the bilateral under arms, and excoriated, red and raw areas to the buttocks, thighs, and peri-area. LPN #6 documented a referral to wound care on 1/31/2023. LPN #1 documented a skin assessment on 2/8/2023 which included open wounds and red areas to the buttocks, under both arms, groin, and face. LPN #3 documented a skin assessment on 2/14/2023 which included open wounds and red areas to the buttocks, under both arms, groin, and face. Review of the progress notes for Resident #2, revealed, .01/31/2023 .Resident referred to Wound care nurse/ADON [Assistant Director of Nursing] to address alteration in skin integrity. Review of the Wound Management Detail Report for Resident #2, revealed on 3/1/2023 a stage 2 wound was noted on the left buttock which measured 1.5 cm long x 0.5 cm wide with bloody exudate (drainage) and another stage 2 wound on the left buttock which measured 0.4 cm long x 0.4 cm wide with bloody exudate (drainage). A stage 2 wound was noted on the right buttock which measured 2.5 cm long x 1.5 cm wide with no exudate. Review of the Wound Management Detail Report for Resident #2 revealed on 3/1/2023 a stage 2 wound was noted on the left buttock which measured 1.5 cm long x 0.5 cm wide with bloody exudate, and another stage 2 (left buttock) which measured 0.4 cm long x 0.4 cm wide with bloody exudate. A stage 2 wound was noted on the right buttock, 2.5 cm long x 1.5 cm wide with no exudate. On 3/6/2023 the DON documented an unstageable sacral wound with slough and/or eschar which measured 5.5 cm long x 5 cm wide with seropurulent (yellow or tan, cloudy and thick) exudate. Review of the progress notes for Resident #2 revealed, .01/31/2023 .Resident referred to Wound care nurse/ ADON to address alteration in skin integrity [there were no wound care notes provided by the facility related to abnormal skin integrity found in the 1/31/2023 assessment, and no new orders noted related to findings] .03/02/2023 .Nutrition- Resident is noted to have stage 2 pressure injuries to her L buttocks, top 1.5 [cm] x .5 [cm], and to bottom .4 [cm] x .4 [cm], and to R buttocks 2.5 [cm] [x] 1.5 [cm] .Recommend to add Proheal Critical Care 30 ml po BID .3/06/2023 .3 stage 2 wounds noted last assessment, currently all wounds have merged together into 1 wound .3/06/2023 .[Nurse Pratitioner wrote] 3/6 - nursing requests eval [evaluation] d/t [due to] worsening skin status. Pt [patient] had 2 smaller stage 2 areas on buttocks and most recently they have merged into one larger, 5.5cm x 5cm unstageable ulcer on her sacrum . There was no documentation of wound characteristics, changes, progress, and additional wounds in progress notes or any other documentation provided by the facility prior to the NP notes on 3/6/2023 (facility policy required weekly documentation of wounds). During an interview on 5/17/2023 at 11:25 AM, Family Member #3 stated, [DON] called me about the wound on [Resident #2] a few days before she died [expired 3/8/2023]. [DON] said that she was going to change the treatment from the one the nurses had been doing. I told her I didn't even know about a wound. [Resident #2] complained about hurting on her bottom, and I was told there would be an air mattress put in place to prevent wounds from forming. That didn't happen until about 2 months before [Resident #2] died. No one from [Facility #1] told me there was a wound until [DON] called in March. Hospice did not ever talk to me about skin issues. I received a text from the hospice nurse weekly with [Resident #2]'s vital signs. Hospice wasn't empathetic at all. I was very disappointed in the services of both the facility and hospice. I haven't been able to talk with anyone about it. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction. Review of the current care plan for Resident #3 revealed problems which included, .problem start date 10/24/2022 .risk for skin breakdown R/T .incont. [incontinent] of my bladder and bowels .HX [history] of redness to my sacrum area .) Interventions included approach start date 10/24/2022, report any signs of skin breakdown (sore, tender, red, or broken areas). Review of the Wound Management Detail Report for Resident #3, revealed, .3/1/2023 .Length 7 cm width 7 cm .exudate amount .moderate .exudate color and consistency .seropurulent [yellow or tan, cloudy, thick] .wound odor .FOUL .stage .Unstageable-Slough [dead cells], and/or Eschar [black, necrotic tissue] . Review of the Weekly Skin Assessment for Resident #3 revealed LPN #3 completed an assessment on 2/14/2023 and documented there were open wounds/red areas to the bilateral upper arms, and dressings to the right side of the face. LPN #3 completed an assessment on 2/21/2023 and documented there were no open wounds or red areas. On 2/28/2023 LPN #3 completed an assessement on 2/28/2023 and documented there was an open wound/red areas to the sacrum, and the dressing was changed (There were no physician orders for a dressing to sacrum for an unstageable pressure injury until 3/1/2023). Review of the Physician Order Report for Resident #3 revealed, .Barrier cream to buttocks BID for prevention Special Instructions: Prevention .Twice A Day 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM .10/19/2022 .Unstageable to coccyx .Cleanse area with wound cleaner and pat dry, skin prep periwound, apply Santyl [debriding agent], cover with foam dressing .3/1/2023 . Review of the MAR for Resident #3 dated 2/1/2023-2/28/2023 revealed the barrier cream to buttocks preventative treatment was documented as provided twice a day by 9 different nurses on 6:00 AM-6:00 PM shift and 9 different nurses on 6:00 PM-6:00 AM shift with no missed documentation. Weekly Skin Assessment were documented as provided by LPN #3 on 2/7/2023 (completed by LPN # 1 on 2/8/2023), 2/14/2023 , 2/21/2023, and 2/28/2023. The sacral wound was first noted on 2/28/2023 by LPN #3, but there was no documentation of a complete assessment of the sacral wound until 3/2/2023 when the wound was assessed as unstageable with slough/eshcar. Review of the progress notes for Resident #3 revealed, .03/02/2023 .Nutrition-Resident is noted to have an unstageable pressure wound to her coccyx with slough/eschar that is 7 [cm] x 7 [cm] . During a telephone interview on 5/16/2023 at 5:20 PM, Family Member #4 stated, On 2/18/2023 I was visiting [Resident #3], and she complained about her bottom hurting. I called for the CNA [unable to recall the CNA's name] and assisted in holding [Resident #3] over on her side while the CNA changed her. I saw an open area on [Resident #3's] backside, and the CNA said there was a dressing, but it came off. I went to talk to the nurse about it, and she said she would replace the dressing. I talked to [previous ADON] about the area, and she did have any knowledge of the wound. Someone had been putting a dressing on the wound, so someone knew about it. Later the nurse put a dressing on [Resident #3]'s wound. The next time I talked to anyone about the wound was when [DON] called and talked to me about changing the treatment for the wound, I believe that was in March [2023]. During an interview on 5/16/2023 at 5:40 PM, CNA #3 stated, I first started taking care of [Resident #3] when she moved to the 3rd floor in January [2023] or early February [2023]. [Resident #3] had a dressing on her bottom at that time. In February [2023] I was giving her a bath and the dressing on her bottom came off and had blood on it. I talked to [RN #2] about the blood on the dressing, and he told [previous ADON]. [previous ADON] came to the room and looked at the wound then put a dressing back on it. During a telephone interview on 5/22/2023 at 8:10 AM, CNA #6 stated, I started working here [Facility #1] on January 10, 2023 and [Resident #3] had a dressing on her bottom at that time. The area on [Resident #3]'s bottom was red, but it wasn't open. When the area opened in February [unable to recall exact date] I let [RN #7] know, and she looked at it [there was no documentation in medical record of wound or dressing by RN #7]. During a telephone interview on 5/22/2023 at 8:18 AM, CNA #4 stated, I notified [RN #2] and [RN #7] about a wound on [Resident #3]'s bottom being open in February [2023] and was told they were aware of it. I also put the open area on a shower sheet, had the nurses sign it and turned it in to [previous ADON]. Both [RN #2] and [RN #7] will tell me they have a skin assessment to complete and asked me if the resident has any skin issues. They usually do not do the skin assessment themselves. During an interview on 5/9/2023 at 12:36 PM, the Director of Nursing (DON) stated, I conducted facility wide skin sweep [audit] and found two other residents with wounds that were being treated without orders. The Nurse Practitioner confirmed she was not aware of the wounds on [Resident #2 and #3]. I looked at documentation and did not find any documents that identified the wounds on [Resident #1, #2, and #3]. I looked at orders, skin assessments, shower sheets, and progress notes and did not find any notes related to the wounds on the residents [Resident #1, #2, and #3]. [The DON was unable to provide all of the shower sheets requested due to being unable to find the documents and stated some of the documents were in a pile and being sorted through]. There were treatments done on the wounds, just the wrong treatments. The wounds were getting better or at least did not get worse. When asked how she knew the wounds were better or did not get worse given the absense of documentation, the DON shrugged her shoulders and did not answer. The DON stated, I talked to [Resident #2 and #3]'s family members [Family Member #3 and Family Member #4], and they knew about the wounds because they actually had assisted with incontinent care of the the residents [Family Member #3 and Family Member #4 had not been notified about the wounds by the nursing staff]. [ADON] returned to work on 3/1/2023 and was terminated immediately. When asked if any other staff was disciplined related to inaccurate assessments and failing to report the wounds, the DON stated, I conducted an in-service and talked to some of the staff individually, but no one else was terminated or written up. During a telephone interview on 5/10/2023 at 8:15 AM, the previous ADON/Wound Care Nurse stated, I agreed to take over wound care only to provide initial assessments of new areas and write orders for treatments. The nurses on the floor were to provide wound care and notify me of any changes to wounds. Nursing staff was responsible for documenting on the wounds and notifying me of any new areas found during care and weekly assessments .I was not notified with any changes to [Resident #1, #2 and #3]'s skin concerns. There had been problems with CNAs [Certified Nursing Assistants] not reporting skin concerns and nurses not completing skin assessments accurately. [DON] was supposed to talk to LPN #3, #4, and #6 about documentation of skin assessments and actually doing the skin assessment rather than copy and pasting from the previous assessment. I do not look at the residents' skin unless nursing notifies me with changes. I was in the facility 3 days a week because of school. When I was out of the facility [DON] took care of concerns with skin issues and wounds. When asked what is the difference between a Stage 2 (reported by the hospice RN #8) and an abraison on the buttocks, previous ADON replied, Stage 2 or abrasion are the same, it just depends on what the nurse calls it. During an interview on 5/10/2023 at 2:55 PM, RN #2 stated, I have completed wound care on [Resident #1, #2, #3, and #5]. I do not know what the dressing orders were, I put the same kind of dressing on that came off. I think [Resident #1, #2, and #3] had the same treatments to their bottoms. I guess the wounds did change. I just followed the orders on the MAR. I thought the documentation was all completed by the Wound Care Nurse. I am not a wound person, and I struggle with wound assessments, so I do not chart on wounds. I just do not know what to chart. I am sure I talked to the Wound Care Nurse about changes in [Resident #1]'s wounds. I just do not recall what the changes were, and I know I did not document any changes or notifications. I never talked to the family about any changes. I have been in-serviced about wounds. It just isn't my thing, and I know I should chart, but I don't. RN #2 stated the Professional Standards of Practice for nursing included proper assessment of wounds, documentation of wound care or wound changes, and notification of changes to the provider and family. During an interview on 5/16/2023 at 1:20 PM, the NP stated, [DON] requested a consult for [Resident #1, Resident #2, Resident #3 and Resident #5]'s wounds on 3/6/2023 and that was the first time I was aware of the wounds on those residents. I do not consult for wounds unless nursing request an evaluation. I depend on the Wound Care Nurse to reccommend treatment orders, and I sign them after the orders are written. During a telephone interview on 5/16/2023 at 2:08 PM, Hospice (Hospice Provider #2) RN #4 stated, I do not provide wound care for [Resident #3] and I did not provide wound care for [Resident #2]. I look at the wounds if the dressing is off or the nurse is providing wound care while I am in the room. I talk with the nurse or Wound Care Nurse when I visit a resident and document wound progress. I use the facility wound measurements for my documentation. During a telephone interview on 5/16/2023 at 3:28 PM, the Medical Director stated, Wound management is a team effort. Everyone is involved from the CNA to the DON. There was an ad hoc QAPI [Quality Assurance Performance Improvement] meeting to discuss the missed wound documentation for a resident. I do not see every wound in the facility. Nurses call me when a wound is complicated. There is a NP in the facility for nursing to consult. I do not see every wound in the facility. During an interview on 5/16/2023 at 5:05 PM, LPN #4 stated, When [previous ADON] was the Wound Care Nurse the protocol was for the nurses to provide wound care and monitor the wounds for changes. Nurses were to notify [previous ADON] with any new areas or changes to existing wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facilty policy review, employee job description review, medical record review, and interview, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing care including but not limited to assessing, evaluating, and implementing resident care plans and responding to resident's needs for 7 of 7 (Resident #1, #2, #3, #4, #5, #6 and #7) sampled residents reviewed for skin integrity/wounds. The findings include: Review of the facility policy titled, Communication, Skin Integrity Manual, reviewed 8/2021, revealed, .Physician .Notify on admission if new pressure ulcer is present and notify promptly of in-house development .Notify for lack of progress in wound healing .Weekly Skin And Wound Assessments-Weekly assessments include type, stage or depth of tissue injury, location, and measurement of site (length, width, and depth) .Daily Pressure Ulcer Monitoring-when a pressure ulcer is present, daily monitoring will include .evaluation of ulcer if not dressing present .evaluation of status of dressing if present .status of the area surrounding the ulcer .presence of possible complications such as signs of increasing of area of ulceration .Weekly Wound Documentation .When a wound is present on a patient, the status of the wound should be documented weekly via the Wound Management or other process as designated by the regional nurse . Review of the facility policy titled, Patient Care Policies, reviewed/revised 2/2023, revealed, .Twenty-four-hour nursing service is provided by trained partners under the direction of a registered professional nurse who is responsible to the patient for the nursing services provided and accountable to the administration for all nursing care outcomes The patient care plan process involves the entire inter-disciplinary team, including the patient and/or patient representative .The center will include the attending physician in the development of the patient's plan of care by incorporating the physician's plan of care (orders) into the care plan .The care plan serves as a guide for care decisions and is made available for use by all patient care personnel . Review of the facility job description for Director of Nursing reviewed 11/7/2022, revealed, .provide an administrative and overall managerial authority for all functions of the Nursing Department including but not limited to care delivery and service functions .accountable to the center's administrator or the management of the Nursing Department .responsible for maintaining clinical competency .Practices continuous quality improvement thinking and problem-solving skills .Be responsive to urgent patient care matters 24 hours/7 days per week (or delegates to a qualified RN) .Maintains a system to ensure knowledge of patient status .Monitors to see that treatments and medications are administered as ordered .Monitors to see that there is accurate and adequate documentation in the medical record . Review of the facility job description for Wound Care Nurse reviewed 11/7/2022, revealed, .Integrates current standards of practice as well as local, state, and federal regulations related to nursing services in the care of patients .Wound Care Certification preferred .Utilizes the nursing process in assessment, planning and implementing care .Exihibits organizational ability related to workflow, prioritizing t meet the patient care needs .assure accurate patient assessment and development/revision of individualized plans of care related to wounds and the prevention of pressure ulcers .Maintains open and ongoing communication with patients and families regarding the status of a patient's wound .Visually inspects the skin of all patients at least weekly-may delegate the inspection to a qualified licensed provider when indicated .Updates provider on the status of wound and need for modification of wound care/dressings .Keeps the patient and family updated on the status of wounds and progress of healing .Performs accurate measurement of pressure ulcers and wounds on a minimum of weekly and records in the EHR [Electronic Health Record] . Review of the facility job description for Registered Nurse revised 11/2/2021, revealed, .Is responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skills, leadership, and communication skills .Utilizes the nursing process in assessment, planning, and implementing current standards of practice .Monitor unit/units to ensure that appropriate nursing care (according to established policies and procedures) is being provided an that doctors and families are being notified of changes in patients' condition . Review of the facility job description for Licensed Practical Nurse revised on 11/2/2021, revealed, .Is responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skills, leadership, and communication skills .Utilizes the nursing process in assessment, planning, and implementing current standards of practice .Working with the interdisciplinary care team, to assure accurate patient assessment .Assume responsibility for assisting with meds and treatments . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side, and Vascular Dementia. Review of the Physician Order Report for Resident #1 revealed, .10/19/2022 .Barrier cream to buttocks BID [twice a day] for prevention .1/26/2023-2/28/2023 .Abrasion to left buttock: Cleanse area with wound cleanser, pat dry, apply skin barrier to peri wound, apply medihoney and cover with foam/hydrocolloid dressing once weekly and as needed until healed .1/26/2023-2/28/2023 .Bilateral Red Blanchable heels: Cleanse heels with soap and water, pat dry. Apply skin barrier cover with foam/hydrocolloid dressing and wrap with Coban [self-adhesive wrap] or kerlix [bandage roll]. Change weekly and as needed for protection . Continued review revealed wound treatment orders for abrasion to left buttock, and bilateral red blanchable heels were discontinued on 2/28/2023, and orders were added for Proheal Critical Care [protein supplement]. A stage 2 (pressure injury which is an open wound which expands to the deeper layers of the skin) to left buttock, unstageable (pressure injury which is covered by a layer of dead tissue) to right buttock, unstageable to bilateral heels, unstageable to right medial ankle, and unstageable left ankle. Review of the Medication Administration Record (MAR) for Resident #1, dated 1/1/2023-1/31/2023, revealed an order for barrier cream to buttocks BID [twice daily] was documented as administered twice a day as ordered without exception. Review of the progress notes for Resident #1 revealed, .1/26/2023 12:13 PM A SKIN ASSESSMENT WAS PERFORMED ON THE PATIENT THIS MORNING. RESIDENT NOTED TO HAVE ABRASION TO UPPER LEFT BUTTOCK, BILATERAL HEELS ARE RED BUT BLANCHABLE, AND THICK LAYERS OF SCABBED SKIN TO BILATERAL ANKLES. NP [Nurse Practitioner] AND FAMILY WERE MADE AWARE WITH THE TREATMENT PLAN STARTED. THE PATIENT WAS admitted TO [NAME] HOSPICE LAST NIGHT AND A REQUEST WAS MADE FOR THE RESIDENT TO RECEIVE A SPECIALIZED MATTRESS. EDUCATED STAFF ON HOW TO MAINTAIN THE RESIDENT'S SKIN INTEGRITY .02/17/2023 02:43 PM Nutrition .She [Resident #1] is noted to have an abrasion to her L [left] buttock that is stable .Food & Nutrition Service .3/2/2023 11:03 PM .Nutrition- Resident is noted to have multiple pressure injuries- Unstageable to L [left] ankle that is 5 x 5 [length by width] cm [centimeter] with slough [yellow/white material which consists of dead cells that accumulate in the wound bed], Stage 2 to R [right] heel up to lateral ankle 5 x 5 cm, unstageable to L heel 3 x 2.5 cm with slough, unstageable to R buttocks 7 x 3 cm with slough, and stage 2 to L buttock 1 x 1 cm. There was no documentation for wound characteristics, changes, progress, and additional wounds in the progress notes dated 1/27/2023-2/27/2023 or any documentation provided by the facility (facility policy required weekly documentation of wounds). During an interview on 5/9/2023 at 12:36 PM, the Director of Nursing (DON) stated, Sometime around [2/20/2023] [Family Member #2] called and wanted to know why she wasn't told about [Resident #1]'s wound on her bottom. During that phone call, I called [ADON, also the Wound Care Nurse] and she assured me the wound was only an abrasion, and there was a treatment in place. I totally trusted [ADON], and I did not go and put eyes on the wound at the time. Later [Family Member #2] wanted a meeting to look at the wound. I went and assessed the wound the day of the meeting [2/28/2023]. I found 5 wounds, [1] a stage 2 and [2] an unstageable on the buttocks, [3] an unstageable on the left ankle, [4] a stage 2 on the right heel and [5] a stage 2 right ankle. There were treatment orders in place for the left buttocks and the heels. The treatments were prophylactic [intended to prevent disease] to prevent worsening of the wounds. Nurses were using the same order for all the wounds, no new orders existed for the other wounds. I investigated immediately and notified the Nurse Practitioner [NP] and obtained orders to treat the wounds. The Nurse Practitioner confirmed she was not aware of the wounds on [Resident #1] .The DON stated, [Family Member #1] admitted he knew about the abrasion [upper left buttock] on [Resident #1] during the 2/28/2023 meeting. He didn't understand that the abrasion was a wound. Review of the employee file for the previous ADON revealed, .Supervisory Adverse Action Notice .Employee Name [previous ADON] .Supervisor's Name [DON] .Date 3/1/23 .Supervisor's Statement of Incident: Multiple wounds on multiple patients identified [without] documentation and orders .Supervisor's Response to Employee's Correction Plan Above: Termination re: [re: concerning] failure to assess timely, failure to initiate treatments, treating without a physicians [physician's] order, failure to notify family and MD of wounds, failure to document timely . The document was signed by the DON and the previous ADON on 3/1/2023. During a telephone interview on 5/9/2023 at 1:58 PM, Family Member #1 stated, [ADON] told me [Resident #1] had alot of dead skin on her heels and had orders for ointment. [ADON] said there was an abrasion on one side of [Resident #1]'s bottom. I asked [ADON] if by abrasion she meant scratch, and [ADON] said no it was like something from laying still all the time. [ADON] told me there was a special mattress to help prevent the area from getting worse. No one told me she had all those wounds or that the abrasion was worse until my wife insisted she wasn't getting told the truth about the wounds. During a telephone interview on 5/9/2023 at 2:37 PM, Family Member #2 stated, I came to the facility on 2/19/2023. During my visit the tech took the brief off [Resident #1], and I saw the wound on her bottom. There wasn't a dressing on the wound so I went and asked the nurse if something should be on the wound. The nurse was an agency nurse and didn't know anything about the wound but said she would put something on it. I called [DON] the next day [2/20/2023] to find out why they had not told me about the wound. [DON] told me she spoke to the Wound Care Nurse and assured me it was an abrasion, and there was already a treatment in place. [DON] told me the Wound Care Nurse spoke to [Family Member #1] about the abrasion. After thinking about that conversation I tried to call [DON] back multiple times to question what I saw on [2/19/2023]. On [2/24/2023] I just went up to the facility to speak to the Administrator. I told him I felt like I had been lied to about [Resident #1]'s wound because what I saw was not just an abrasion. I told him that I wanted to see the wounds for myself. [Administrator] asked me if he could set up a meeting with [DON] on [2/28/2023] when she returned to work. I agreed to the meeting and assumed he would check to see if I was being told the truth before the meeting. In fact it wasn't until the day of the meeting that anyone looked at [Resident #1]'s wounds. On [2/28/2023] [DON] started the meeting by saying that she had assessed [Resident #1]'s skin that day. [DON] started crying and said, 'If you think her bottom looks bad, you should see her heels and ankles, they are horrific.' During an interview on 5/9/2023 at 5:11 PM, the Administrator stated, [Family Member #2] came to the facility on 2/24/2023 and voiced concerns about [Resident #1] having a wound that she was not aware of, and she thought it was more than what she had been told. She wanted to see the wound. [Family Member #2] wanted to meet with the Wound Care Nurse and DON about [Resident #1]'s care. I told her that [DON] would not be back until 2/29/2023. I did not have anyone else look into the wound on [Resident #1]. I waited for [DON]. During a telephone interview on 5/10/2023 at 8:15 AM, the previous ADON/Wound Care Nurse stated, I wrote the order for treatment for the left buttock abrasion and both heels when [Resident #1] was admitted to hospice [1/25/2023]. The hospice nurse [Registered Nurse-RN #8] notified the floor nurse [Licensed Practical Nurse-LPN #2] that there was a stage 2 on [Resident #1]'s bottom and needed skin prep to both heels. There was an order for barrier cream every day, twice a day, someone saw the change in [Resident #1]'s buttocks and did not report the change to me. I saw [Resident #1] the next day [1/26/2023] and wrote orders for a treatment for an abrasion on the left buttocks and preventative treatments for both heels. During a telephone interview on 5/10/2023 at 11:08 AM, LPN #5 stated, I work for [Hospice Provider #1] and was assigned to [Resident #1]. I never provided wound care for [Resident #1]. I got updates on [Resident #1]'s wounds from the nurse during my weekly visits. I did not see the wounds because someone had already completed wound care. The only orders for wound care were for an abrasion on her buttock and both heels as a preventative. I wasn't told about the open areas until [Family Member #2] told me she had seen the wound on [Resident #1] during incontinent care. Family Member #2 showed me pictures she took of the wounds on 2/19/2023. During a telephone interview on 5/10/2023 at 12:15 PM, Hospice (Hospice Provider #1) RN #8 stated, I admitted [Resident #1] to hospice services the evening of 1/25/2023. I completed a skin assessment as part of the admission process. I notified the floor nurse about a Stage 2 wound on the left buttocks and Deep Tissue Injuries [DTI]s on heels. I requested barrier cream on Stage 2 and skin prep for heels pending an evaluation by the facility Wound Care Nurse. The facility accepted full responsibility for the wound care. During a telephone interview on 5/10/2023 at 2:31 PM, Hospice (Hospice Provider #1) CNA #2 stated, I was assigned to [Resident #1] in the facility. I provided bed baths to [Resident #1] during visits as part of care. There was a dressing on her bottom and both of her heels. The dressings were always in place, and I did not see skin area under the dressings. I do not recall the exact date in February of the visit, but I came in, and there was a strong odor like feces in [Resident #1]'s room. I checked to see if [Resident #1] had a bowel movement, and she was clean. The dressings were dirty with foul smelling drainage on her bottom and heels. I reported the dirty dressings and foul odor to the hospice nurse and to the facility Wound Care Nurse that day. During an interview on 5/10/2023 at 2:55 PM, RN #2 reviewed a CNA shower sheet skin assessment for Resident #1 dated 1/25/2023. RN #2 confirmed the CNA #7 had documented an open area to Resident #1's right buttocks and the document was signed by him. RN #2 stated, I did not report the area to the Wound Care Nurse or the NP because there was already a treatment in place. RN #2 then reviewed Resident #1's MAR dated 1/2023 and confirmed the order on the MAR had a start date of 1/26/2023. RN #2 confirmed the MAR specified the left buttock abrasion, but there was not an order for a right buttock wound. During a telephone interview on 5/10/2023 at 3:30 PM, the facility Registered Dietitian (RD) stated, During the morning meetings the team discussed [Resident #1]'s weight loss and put interventions in place. I was unaware of any worsening wound issues for [Resident #1] until [DON] reported the new wounds [2/28/2023]. When I am notified of a resident's wounds worsening, I put orders in place for Proheal [protein supplement to promote wound healing]. During a telephone interview on 5/10/2023 at 3:41 PM, the Minimum Data Set (MDS) Coordinator stated, I do a daily order check to see if any orders for wound care were written. I do not always attend the morning meetings, but the Wound Care Nurse would let me know about any new wounds for residents. An abrasion would not be included on the resident's MDS assessment. There was an MDS assessment dated [DATE] for significant change related to admission to hospice and the care plan was updated. The MDS Coordinator reviewed Resident #1's care plan and confirmed the actual abrasion wound was not care planned. The MDS Coordinator stated an abrasion would not be included on a MDS assessment but should be included in the care plan. During an interview on 5/10/2023 at 6:31 PM, RN #7 stated, I did not ever see the wounds on [Resident #1] another nurse told me about the wounds. I did not have to do any dressing changes on her at night. Wound care is usually done on day shift by the nurse. Skin assessments are due to be completed by the nurse weekly and when CNAs report new issues. During an interview on 5/16/2023 at 6:00 PM, LPN #3 stated, I have worked in this facility for 3 years. Nurses were responsible for providing wound care and notifying the Wound Care Nurse [previous ADON] of any changes or new areas of concern. [previous ADON] looked at new areas and wrote orders for treatments, then the nurses reported any changes found during care or weekly skin assessments. I am not sure why I did not note the wounds on [Resident #1]'s skin assessments. LPN #3 reviewed the Weekly Skin Assessments he completed for Resident #1 and stated the assessments were probably not accurate. Review of Weekly Skin Assessment LPN #3 completed on 5/8/2023 for Resident #1 revealed LPN #3 documented there was not a wound on the assessment which had been identified by the Wound Care Nurse on 5/5/2023. LPN #3 confirmed the skin assessment he documented on 5/8/2023 was inaccurate. During an interview on 5/16/2023 at 6:32 PM, CNA #1 stated, I got a write up [dated 1/25/2023, signed 2/1/2023] by [previous ADON] that said I did not report an area on [Resident #1] that had opened up. I reported that area and another area later on [Resident #1]'s bottom. I told [RN #7, RN #2, previous ADON] about the two wounds on [Resident #1]'s bottom. I marked all of my shower sheets with both areas and turned them in to the nurses like I was supposed to do and put the signed sheet in [previous ADON]'s bin. I told [DON] that I didn't feel like I should sign the write up because they knew about the wounds on [Resident #1]. All of them did [RN #7, RN #2, previous ADON]. During a telephone interview on 5/22/2023 at 7:48 AM, LPN #2 stated, On 1/25/2023 [Hospice RN #8] told me that [Resident #1] had a wound on her buttocks and blanchable soft heels. The hospice nurse suggested barrier cream for the buttocks and skin prep for the heels pending evaluation by [previous ADON]. I called [previous ADON] and was told she would be in the next day to look at [Resident #1]'s wounds and write orders. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease and Type 2 Diabetes Mellitus. Review of the Physician Order Report for Resident #2 revealed, .APPLY THICK LAYER OF BARRIER CREAM TO BILATERAL BUTTOCKS EVERY SHIFT AND AFTER EVERY INCONTINENT EPISODE .7/23/2021 .Barrier cream to buttocks BID for prevention .06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM .10/19/2022 . Continued review revealed the only wound treatment orders noted were dated 3/1/2023 and 3/6/2023. Review of the Weekly Skin Assessment for Resident #2 revealed LPN #6 documented a skin assessment on 1/31/2023 which included an open wound and red areas to the bilateral under arms, and excoriated, red and raw areas to the buttocks, thighs, and peri-area. LPN #6 documented a referral to wound care on 1/31/2023. LPN #1 documented a skin assessment on 2/8/2023 which included open wounds and red areas to the buttocks, under both arms, groin, and face. LPN #3 documented a skin assessment on 2/14/2023 which included open wounds and red areas to the buttocks, under both arms, groin, and face. Review of the progress notes for Resident #2, revealed, .01/31/2023 .Resident referred to Wound care nurse/ADON [Assistant Director of Nursing] to address alteration in skin integrity. Review of the Wound Management Detail Report for Resident #2, revealed on 3/1/2023 a stage 2 wound was noted on the left buttock which measured 1.5 cm long x 0.5 cm wide with bloody exudate (drainage) and another stage 2 wound on the left buttock which measured 0.4 cm long x 0.4 cm wide with bloody exudate (drainage). A stage 2 wound was noted on the right buttock which measured 2.5 cm long x 1.5 cm wide with no exudate. Review of the Wound Management Detail Report for Resident #2 revealed on 3/1/2023 a stage 2 wound was noted on the left buttock which measured 1.5 cm long x 0.5 cm wide with bloody exudate, and another stage 2 (left buttock) which measured 0.4 cm long x 0.4 cm wide with bloody exudate. A stage 2 wound was noted on the right buttock, 2.5 cm long x 1.5 cm wide with no exudate. On 3/6/2023 the DON documented an unstageable sacral wound with slough and/or eschar which measured 5.5 cm long x 5 cm wide with seropurulent (yellow or tan, cloudy and thick) exudate. Review of the progress notes for Resident #2 revealed, .01/31/2023 .Resident referred to Wound care nurse/ ADON to address alteration in skin integrity [there were no wound care notes provided by the facility related to abnormal skin integrity found in the 1/31/2023 assessment, and no new orders noted related to findings] .03/02/2023 .Nutrition- Resident is noted to have stage 2 pressure injuries to her L buttocks, top 1.5 [cm] x .5 [cm], and to bottom .4 [cm] x .4 [cm], and to R buttocks 2.5 [cm] [x] 1.5 [cm] .Recommend to add Proheal Critical Care 30 ml po BID .3/06/2023 .3 stage 2 wounds noted last assessment, currently all wounds have merged together into 1 wound .3/06/2023 .[Nurse Pratitioner wrote] 3/6 - nursing requests eval [evaluation] d/t [due to] worsening skin status. Pt [patient] had 2 smaller stage 2 areas on buttocks and most recently they have merged into one larger, 5.5cm x 5cm unstageable ulcer on her sacrum . There was no documentation of wound characteristics, changes, progress, and additional wounds in progress notes or any other documentation provided by the facility prior to the NP notes on 3/6/2023 (facility policy required weekly documentation of wounds). During an interview on 5/17/2023 at 11:25 AM, Family Member #3 stated, [DON] called me about the wound on [Resident #2] a few days before she died [expired 3/8/2023]. [DON] said that she was going to change the treatment from the one the nurses had been doing. I told her I didn't even know about a wound. [Resident #2] complained about hurting on her bottom, and I was told there would be an air mattress put in place to prevent wounds from forming. That didn't happen until about 2 months before [Resident #2] died. No one from [Facility #1] told me there was a wound until [DON] called in March. Hospice did not ever talk to me about skin issues. I received a text from the hospice nurse weekly with [Resident #2]'s vital signs. Hospice wasn't empathetic at all. I was very disappointed in the services of both the facility and hospice. I haven't been able to talk with anyone about it. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction. Review of the current care plan for Resident #3 revealed problems which included, .problem start date 10/24/2022 .risk for skin breakdown R/T .incont. [incontinent] of my bladder and bowels .HX [history] of redness to my sacrum area .) Interventions included approach start date 10/24/2022, report any signs of skin breakdown (sore, tender, red, or broken areas). Review of the Wound Management Detail Report for Resident #3, revealed, .3/1/2023 .Length 7 cm width 7 cm .exudate amount .moderate .exudate color and consistency .seropurulent [yellow or tan, cloudy, thick] .wound odor .FOUL .stage .Unstageable-Slough [dead cells], and/or Eschar [black, necrotic tissue] . Review of the Weekly Skin Assessment for Resident #3 revealed LPN #3 completed an assessment on 2/14/2023 and documented there were open wounds/red areas to the bilateral upper arms, and dressings to the right side of the face. LPN #3 completed an assessment on 2/21/2023 and documented there were no open wounds or red areas. On 2/28/2023 LPN #3 completed an assessement on 2/28/2023 and documented there was an open wound/red areas to the sacrum, and the dressing was changed (There were no physician orders for a dressing to sacrum for an unstageable pressure injury until 3/1/2023). Review of the Physician Order Report for Resident #3 revealed, .Barrier cream to buttocks BID for prevention Special Instructions: Prevention .Twice A Day 06:00 AM - 06:00 PM, 06:00 PM - 06:00 AM .10/19/2022 .Unstageable to coccyx .Cleanse area with wound cleaner and pat dry, skin prep periwound, apply Santyl [debriding agent], cover with foam dressing .3/1/2023 . Review of the MAR for Resident #3 dated 2/1/2023-2/28/2023 revealed the barrier cream to buttocks preventative treatment was documented as provided twice a day by 9 different nurses on 6:00 AM-6:00 PM shift and 9 different nurses on 6:00 PM-6:00 AM shift with no missed documentation. Weekly Skin Assessment were documented as provided by LPN #3 on 2/7/2023 (completed by LPN # 1 on 2/8/2023), 2/14/2023 , 2/21/2023, and 2/28/2023. The sacral wound was first noted on 2/28/2023 by LPN #3, but there was no documentation of a complete assessment of the sacral wound until 3/2/2023 when the wound was assessed as unstageable with slough/eshcar. Review of the progress notes for Resident #3 revealed, .03/02/2023 .Nutrition-Resident is noted to have an unstageable pressure wound to her coccyx with slough/eschar that is 7 [cm] x 7 [cm] . During a telephone interview on 5/16/2023 at 5:20 PM, Family Member #4 stated, On 2/18/2023 I was visiting [Resident #3], and she complained about her bottom hurting. I called for the CNA [unable to recall the CNA's name] and assisted in holding [Resident #3] over on her side while the CNA changed her. I saw an open area on [Resident #3's] backside, and the CNA said there was a dressing, but it came off. I went to talk to the nurse about it, and she said she would replace the dressing. I talked to [previous ADON] about the area, and she did have any knowledge of the wound. Someone had been putting a dressing on the wound, so someone knew about it. Later the nurse put a dressing on [Resident #3]'s wound. The next time I talked to anyone about the wound was when [DON] called and talked to me about changing the treatment for the wound, I believe that was in March [2023]. During an interview on 5/16/2023 at 5:40 PM, CNA #3 stated, I first started taking care of [Resident #3] when she moved to the 3rd floor in January [2023] or early February [2023]. [Resident #3] had a dressing on her bottom at that time. In February [2023] I was giving her a bath and the dressing on her bottom came off and had blood on it. I talked to [RN #2] about the blood on the dressing, and he told [previous ADON]. [previous ADON] came to the room and looked at the wound then put a dressing back on it. During a telephone interview on 5/22/2023 at 8:10 AM, CNA #6 stated, I started working here [Facility #1] on January 10, 2023 and [Resident #3] had a dressing on her bottom at that time. The area on [Resident #3]'s bottom was red, but it wasn't open. When the area opened in February [unable to recall exact date] I let [RN #7] know, and she looked at it [there was no documentation in medical record of wound or dressing by RN #7]. During a telephone interview on 5/22/2023 at 8:18 AM, CNA #4 stated, I notified [RN #2] and [RN #7] about a wound on [Resident #3]'s bottom being open in February [2023] and was told they were aware of it. I also put the open area on a shower sheet, had the nurses sign it and turned it in to [previous ADON]. Both [RN #2] and [RN #7] will tell me they have a skin assessment to complete and asked me if the resident has any skin issues. They usually do not do the skin assessment themselves. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Adult Failure to Thrive, and Muscle Weakness. Review of the current care plan revealed Resident #4 had problems which included 9/26/2022 at risk for skin breakdown R/T decreased mobility, 9/26/2022 Diabetes at risk for complications. Interventions included report any signs of skin breakdown (sore, tender, red, or broken areas) and weekly skin assessment. Review of the Quarterly MDS assessment dated [DATE] Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Physician Order Report revealed Resident #4 did not have orders for intervention of dry flaky skin. RN #2 stated he would get a physician's order for interventions if skin issues were found during an assessment. Review of the Weekly Skin Assessment for Resident #4 revealed LPN #6 documented a skin assessment on 4/29/2023 which included dry, flaky skin on the bilateral lower extremities. RN #2 documented a skin assessment on 5/10/2023 which included dry, flaky skin on the bilateral lower extremities. Observation of Weekly Skin Assessment and interview on 5/10/2023 at 5:05 PM, revealed RN #2 completed a head to toe weekly skin assessment and documented that Resident #4 had scaley, dry flaky skin on bilateral extremities. Resident #4 stated, I see you [RN#2] are going all out since the State is here watching. When asked about getting a weekly skin assessment Resident #4 replied, The nurses .don't come and do the skin assessments weekly. During an interview on 5/17/2023 at 3:50 PM, the DON reviewed Resident #4's skin assessment dated [DATE] and Resident #4's Physician Order Report. The DON stated, I would expect the nurse to contact the NP and obtain an order for dry skin treatment if the skin assessment noted dry flaky skin. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Periprosthetic Fracture around an Internal Prosthetic Joint and Age-related Osteoporosis with Current Pathological Fracture of the Right Femur. Review of the Significant Change in Status MDS assessment dated [DATE] revealed Resident #5 was at risk of developing pressure ulcers/injuries but had no pressure wounds at the time of the assessment. Resident #5 had applications of nonsurgical dr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, employee job description review, medical record review, and interview, the Administration failed to administer the facility in a manner to ensure resources were used effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Administration's failure to adequately administer the facility resulted in the failure to notify the provider and/or family representative in changes to resident condition for 4 of 6 (Resident #1, #2, #3 and #4) sampled residents, failure to ensure Comprehensive Care Plans were revised with interventions implemented for an actual skin impairment for 1 of 7 (Resident #1) sampled residents, failure of nursing staff to provide care and treatment consistent with professional standards of practice to promote healing and prevent new ulcers from developing for 3 of 3 (Resident #1, #2, and #3) sampled residents, and failure to employ nursing staff with the appropriate competencies and skills sets to provide nursing care including but not limited to assessing, evaluating, and implementing resident care plans and responding to resident's needs for 7 of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents. The findings include: The following information supports the Administration was aware/should have been aware of allegations related to notification of changes in resident condition, failure of nursing staff to provide necessary care to treat pressure ulcers and prevent new pressure injury, failure of nursing staff to ensure competencies for assessment and care of residents with actual skin impairments and failed to take action(s) as appropriate: Review of the facility policy titled, Patient Care Policies, reviewed/revised 2/2023, revealed, .Twenty-four-hour nursing service is provided by trained partners under the direction of a registered professional nurse who is responsible to the patient for the nursing services provided and accountable to the administration for all nursing care outcomes Review of the facility job description for the Administrator updated 8/2010, revealed, .to direct the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care be provided to our residents .Maintain an adequate liaison with families and residents .Counsel/discipline personnel as necessary .Ensure that each resident receives nursing, medical, and psychological services to attain and maintain the highest possible mental and physical functional status as defined by the comprehensive assessment and care plan . Review of the facility job description for Director of Nursing reviewed 11/7/2022, revealed, .provide an administrative and overall managerial authority for all functions of the Nursing Department including but not limited to care delivery and service functions .accountable to the center's administrator or the management of the Nursing Department .responsible for maintaining clinical competency .Practices continuous quality improvement thinking and problem-solving skills .Be responsive to urgent patient care matters 24 hours/7 days per week (or delegates to a qualified RN) .Maintains a system to ensure knowledge of patient status .Monitors to see that treatments and medications are administered as ordered .Monitors to see that there is accurate and adequate documentation in the medical record . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side, and Vascular Dementia. Review of the Physician Order Report for Resident #1 revealed, . 2/28/2023 .stage 2 (pressure injury which is an open wound which expands to the deeper layers of the skin) to left buttock, unstageable (pressure injury which is covered by a layer of dead tissue) to right buttock, unstageable to bilateral heels, unstageable to right medial ankle, and unstageable left ankle. Review of the Medication Administration Record (MAR) for Resident #1, dated 1/1/2023-1/31/2023, revealed an order for barrier cream to buttocks BID [twice daily] was documented as administered twice a day as ordered without exception. Review of the progress notes for Resident #1 revealed, .1/26/2023 12:13 PM A SKIN ASSESSMENT WAS PERFORMED ON THE PATIENT THIS MORNING. RESIDENT NOTED TO HAVE ABRASION TO UPPER LEFT BUTTOCK, BILATERAL HEELS ARE RED BUT BLANCHABLE, AND THICK LAYERS OF SCABBED SKIN TO BILATERAL ANKLES .[Resident #1] is noted to have an abrasion to her L [left] buttock that is stable .3/2/2023 11:03 PM .Nutrition- Resident is noted to have multiple pressure injuries- Unstageable to L [left] ankle that is 5 x 5 [length by width] cm [centimeter] with slough [yellow/white material which consists of dead cells that accumulate in the wound bed], Stage 2 to R [right] heel up to lateral ankle 5 x 5 cm, unstageable to L heel 3 x 2.5 cm with slough, unstageable to R buttocks 7 x 3 cm with slough, and stage 2 to L buttock 1 x 1 cm. There was no documentation for wound characteristics, changes, progress, and additional wounds in the progress notes dated 1/27/2023-2/27/2023 or any documentation provided by the facility (facility policy required weekly documentation of wounds). During an interview on 5/9/2023 at 12:36 PM, the Director of Nursing (DON) stated, Sometime around [2/20/2023] [Family Member #2] called and wanted to know why she wasn't told about [Resident #1]'s wound on her bottom. During that phone call, I called [ADON, also the Wound Care Nurse] and she assured me the wound was only an abrasion, and there was a treatment in place. I totally trusted [ADON], and I did not go and put eyes on the wound at the time. Later [Family Member #2] wanted a meeting to look at the wound. I went and assessed the wound the day of the meeting [2/28/2023]. I found 5 wounds, [1] a stage 2 and [2] an unstageable on the buttocks, [3] an unstageable on the left ankle, [4] a stage 2 on the right heel and [5] a stage 2 right ankle. There were treatment orders in place for the left buttocks and the heels. The treatments were prophylactic [intended to prevent disease] to prevent worsening of the wounds. Nurses were using the same order for all the wounds, no new orders existed for the other wounds. I investigated immediately and notified the Nurse Practitioner [NP] and obtained orders to treat the wounds. The Nurse Practitioner confirmed she was not aware of the wounds on [Resident #1] .The DON stated, [Family Member #1] admitted he knew about the abrasion [upper left buttock] on [Resident #1] during the 2/28/2023 meeting. He didn't understand that the abrasion was a wound. During a telephone interview on 5/9/2023 at 2:37 PM, Family Member #2 stated, I came to the facility on 2/19/2023. During my visit the tech took the brief off [Resident #1], and I saw the wound on her bottom. There wasn't a dressing on the wound so I went and asked the nurse if something should be on the wound. The nurse was an agency nurse and didn't know anything about the wound but said she would put something on it. I called [DON] the next day [2/20/2023] to find out why they had not told me about the wound. [DON] told me she spoke to the Wound Care Nurse and assured me it was an abrasion, and there was already a treatment in place. [DON] told me the Wound Care Nurse spoke to [Family Member #1] about the abrasion. After thinking about that conversation I tried to call [DON] back multiple times to question what I saw on [2/19/2023]. On [2/24/2023] I just went up to the facility to speak to the Administrator. I told him I felt like I had been lied to about [Resident #1]'s wound because what I saw was not just an abrasion. I told him that I wanted to see the wounds for myself. [Administrator] asked me if he could set up a meeting with [DON] on [2/28/2023] when she returned to work. I agreed to the meeting and assumed he would check to see if I was being told the truth before the meeting. In fact it wasn't until the day of the meeting that anyone looked at [Resident #1]'s wounds. On [2/28/2023] [DON] started the meeting by saying that she had assessed [Resident #1]'s skin that day. [DON] started crying and said, 'If you think her bottom looks bad, you should see her heels and ankles, they are horrific.' During an interview on 5/9/2023 at 5:11 PM, the Administrator stated, [Family Member #2] came to the facility on 2/24/2023 and voiced concerns about [Resident #1] having a wound that she was not aware of, and she thought it was more than what she had been told. She wanted to see the wound. [Family Member #2] wanted to meet with the Wound Care Nurse and DON about [Resident #1]'s care. I told her that [DON] would not be back until 2/29/2023. I did not have anyone else look into the wound on [Resident #1]. I waited for [DON]. The Administrator confirmed he did not have any nursing staff to assess the wounds from the time he was notified by the family on 2/24/2023 until the DON returned to the facility on 2/28/2023. Administration failed to ensure notification to the resident's physician and if applicable the resident representative with changes in status for 4 of 6 sampled residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for skin integrity/wounds. Refer to F-580 Administration failed to ensure Comprehensive Care Plans were revised with interventions implemented for an actual skin impairment for 1 of 7 (Resident #1) sampled residents reviewed for skin impairments. Refer to F-657. Administration failed to ensure nursing staff provided care and treatment consistent with professional standards of practice to promote healing and prevent new ulcers from developing for 3 of 3 (Resident #1, #2, and #3) sampled residents reviewed for pressure ulcers. Refer to F-686 Administration failed to ensure the facility provided nursing staff with the appropriate competencies and skills sets to provide nursing care including but not limited to assessing, evaluating, and implementing resident care plans and responding to resident's needs for 7 of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents reviewed for skin integrity/wounds. Refer to F-726

Based on facility policy review, observation, and interview, the facility failed to preserve the dignity of residents who required assistance with meals during the lunch meal observation on 6/20/2022, related to staff standing while assisting residents with meals and labeling residents as 'feeders.' The findings include: Review of the facility's policy titled, Assistance with Meals, revised on 7/2017, revealed, .Dining Room Residents .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .Not standing over residents while assisting them with meals .avoiding the use of labels when referring to residents .e.g (for example) [feeders] . Observation on 6/20/2022 at 12:10 PM in the dining room revealed Certified Nurse Technician (CNT) was standing over a resident while assisting the resident to eat. During an interview on 6/20/2022 at 12:17 PM in the dining room, CNT #3 stated, Technically she [named CNT #2] should be sitting instead of standing. During an interview on 6/20/2022 at 12:30 PM, the Director of Nursing (DON) confirmed CNTs should not stand when assisting a resident with their meal. Observation on 6/20/2022 at 12:39 PM revealed staff passing meal trays on the 4th floor. Continued observation revealed Licensed Practical Nurse (LPN) #1 stated to the CNTs, the rest on the cart are 'feeders.' During an interview on 6/20/2022 at 12:40 PM, LPN #1 confirmed she addressed the residents who were assisted with meals as 'feeders.' She stated, the people who need fed, are the feeders. During an interview on 6/22/2022 at 4:40 PM, the DON stated she expected staff to address residents as assisted diners not feeders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to allow decision making for a prescribed diet for 1 of 28 sampled residents (Resident #24). The findings include: Review of the facility's policy titled, Patient's Rights revised 2/2022, revealed .Individuals have the right to participate in planning and making decisions about their own care, including the right to accept or refuse medical or surgical treatment . Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses which included Wernicke's Encephalopathy, Dysphagia, and Gastrostomy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #24 required total assistance with one staff member for Activities of Daily Living. Resident #24 required a feeding tube to receive hydration and nutrition. Review of the current care plan dated 7/19/2021, revealed Resident #24 had swallowing difficulties which were related to dysphagia. Continued review revealed Resident #24 had a history of refusing tube feedings. Review of the Physician Order Report dated 6/22/2022, revealed .Jevity 1.5 bolus 480 mL [milliliter] cans TID [three times a day] 85 mL FWF [free water flush] before and after formula administered [Dx [diagnosis]: Dysphagia] . Review of the Progress Notes dated 1/12/2022, revealed .47 YOF [year old female] continue to be NPO [nothing by mouth], Enteral Nutrition Dependent receiving Jevity 1.5 Bolus 480 mL QID [four times a day] with 75 mL FWF before and after formula administered. She also has available additional bolus PRN [as needed] which she receives often. Resident has recently been shouting out feed me to staff and asking for PO [by mouth] foods . Review of the Progress Notes dated 1/24/2022, revealed .Resident continuously shouting out wanting to be fed. Switching to continuous feeds from bolus in hopes to keep resident satisfied throughout the day . During an interview on 6/20/2022 at 2:14 PM, Resident #24 stated she could not eat anything by mouth because she failed a swallow study test. Resident #24 stated she wanted to eat food by mouth even though she failed the swallow study. During an interview on 6/22/2022 at 11:45 AM, the Assistant Director of Nursing (ADON) stated Resident #24 had requested another swallow study because she wanted to eat by mouth. Resident #24 had a prior swallow study performed in the hospital before being admitted to the facility. Resident #24 had failed the swallow study and a feeding tube was placed while in the hospital. Resident #24 had another swallow study recently and she did not pass the study. The Speech Therapist evaluated Resident #24 and expressed she did not feel safe feeding the resident by mouth. During an interview on on 6/22/2022 at 3:45 PM, the Director of Therapy stated Resident #24 had two video swallow studies on 9/2021 and 5/2022. The Speech Therapist had administered five screenings over the course of a year to determine if Resident #24 was a candidate for speech therapy services. Resident #24 had told the Director of Therapy she wanted to have a regular diet to eat by mouth when she was first admitted to the facility. During an interview on 6/22/2022 at 4:01 PM, Family Member #1 stated Resident #24 was of sound mind to make decisions. Resident #24 had voiced to her she wants to have a regular diet and was the reason why she wanted another swallow study completed. Resident #24, hated the peg tube with a passion. The doctor had control on whether she kept the peg tube. The facility had not presented her with the choice to eat by mouth and sign a waiver understanding the risks that comes with going against physician orders. During an interview on 6/22/2022 at 4:12 PM, the Speech Therapist stated Resident #24 had the swallow study as an outpatient and the Speech Pathologist was responsible for explaining the results to Resident #24. The Speech Therapist was required to only receive the results of the swallow study and to follow recommendations. The Speech Therapist was not aware Resident #24 wanted to eat by mouth. During an interview on 6/22/2022 at 4:35 PM, the Director of Nursing (DON) stated staff had spoken to Resident #24 about the results of the swallow study. Resident #24 had not voiced to her she wanted to start eating by mouth. The DON confirmed the facility had not given Resident #24 the opportunity to make an informed decision regarding changing her diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure call lights were within reach for 5 of 59 sampled Residents (Resident #14, #18, #34, #45 and #48) reviewed. The findings include: Review of the undated facility's policy titled, Call Lights, revealed, .Be sure the call light is always within easy reach of the patient . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which included Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Chronic Obstructive Pulmonary Disease Unspecified, and Anxiety Disorder Unspecified. Review of the Finalized Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnosis which included Epilepsy and History of Falling. Review of the Annual MDS assessment for Resident #18 dated 4/7/2022, revealed a BIMS score of 4 which indicated severe cognitive impairment. Observation in Resident #18's room on 6/20/2022 at 9:26 AM, revealed the resident lying in bed on her back. Continued observation revealed the call light was behind the head of the bed on the floor. Observation and interview in Resident #18's room on 6/20/2022 at 11:49 AM, Licensed Practical Nurse (LPN) #1 confirmed the call light was behind the head of the bed on the floor and it was not within Resident #18's reach. LPN #1 stated, We are going to have to do better with these call lights. Observation in Resident #34's room on 6/20/2022 at 9:30 AM, revealed the resident's call light was lying in the floor. Resident #34 stated, No I can't reach my call light, can you get it for me. During and interview on 6/20/2022 at 9:35 AM, Registered Nurse #1 confirmed the call light should be in reach of Resident #34. During an interview on 6/20/2022 at 12:30 PM, the Director of Nursing (DON) confirmed call lights should be within the residents' reach while in their room. Review of medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance, Muscle Weakness Generalized, and History of Falling. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #45 had a BIMS score of 3, which indicated severe cognitive impairment. Observation of the call light on 6/20/2022 at 9:57 AM and 11:37 AM, in Resident #45's room, revealed the call light to be underneath Resident #45's bed and not within reach. During an interview on 6/21/2022 at 10:06 AM, the Assistant Director of Nursing (ADON) and the Nursing Supervisor confirmed call lights should be within reach of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review and staff interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis for 2 of 28 sampled residents (Resident #34 and Resident #50) reviewed for PASARRs. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review [PASARR], revised 11/2016 revealed, .The Omnibus Budget Reconciliation Act [OBRA-1987] requires all centers to screen patients before admission to determine if they have Mental Illness, Intellectual of Developmental Disability of related condition regardless of method of payment . Review of the medical record revealed Resident #34 was admitted on [DATE] with a diagnosis which included Dementia, Generalized Anxiety Disorder, Major Depressive Disorder and Sedative, Hypnotic or Anxiolytic Dependence. Review of the PASARR dated 7/9/2019, revealed .Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past .No mental health diagnosis is known or suspected . Continued review of the PASARR revealed .Has the individual been prescribed psychoactive [mental health] medications now or within the past 6 months .No . During an interview and medical record review on 6/22/2022 at 9:48 AM, Director of Nursing (DON) confirmed Resident #34's PASAAR was not completed by the (named state agency) prior to the resident's admission. The DON confirmed Resident #34 had a diagnosis of Generalized Anxiety Disorder and had been taken Clonazepam (Antianxiety) and Sertraline (Antidepressant) in the last 6 months. Review of the medical record revealed Resident #50 was admitted on [DATE] with diagnosis which included Fracture of lower end of Right Radius, Bipolar Disorder, and Anxiety Disorder. Review of Resident #50's medical record revealed no PASARR in the record. During an interview with DON she confirmed Resident #50 did not have a PASAAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interview, the facility failed to implement approaches on the care plan for 1 of 28 sampled residents (Resident #34). The Findings include: Review of the facility's policy titled, Documentation Guidelines Section VII: Patient Care Plans, dated 10/2021, revealed, .The center will ensure an interdisciplinary and comprehensive approach to the development of the patient's care plan of care .Care Plan Approaches are specific, individualized steps partners and patients will take together to assist the patient to achieve the goal .Responsibility for each approach is taken by the individuals and/or departments who added them to the care plan . Review of the medical record revealed Resident #34 was admitted on [DATE] with a diagnosis which included Dementia, Generalized Anxiety Disorder, Major Depressive Disorder and Sedative, Hypnotic or Anxiolytic Dependence. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognitive abilities. Continued review of the MDS revealed Resident #34 required limited to extensive assist with Activities of Daily Living (ADLs). Review of the Care Plan dated 8/5/2020-Present, revealed a plan of care developed to address falls with the approaches for the use of signs in bathroom reminding resident to lock wheelchair before transferring, resident not to be left in restroom alone, and 8/19/2019 Maintenance to install anti-slip strips in front of toilet. Observation in Resident #34's room on 6/20/2022 at 9:30 AM, 9:50 AM, and 3:44 PM, revealed no signage or anti-slip strips in front of toilet. Observation in Resident #34's room on 6/21/2022 at 10:00 AM, revealed Resident #34 coming from bathroom independently. Continued observation in Resident #34's room revealed no signage or anti-slip strips in front of toilet. Observation and interview in Resident #34's room on 6/22/2022 at 5:30 PM, revealed Resident #34 in his bathroom alone. Continued observation and interview in Resident #34's room, Director of Nursing (DON) confirmed resident was in bathroom alone, no sign in the bathroom to remind him to lock wheels or anti-slip strips in front of toilet. DON stated, The strips are probably not there because he has changed rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review, medical record review, observations, and interviews, the facility failed to ensure 1 of 59 sampled residents (Resident #45) had clean and groomed fingernails. The findings include: Review of facility's documentation titled, Fingernails/Toenails, Care of, revised 2/2018, revealed, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed . Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance. Review of the Comprehensive Care Plan for Resident #45 dated 11/9/2021, revealed, .Keep nails cleaned and trimmed . Observation on 6/20/2022 at 9:57 AM and 11:37 AM, in Resident #45's room revealed the resident had brown debris under her fingernails on both hands. Observation and interview on 6/20/2022 in Resident #45's room at 11:42 AM, with Licensed Practical Nurse (LPN) #1 she looked at the resident's hands and confirmed the resident had brown debris under her fingernails on both hands. During an interview on 6/21/2022 at 10:06 AM, the Assistant Director of Nursing (ADON) and the Nursing Supervisor, confirmed nail care should be done weekly with showers and as needed when visibly dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to store oxygen tubing properly for 1 of 2 sampled resident (Resident #42) observed. The findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Physician Order Report dated 6/22/2022, revealed .Oxygen 3 Liters per Nasal Cannula . Observation in Resident #42's room on 6/20/2022 at 3:25 PM and 3:39 PM, revealed the oxygen nasal cannula tubing was wrapped around the oxygen flow meter. Observation an interview in Resident #24's room on 6/20/2022 at 4:05 PM, with Registered Nurse (RN) #1, revealed the oxygen tubing was wrapped around the oxygen flow meter. RN #1 confirmed the oxygen nasal cannula tubing was supposed to be stored in a bag. During an interview on 6/22/2022 at 4:39 PM, the Director of Nursing expected the oxygen nasal cannula tubing was to be stored in a bag.

Based on facility policy review, medical record review, and interview, the facility failed to serve food in a sanitary manner for residents being assisted with the lunch meal. The findings include: Review of the facility's policy titled, Preventing Foodborne Illness-Food Handling, revised on 7/2014, revealed, .Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized .All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness .Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents . Review of the facility's policy titled, Assistance with Meals, revised on 7/2017, revealed, .Dining Room Residents .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .Not standing over residents while assisting them with meal .avoiding the use of labels when referring to residents [feeders] .All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling . Observation in the Dining room on 6/20/2022 at 12:14 PM, revealed Certified Nurse Technician (CNT) #2 touched half of the pimento cheese sandwich with her bare hand. During interview on 6/20/2022 at 12:15 PM, CNT #2 stated, I should have cut the sandwich up with the fork instead of touching the sandwich with my bare hands. During an interview with Director of Nursing (DON) on 6/20/2022 at 12:30 PM, she confirmed food should not be handled with your bare hands when assisting a resident with their meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to prevent the spread of infection in 1 of 44 resident rooms. The findings include: Observation on 6/20/2022 at 10:00 AM, Certified Nurse Technician (CNT) #1 walked into room [ROOM NUMBER] with a dirty linen barrel, stripped the bed, put the dirty linens into the dirty linen barrel, and brought the dirty linen barrel out of the room into the 400 Hallway. During an interview on 6/20/2022 at 10:12 AM, on the 400 Hall outside of room [ROOM NUMBER], CNT #1 confirmed she took the dirty linen barrel into room [ROOM NUMBER]. She stated, I am supposed to bring linens out of the room in a bag to the barrel in the hall. I forgot the bag. I wanted to get the linens out of the room before the resident returned. I know I am not supposed to take the barrel into the room. During an interview on 6/22/2022 at 5:50 PM, the Infection Control Nurse/Assistant Director of Nursing stated she expected Certified Nursing Technicians (CNTs) to place dirty linens in a bag and transport them to the dirty linen barrel outside of the resident room in the Hall. She stated, CNTs are not supposed to take the yellow barrels [dirty linen barrels] into the resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to notify the physician and resident representative on a fall for 1 (#1) of 3 residents reviewed for falls. The findings include: Facility policy review, Incident and Accident Process, dated 3/1/01 and revised on 8/13/13 revealed .An incident or accident is defined as Falls Found on floor . Continued review revealed documentation and reporting of an incident/accident would include .all known facts, results of assessment including a complete description of injuries, treatment, notification of physician and family .Complete an Incident Report .Report the occurrence so it gets to the 24 hour report .Accidents not resulting in injuries should still be reported. Injuries can be found or develop later .Occurrences of an unusual nature will be reported as required by State Law . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Difficulty in Walking, History of Falling, Muscle Weakness, and Unspecified Lack of Coordination. Medical record review of nurses' note dated 9/16/19 at 1:25 PM revealed .resident observed sitting on floor with legs folded behind her and back against wall beside bathroom door. when [When] asked what she was trying to do. resident [Resident] stated she was trying to turn lights off at the light switch behind door. resident appears with no apparent injuries to joints, full range of motion present. resident denies hitting head or any acute injuries r/t [related to] fall. vitals [Vital signs] wnl [with in normal limits]. resident assisted to standing position by assist of nurse and CNA [Certified Nursing Aide], then sat . on rollator [mobility device, with a seat]. resident transferred to recliner in room for further assessment. resident remains alert at baseline with no acute discomfort voiced. vitals remain wnl. proper staff aware per protocol . Further review revealed the physician and resident representative had not been notified of the fall on 9/16/19. Interview with the Director of Nursing (DON) on 10/9/19 at 3:46 PM in the Library confirmed the facility failed to notify the physician, resident representative and DON of the fall on 9/16/19 for Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to complete a fall investigation for 1 (#1) of 3 residents reviewed for falls. The findings include: Facility policy review, Incident and Accident Process, dated 3/1/01 and revised on 8/13/13 revealed .An incident or accident is defined as Falls Found on floor . Continued review revealed documentation and reporting of an incident/accident would include .all known facts, results of assessment including a complete description of injuries, treatment, notification of physician and family .Complete an Incident Report .Report the occurrence so it gets to the 24 hour report .Accidents not resulting in injuries should still be reported. Injuries can be found or develop later .Occurrences of an unusual nature will be reported as required by State Law . Medical record review revealed Resident # 1 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Difficulty in Walking, History of Falling, Muscle Weakness, and Unspecified Lack of Coordination. Medical record review of Quarterly Minimum Data Set, dated [DATE] revealed Resident #1's balance was not steady, but able to stabilize without staff assistance. Medical record review of nurses' note dated 9/16/19 at 1:25 PM revealed .resident observed sitting on floor with legs folded behind her and back against wall beside bathroom door. when [When] asked what she was trying to do. resident [Resident] stated she was trying to turn lights off at the light switch behind door. resident appears with no apparent injuries to joints, full range of motion present. resident denies hitting head or any acute injuries r/t [related to] fall. vitals [Vital signs] wnl [with in normal limits]. resident assisted to standing position by assist of nurse and CNA [Certified Nursing Aide], then sat . on rollator [mobility device, with a seat]. resident transferred to recliner in room for further assessment. resident remains alert at baseline with no acute discomfort voiced. vitals remain wnl. proper staff aware per protocol . Further review revealed the physician and resident representative had not been notified of the fall on 9/16/19. Interview with the Director of Nursing (DON) on 10/9/19 at 3:46 PM in the Library confirmed the facility failed to complete a fall investigation for Resident #1 for the fall on 9/16/19.

Based on review of the menu, observation and interview, the facility dietary department failed to serve pureed food at the portion size specified on the menu and failed to prepare the pureed consistency appropriately for 8 of 8 pureed diets. The findings include: Review of the menu for 10/7/19 mid-day meal revealed the puree consistency diets were to receive a #16 scoop (2 ounces) of pureed meat and a #8 scoop (4 ounces) of pureed broccoli with cheese. Observation on 10/7/19 at 11:25 AM at the dietary department trayline revealed the resident mid-day meal service was in progress. Further observation, with the facility Registered Dietitian (RD) present, revealed the dietary staff member serving the food used a partially filled #8 scoop for the pureed meat and a #12 scoop (2.6 ounces) of pureed broccoli. Further observation revealed the pureed meat, pureed rice and pureed broccoli were all a very thin consistency and ran together in the plate. Interview with the RD on 10/7/19 at 11:25 AM at trayline confirmed the dietary staff failed to serve the portion size specified by the menu for the pureed meat and the pureed broccoli. Further interview confirmed the pureed food consistency was runny.

Based on review of the facility policies, review of the Equipment Cleaning Schedule, observation and interview, the facility failed to maintain dietary equipment in a sanitary manner and failed to dispose of expired food of the emergency food supply in 1 of 6 observations. The findings include: Review of the facility policy, Safety & Sanitation Best Practice Guidelines - Cleaning Equipment, reviewed/revised on 11/2017 revealed .Equipment must be cleaned and/or sanitized after each use . Review of the facility policy, Safety & Sanitation Best Practice Guidelines - Dry Storage, reviewed/revised on 11/2017 revealed .Scoops should be stored in a sanitary method with handles of scoops not contacting food . Review of the facility policy, Safety & Sanitation Best Practice Guideline - Emergency/Disaster Planning, reviewed/revised 11/2017, revealed .shelf stable or canned items without manufacturer's shelf life directions should be rotated every 6-12 months. A system should be set up to monitor and rotate supplies and check manufacturer's Use By, Best By and Expiration date on all items . Review of the Equipment Cleaning Schedule revealed .Tilting Skillet Clean and sanitize pan and cover, inside and outside after each use .Microwave .Clean interior surfaces .at the end of each shift .Ovens .Clean outside surfaces .at the end of each shift .Clean interior surfaces and racks .Weekly . Observation of the resident mid-day meal trayline service on 10/7/19 at 11:25 AM, with the Registered Dietitian (RD) present, revealed 3 dietary male staff members with beards working on the trayline. Further observation revealed 1 male staff member failed to wear a beard covering while working on the trayline. Further observation revealed 1 female dietary staff member preparing food in the dietary department with her bangs hanging out of the hair covering. Observation on 10/7/19 at 11:47 AM, with the RD present, revealed the 2 range top spill pans with an accumulation of dried food debris, including round noodles, along with a blackened accumulation of debris. Further observation revealed the tilt skillet interior lid had condensation and a sticky brown colored accumulation of debris. The tilt skillet handle had sticky debris present. The interior of the microwave had yellow colored debris present. The 2 crumb trays of the table top toaster were filled with crumbs. The convection oven interior surfaces, including the racks and doors, had a heavy accumulation of blackened debris. A scoop was stored in the bins of flour and sugar in a manner where contact could be made with the bin contents. The storage bin with corn meal had food debris present in the meal. Observation on 10/7/19 at 11:47 AM of the emergency food supply, with the RD present, revealed the following foods were dated February 2018, Blackeyed Peas, Peaches, Ravioli, Beef Hash, Applesauce, Pork-n Beans, [NAME] Beans, and Chili Con Carne. Interview with the RD on 10/7/19 at 11:25 AM in the dietary department confirmed 1 male staff member failed to cover the facial hair and 1 female staff member failed to completely cover her hair while in the food preparation/service areas. Interview with the RD on 10/7/19 at 11:47 AM in the dietary department confirmed the dietary equipment was not maintained in a sanitary manner. Further interview revealed the round noodles were prepared last Thursday. Further interview revealed the tilt skillet was last used .2 weeks ago . Further interview confirmed the emergency food supply had 8 cases of food dated 2/2018. When asked what the facility policy was regarding the food rotation the RD stated .replaced annually .