**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to conduct timely revisions of the comprehensive care plan for two residents (Resident #1 and Resident #5) in a survey sample of 14 residents. For Resident #1 (R1) the failure to revise the care plan and implement interventions that ensured R1 received the required dialysis treatments as ordered, resulted in R1 missing 3 dialysis sessions and 3 partial treatments, which resulted in four hospitalizations. This constituted four occurrences of harm. The findings included: 1. For R1, the facility staff failed to address and implement interventions to ensure that the resident received dialysis services when the family was unable to accompany the resident, which resulted in 3 missed sessions and 3 partial treatments. This failure resulted in four hospitalizations for urgent treatment of fluid overload, a potentially life-threatening condition which occurs when fluid & toxins are not removed as scheduled with dialysis. According to the closed record review, R1 was ordered to receive dialysis on Monday, Wednesday, and Fridays. From August 1, 2023, until October 17, 2023, R1 had four hospitalizations, (8/2/23, 10/4/23, 10/13/23, and 10/17/23). According to R1's clinical record, a physician's order dated 8/1/23 noted that R1 required a companion during dialysis. According to the clinical record, the comprehensive care plan was not revised to address this need until 10/13/23. The associated goal read, I will not have any ill effects from my dialysis treatment and will receive my treatment timely through next care plan review. The intervention was noted as: family member is aware of dialysis days/times, however, will often no show up at the dialysis center therefore resident does not receive dialysis as scheduled. No interventions were found to ensure that R1 received treatments when facility staff were aware that the family would frequently not be able to attend the dialysis treatments. A review of the progress notes revealed a progress note entry dated 07/31/2023 at 10:27 a.m., that read, Resident returned from dialysis @ approximately 0800 via [transport company name redacted]. No s/s [signs or symptoms] distress. NNO [no new orders]. Fistula to RUA [right upper arm], thrill and bruit present. Pressure dressing in place, CDI [clean, dry, intact]. VSS [vital signs stable]. Received call from dialysis that the resident received very little dialysis d/t [due to] pulling needles out. Dialysis nurse also stated that to continue dialysis the resident will need someone to sit with her during treatment time. Management notified. Will continue to monitor. On 08/02/2023 at 2:10 p.m., a progress note was entered that read, Resident sent back from dialysis without receiving treatment. Daughter did not attend appointment due to childcare. NP spoke with daughter. [name redacted] informed NP that she would not be able to meet resident at dialysis, but she also did not want resident changed from full code. Daughter requested that resident be sent to ED [emergency department]. EMS [emergency medical services] called, resident left facility at 1108. Report called to ED and daughter aware. On 08/02/2023, the nurse practitioner (NP) entered a note that read in part, Date of Service: 08/02/2023, . Chief Complaint / Nature of Presenting Problem: No dialysis x 6 days, pt pulling lines out, dtr [daughter] cannot go to dialysis with pt due to children and no money for childcare. Dialysis will not do pt dialysis without family member present to keep her from pulling out line. [daughter's name redacted], pt dtr will not be able to go to dialysis with pt, she requests pt go to hospital . Plan: N18.6: ESRD (end stage renal disease) Pt unable to receive dialysis any longer through our facility, as she keeps pulling lines out, risk of bleeding to death. Dtr was asked to be present when she receives dialysis, dtr declined as she has no childcare and cannot afford it. Pt has not had sufficient dialysis in a week, in danger of fluid overload, etc. Sent to ER . R1's hospital records dated 8/2/23 read, ED Triage Notes Addendum: Pt arrived via EMS. From [facility name redacted]. dialysis pt last dialysis July 20, 2023. facility states family has to go with pt when she goes but that been unable to get in touch with family. Pt takes stuff off, so she has to have someone with her On 10/04/2023 at 8:21 p.m., a progress note read, Received call from [dialysis clinic name redacted] nurse stating that they are sending pt to ED due to family not present to sit with her during dialysis appt this AM and increased facial swelling. Pt sent to ED from Dialysis-no updates at this time. Will continue to monitor and awaiting updates from ED. Hospital records in R1's chart dated 10/4/23 read, visit information: arrival: 10/4/23 6:55 p.m., Chief complaint: shortness of breath . ED notes . missed dialysis, edema in eye/[NAME], chest x-ray shows fluid on lungs, on bipap, had temp 100.7 additional EMS patient and scene information: confused/does not cooperate. went to dialysis today. Issues with family can only get dialysis with a sitter, family did not show up so no dialysis. cxr [chest x-ray] fluid on lungs. de-satted [oxygen saturation levels dropped] to 67% so they placed her on BIPAP. fever 100.7 so they gave Tylenol. BP there ran 230/90s. they placed a nitro patch The hospital discharge summary noted, diagnosis to include acute respiratory failure with hypoxia, volume overload state . concern for uremic encephalopathy . Presented to hospital with respiratory distress after missing dialysis, noted to have lethargy, concerning for acute metabolic encephalopathy, hyperkalemia noted, underwent emergent HD [hemodialysis], hypertensive urgency, likely secondary to volume overload state and missing dialysis . concern for uremic encephalopathy . at baseline after HD On 10/08/2023 at 8:15 p.m., a progress note entry read, . Spoke with hospice nurse-family unable to sit with pt tomorrow for Dialysis and [dialysis clinic name redacted] will not give pt dialysis unless family present. Placed in primary care book. No distress noted-will notify primary care of worsening changes. On 10/13/23, the nurse practitioner entered another note that read, Date of Service: 10/13/23 . discharged to hospital r/t not being able to receive dialysis MWF . Discharge . Facility Course: Sent to hospital for further eval. Pt daughter is to go with her for dialysis, pt daughter did not, [dialysis clinic name redacted] will not do dialysis without the daughter present. Pt sent to ER for dialysis, as she cannot miss it, or edema builds up extremely quickly. On 10/17/2023, the NP wrote a note that read, .Chief Complaint / Nature of Presenting Problem: Edema of eyelids . Plan: ESRD missed dialysis, edema eyelids, sent to ED for dialysis A facility nurse also documented on 10/17/23, Resident up to w/c in dayroom. Facial swelling noted. Due to resident not receiving dialysis. New order noted to send resident to ED for further eval. Daughter [name redacted] notified. Resident left facility at 11:11. The care plan was not updated to address these missed dialysis treatments, the increased symptoms, or the resulting hospitalizations. On 1/16/24 and 1/17/24, interviews were conducted with multiple facility staff. They included, LPN C, LPN B/unit manager, Employee C/social worker, Employee D/admissions director, the facility administrator, and nurse practitioner. All of which indicated they were aware that Resident #1 required someone to be present for dialysis treatments for safety reasons. Each of them verbalized that the resident's family was supposed to accompany her. None of the staff identified that the facility had an obligation to implement interventions to ensure the resident received these life sustaining care and services. No one voiced an explanation as to why the care plan had not been updated to address the lack of consistent support R1 needed while at dialysis or the outcomes of the missed treatments. On 1/16/24, when asked why the facility didn't implement alternate measures or send someone with the resident she responded, the administrator stated that facility doesn't provide one on one care and didn't have the staffing to do this. On 1/17/24, when asked what the facility did in terms of other interventions to ensure R1 received the needed dialysis treatments, when they were aware that R1's family was not able to meet the resident and stay with them during dialysis consistently, the administrator didn't respond. On the afternoon of 1/30/23, an interview was conducted with Employee L and Employee M, the MDS (minimum data set - an assessment tool) nurses. Both Employee L and M confirmed that they develop and revise care plans. When asked about the purpose of the care plan, Employee L said, it is to provide an individualized picture of the care the resident needs based on diagnosis, medications, and ADL's (activities of daily living). It is anything we are going to provide while they are here. When asked about resident changes, both employees agreed that changes are reflected on the care plan. R1 was discussed and noted that on 8/1/23, an order was noted that the Resident needed a sitter while at dialysis. Employee M confirmed that it was not added to the care plan until 10/17/23. When asked why the delay and what interventions had been implemented when they were aware the family was not able to meet R1 consistently, Employees L and M said, We aren't involved in those discussions, while we are nurses those discussions are held between administration and the clinical team and we were not involved. The facility policy titled; Care Plan was reviewed. The facility in part read, . 22. There may be additional problem areas not triggered by the MDS, which will need to be addressed in the care plan. 23. The IDT is to review the 24-hour report during morning meeting for significant changes or changes in resident's ADL status. The IDT will add minor changes in resident's status to the existing care plans . No further information was provided. 2. The facility staff failed to revise the care plan for Resident #5 (R5) who had a MRSA infection and required transmission-based precautions be implemented. On 1/16/24 at approximately 11:30 a.m., during a facility tour, R5 was observed from the hallway to be lying in bed with an IV pole at the bedside and a medication bag hanging from the pole. Within the room there was a red 55-gallon trash barrel and a yellow 55-gallon trash barrel. There was no signage outside the room to indicate that any special isolation requirements were in place. On 1/16/24, a clinical record review was conducted. According to the clinical record, R5 was readmitted to the facility on [DATE], with diagnoses that included, but were not limited to, MRSA and ESBL [highly resistant bacterial infections] in the wound rt foot, per the hospital discharge records. On 12/27/23, an order for contact isolation was entered, which remained an active order at the time of survey. Review of the care plan revealed no mention of the MRSA or ESBL infections nor the transmission-based precautions. On 1/17/24 at approximately 10:30 a.m., observations were conducted of R5's room and signage was noted on the outside of the room to indicate the resident was on isolation. When asked about these findings, the director of nursing, who is the facility infection preventionist, stated that R1 remains on precautions and should be included in the care plan. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to ensure a Resident who required dialysis received scheduled dialysis treatments as ordered by the physician for 1 Resident (Resident #1) in a survey sample of 3 dialysis Residents reviewed. Resident #1 (R1) was hospitalized 4 times during a 3-month period due to missed dialysis treatments, requiring hospitalization for urgent dialysis due to being symptomatic of fluid overload, this constituted harm. The findings included: According to the clinical record R1, was initially admitted to the facility on [DATE]. Diagnoses for R1 included but were not limited to end stage renal disease and legal blindness. On [DATE] and [DATE], a closed record review was conducted of R1's chart. This review revealed that R1 was ordered to receive dialysis on Monday, Wednesday, and Fridays. From [DATE], until [DATE], R1 had four hospitalizations, ([DATE], [DATE], [DATE], and [DATE]) due to missing multiple dialysis treatments and being symptomatic with fluid overload because of not being dialyzed due to not having someone accompany the resident to the treatments. According to the clinical record, the following details were documented: 1. A progress note entry dated [DATE] at 10:27 a.m., read, Resident returned from dialysis @ approximately 0800 via [transport company name redacted]. No s/s [signs or symptoms] distress. NNO [no new orders]. Fistula to RUA [right upper arm], thrill and bruit present. Pressure dressing in place, CDI [clean, dry, intact]. VSS [vital signs stable]. Received call from dialysis that the resident received very little dialysis d/t [due to] pulling needles out. Dialysis nurse also stated that to continue dialysis the resident will need someone to sit with her during time. Management notified. Will continue to monitor. 2. Another progress note dated [DATE] at 10:41 a.m., read, Dialysis called and informed staff at this point resident is no longer allowed to come to dialysis unless someone is with her. This nurse and SSD [social services director] called [sic] and spoke to daughter [name redacted] about this. She stated she was going to call and talk with her sister and weigh options between going with resident or placing on hospice. 3. On [DATE] at 1:49 p.m., a note read, SSD spoke with daughter [name redacted] who advised they would have family accompany resident with dialysis and will meet resident at [dialysis name redacted] at chair time. SSD and [name redacted] called [dialysis name redacted] together to request change in chair time since family will have to accompany resident for each treatment. [dialysis name redacted] advised chair time can be changed to 9am. 4. On [DATE] at 06:06 a.m., a SBAR - Change of Condition note read, Situation: Puffy, swollen eyes. Background: CNA reported change in condition. CNA noted puffiness, swelling to both eyes around 515am. Assessment: Resident able to open eyes without difficulty. Some puffiness noted. No redness or drainage noted at present. No c/o pain. Response: CNA wash resident face with warm bath cloth. Nurse assess resident for redness, drainage, and pain to both eyes, none noted or voiced at present. 5. On [DATE] at 10:46 a.m., the nursing note read, This nurse noted resident to have very swollen eyes. Resident stated she could feel they were swollen but she was not having any pain associated with it. NP [nurse practitioner] made aware and assessed. She noted resident's eyes. Lungs sounded clear. NP stated she would reassess later to check for changes. 6. On [DATE] at 2:10 p.m., a note was entered that read, Resident sent back from dialysis without receiving treatment. Daughter did not attend appointment due to childcare. NP spoke with daughter. [name redacted] informed NP that she would not be able to meet resident at dialysis, but she also did not want resident changed from full code. Daughter requested that resident be sent to ED [emergency department]. EMS [emergency medical services] called, resident left facility at 1108. Report called to ED and daughter aware. 7. On [DATE], the nurse practitioner (NP) entered a note that read, Date of Service: [DATE], . Chief Complaint / Nature of Presenting Problem: No dialysis x 6 days, pt pulling lines out, dtr cannot go to dialysis with pt due to children and no money for childcare. Dialysis will not do pt dialysis without family member present to keep her from pulling out line. [daughter's name redacted], pt dtr will not be able to go to dialysis with pt, she requests pt go to hospital . Plan: N18.6: ESRD (end stage renal disease) Pt unable to receive dialysis any longer through our facility, as she keeps pulling lines out, risk of bleeding to death. Dtr was asked to be present when she receives dialysis, dtr declined as she has no childcare and cannot afford it. Pt has not had sufficient dialysis in a week, in danger of fluid overload, etc. Sent to ER . 8. The hospital records that were included in R1's facility chart dated [DATE] read, ED Triage Notes Addendum: Pt arrived via EMS. From [facility name redacted]. dialysis pt last dialysis [DATE]. facility states family has to go with pt when she goes but that been unable to get in touch with family. Pt takes stuff off, so she has to have someone with her . 9. On [DATE], the nurse practitioner wrote a note in the chart of R1. Excerpts from the note read, . chief Complaint/Nature of Presenting Problem: Eyes puffy, bilaterally. No distress . Plan: ESRD [end stage renal disease] recent av fistula clotted, continue current medication, Dialysis MWF, con't with nephrology, monitor for fvo [fluid volume overload], particularly lungs, DM II on insulin, continue current medication, con't to monitor closely . 10. On [DATE] at 8:21 p.m., a note read, Received call from [dialysis clinic name redacted] nurse stating that they are sending pt to ED due to family not present to sit with her during dialysis appt this AM and increased facial swelling. Pt sent to ED from Dialysis-no updates at this time. Will continue to monitor and awaiting updates from ED. 11. Hospital records in R1's chart dated [DATE] read, visit information: arrival: [DATE] 6:55 p.m., Chief complaint: shortness of breath . ED notes . missed dialysis, edema in eye/[NAME], chest x-ray shows fluid on lungs, on bipap, had temp 100.7 additional EMS patient and scene information: confused/does not cooperate. went to dialysis today. Issues with family can only get dialysis with a sitter, family did not show up so no dialysis. cxr [chest x-ray] fluid on lungs. de-satted [oxygen saturation levels dropped] to 67% so they placed her on BIPAP. fever 100.7 so they gave Tylenol. BP there ran 230/90s. they placed a nitro patch . The discharge summary noted, diagnosis to include acute respiratory failure with hypoxia, volume overload state . concern for uremic encephalopathy . Presented to hospital with respiratory distress after missing dialysis, noted to have lethargy, concerning for acute metabolic encephalopathy, hyperkalemia noted, underwent emergent HD [hemodialysis], hypertensive urgency, likely secondary to volume overload state and missing dialysis . concern for uremic encephalopathy . at baseline after HD 12. On [DATE] at 8:15 p.m., a progress note entry read, S/P [status post] return from hospital-day 3-Pt alert/confused. Requires assist with all ADL's and transfers. Incontinent of bowel and bladder. Feeds self after tray set up. Requires Dialysis three times a week. Spoke with hospice nurse-family unable to sit with pt tomorrow for Dialysis and [dialysis clinic name redacted] will not give pt dialysis unless family present. Placed in primary care book. No distress noted-will notify primary care of worsening changes. 13. The nurse practitioner entered another note that read, Date of Service: [DATE], Transition of Care: No transition occurred . Discharge Summary . Chief Complaint / Nature of Presenting Problem: discharged to hospital r/t not being able to receive dialysis MWF . Discharge . Facility Course: Sent to hospital for further eval. Pt daughter is to go with her for dialysis, pt daughter did not, [dialysis clinic name redacted] will not do dialysis without the daughter present. Pt sent to ER for dialysis, as she cannot miss it, or edema builds up extremely quickly. 14. On [DATE], R1 was again sent to the hospital symptomatic for fluid overload. The NP wrote a note that read, .Chief Complaint / Nature of Presenting Problem: Edema of eyelids . Plan: ESRD [End Stage Renal Disease] missed dialysis, edema eyelids, sent to ED for dialysis. The NP wrote, Resident up to w/c in dayroom. Facial swelling noted. Due to resident not receiving dialysis. New order noted to send resident to ED for further eval. Daughter [name redacted] notified. Resident left facility at 11:11. 15. The hospital records dated [DATE] read, pt arrived to ED via EMS after dispatched as needs ride for dialysis pt complaining of increased swelling of face On [DATE] at approximately 2:15 p.m., an interview was conducted with LPN C. LPN C stated that R1 had been very pleasant and had started rubbing at their skin constantly. LPN C said that R1 did this at dialysis and at one point pulled the dialysis catheter out because she was rubbing at her skin so much. LPN C stated that dialysis told the facility if they couldn't get the resident calm, someone would have to sit with the resident through the dialysis sessions. LPN C said that the facility tried to pre-medicate R1 before dialysis, but it wasn't effective. LPN stated that at times R1 would have to be sent to the hospital for dialysis where they could sedate the resident. LPN C said that it went on for about a month and a half, when the family didn't meet the resident at dialysis, R1 would miss dialysis, and have to be sent to the hospital. LPN C said that it was her understanding that R1 was kept at the hospital and later expired. On [DATE] at 2:31 p.m., an interview was conducted with LPN B, who was the unit manager where R1 resided. LPN B explained that R1's rubbing caused him/her to not be able to do dialysis without someone being there, he/she was pulling out the dialysis line. LPN B stated that dialysis wouldn't let the resident in their building if the resident's daughter wasn't with them. LPN B said, The family wasn't always compliant. We would talk with them, and they would say they were on the way to meet the resident and then wouldn't show up. When asked why R1 didn't return to the facility, LPN B said, I don't know if it was a needs thing, I think the family put on Facebook they were going to put her on hospice. On [DATE] at 2:35 p.m., an interview was conducted with Employee C, the facility's social worker (SW). The SW stated R1 was a dialysis resident who had started to decline. The SW stated that the facility was having an issue with the family providing one on one to sit with the resident at dialysis and had gotten the ombudsman and adult protective services (APS) involved. Employee C said, The daughter locally was in agreement with meeting him/her at dialysis but wouldn't go, so dialysis would send her back. Because the daughters failed to meet the resident at the appointments it caused multiple hospitalizations. When asked why the resident had to have someone with them at dialysis, the SW said, They [dialysis] made that order because he/she was fidgety, restless and pulling at the line. The SW said that she had talked to APS about getting an order to make the daughters meet the resident, but that APS had said they were not able to do that. The SW went on to say that the family was getting the Resident's income and she felt they should have used that money to pay for a sitter so that the resident could get the needed treatment. On [DATE] at 2:55 p.m., an interview was conducted with Employee D, the admissions director. When asked about R1, Employee D said, Dialysis requested that he/she have a sitter due to restlessness. We would take [the resident's name redacted] back from the hospital and the family would agree they would meet them for dialysis, but they weren't consistent. [R1 name redacted] was sent out and due to them [the resident's family] not being able to provide what they said, they ended up just doing hospice at the hospital. On [DATE] at 3:10 p.m., an interview was conducted with the facility Administrator. The administrator said, We started having difficulty with dialysis. They put an order in that someone had to be with the resident [R1]. They [the family of R1] would quit going and dialysis would send the resident back. They said we couldn't send the resident unless the daughter would ride with her to the appointment. We would have to send the resident to the hospital, his/her eyes would swell shut from the fluid build-up, it put us at risk. On [DATE] at 8:43 a.m., the facility administrator requested to talk to the surveyor regarding R1. During the conversation the administrator said, . [R1's name redacted] would go 3 days maybe and we were having to send him/her back to the emergency room. The ER called and said we had to stop sending the resident. I explained the resident was a full code, and it was necessary because [R1] was short of breath and filling up with fluid When asked why they didn't send a staff member to accompany the resident so that R1 could get dialysis if the family didn't show up, the administrator said, We don't do one on one care here, we did it once, but we don't have the staffing here. The administrator further stated that the facility had tried to get the resident's family to change the dialysis to 2 days a week, but the family never followed through with that, but the doctor had said they didn't know if the resident could manage on two days. The administrator said, [R1 name redacted] couldn't manage missing one dialysis appointment and he/she would start filling up with fluid. On [DATE], an interview was conducted with the facility's nurse practitioner (NP). The NP was asked about R1 and the resident's discharge. The NP stated that it was her understanding that the resident's family decided to take the resident to another facility that could transport the resident to dialysis. The NP said that she was aware there were times that the family wouldn't meet R1 and the resident would have to be sent to the hospital for dialysis. When asked why the facility did not send someone to accompany the resident to dialysis so that R1 could have the dialysis treatment, the nurse practitioner said that she thought the facility had done that several times. On [DATE] and again on [DATE], when asked why the facility didn't implement steps or send someone with R1, the administrator responded, that the facility did not provide one on one care and don't have the staffing to do this. When asked when they were aware that R1's family was not able to meet the resident and stay with them during dialysis consistently, what did the facility do in terms of other interventions to ensure R1 received the needed dialysis treatments, the administrator didn't respond. On [DATE] at 2:32 p.m., a telephone call was placed to the daughter of R1. The family member stated that they were told they had to accompany R1 to dialysis and were told they didn't have the staff and it was our responsibility. R1's daughter went on to explain that R1 stayed in the hospital a month, before going to another facility where she passed away. On [DATE] at 3:14 p.m., an interview was conducted with Employee H, the activities director. Employee H stated that she had accompanied R1 to dialysis on one occasion and had her assistant accompany the resident at another time. When asked what had prompted her and her employee to accompany the resident on those 2 days, Employee H said, When we had trouble with the family. When asked why the facility didn't send someone with R1 on the other occasions when family was not able to accompany the resident, Employee H said, I wasn't asked to. On [DATE] at 3:40 p.m., an interview was conducted with Employee J, who coordinates transportation to outside appointments for residents. When asked about R1's transport to dialysis, Employee J said that transportation had not been a problem but the problem was the family meeting the resident at dialysis. When asked if the facility sends a staff member with residents to appointments, Employee J said, Usually not. When asked what happened in case a resident was confused and unable to communicate with the provider about what was going on, Employee J said, We would send someone in that case. I would not send someone who is not cognitively intact to an appointment alone, if the family can't go, then we have to send someone with them. Employee J went on to say that she is also a CNA and at times will accompany residents to appointments. When asked if she ever accompanied R1 to dialysis, Employee J said, No. On [DATE], during a review of the facility staffing, in the presence of the HRM (human resources manager)/Employee G, it was noted that on [DATE], the staff assignment sheet noted CNA E was assigned to provide one on one care. When asked about this provision of one on one care, Employee G stated that a resident had been having behaviors, so CNA E was called in to provide the one on one care. On [DATE], as CNA E was not working at the facility during the survey, a telephone call was placed to CNA E and an interview was conducted. CNA E identified that on [DATE], she was called by the HRM/Employee G and asked to come provide one-to-one care for Resident #12 (R12). CNA E went on to describe that R12 had been very anxious, wandering, and exit seeking. When asked what type of care was provided, CNA E stated that she had stayed with R12 and walked with them until they calmed down around 3 p.m. When asked if she had provided one-to-one care to any other residents, CNA E stated that she had provided one to one care for [name redacted - identified as Resident #11]. A closed clinical record review was conducted of Resident #11's chart. According to the clinical record documentation, Resident #11 (R11) received one on one care around the clock for at least a week in [DATE]. On the afternoon of [DATE], an interview was conducted with the Director of Nursing (DON) and administrator. When asked to explain how R11 and R12 having been provided one to one care, the DON stated that R12 could easily be mistaken for a visitor, ambulated without any assistive devices, and was exit seeking. The DON stated that despite having a wander guard on, with the increased visitors in the facility on the weekend, she had felt for the safety of R12 that one to one care was necessary. The DON and administrator explained that R11 had been having behaviors that required one to one supervision. When asked to explain how they identify when a person needs or is provided one to one supervision, the DON and administrator stated that when a resident has an altercation with another resident, the aggressor is usually put on 1:1. On [DATE] at 8:30 a.m., an interview was conducted with the administrator at the dialysis clinic R1 had attended for treatment. The dialysis administrator (DA) stated that the issue with R1 was that on two separate occasions R1 had pulled the dialysis lines out. DA stated that the governing body for the dialysis clinic met, ,which included the DA, medical director, clinical director, and others, because they didn't have a policy that covered such instances. DA stated that guidelines were developed and implemented to address this incident, which guided the doctor to order that R1 had to have someone at their side during treatment sessions at all times. The DA stated that they were very flexible in moving R1's treatment times to accommodate the family's ability to accompany R1, but on 3 occasions, the dialysis treatment was not provided due to no one being with R1. The DA stated that on numerous occasions R1 had shortened treatment sessions, which were not effective. The DA went on to say, transport was never the issue. When asked if the facility ever sent a staff member to accompany R1, the DA said reviewed the records and noted that there had been one occasion in October. The DA said they talked to the family on several occasions and encouraged them to talk to the facility for a care conference because the the family was having difficulty and had expressed concern about not being able to accompany R1 all the time. On [DATE], the DON provided the surveyor with an in-service sheet that had been provided to facility staff on [DATE]. The document read in part, . 1:1 for aggression or falls should be considered for 48-72 hours to allow the IDT [interdisciplinary team] to come up with a solid intervention. Then of course, based on your discretion. The DON was questioned about this, and she stated it was guidance she had gotten from their corporate office and was educating staff about it. The Surveyor pointed out that they have been saying they don't provide one to one with regards to R1 and that it was the family's responsibility to accompany the resident to dialysis, but it is clear they do, per the provided policy. The DON and Administrator did not respond. A review was conducted of the facility policy titled, Coordination of Hemodialysis. The policy read in part, Residents requiring an outside ESRD [end stage renal disease] facility will have services coordinated by the facility to include care planning, nursing, medications, nutritional, social services, activities, and physician services. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a Dialysis Agreement/Arrangement if there are any residents requiring dialysis services. The agreement shall include how the residents care is to be managed. Two physicians wrote an article* for The American Journal of Kidney Diseases which included the following excerpts: Ultimately, missed dialysis treatments have a significant impact on mortality, morbidity, and resource use, in part due to increased emergency department visits and hospitalizations (including intensive care unit admissions) for urgent but often preventable hemodialysis treatments . Multilevel interventions targeting individual patients, patient-provider relationship/communication, and the process of care delivery should help improve overall dialysis treatment adherence, particularly missed hemodialysis treatments. On [DATE] and again on [DATE], during end of day meetings with the administrator and director of nursing, the above concerns were shared with them. When asked again why they didn't provide a staff member to accompany R1 to dialysis, they stated, We don't provide one on one and didn't have the staffing to do this. When it was reported that the facility had provided 1:1 to other residents, the director of nursing said, Yes, but that was short term, this was different. No further information was provided. *Menez, [NAME] and Jaar, [NAME] G. Missed Hemodialysis Treatments: A Modifiable But Unequal Burden in the World. American Journal of Kidney Disease 2018;72(5)625-627.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide adequate supervision/support to ensure safety during a transfer, resulting in serious adverse outcome (harm) for one of six residents in the survey sample (Resident #1). The findings include: Assessed as requiring two-person assistance, Resident #1 fell forward, hitting head against the wall, while being provided one-person assistance with toileting/transferring. Resident #1 complained of head/neck pain directly after the incident, was emergently hospitalized , diagnosed with an intracranial bleed due to the head injury, and subsequently died. Resident #1 was admitted to the facility with diagnoses that included cerebral infarction with left-sided hemiparesis, atherosclerotic heart disease, hypertension, epilepsy, anxiety, osteoarthritis, atrial fibrillation, diabetes with neuropathy, depression, gastroesophageal reflux disease, adrenal gland neoplasm and obstructive uropathy. The minimum data set (MDS) dated [DATE] assessed Resident #1 as cognitively intact and as requiring the extensive assistance of two people for transfers and limited assistance of two people for toileting. Resident #1's clinical record documented a nursing note dated [DATE] at 7:15 p.m. stating, Resident states was in bathroom getting pants pulled up and CNA [certified nurses' aide] pulled up pants, legs became weak and he head head on wall and hand rail .Hx [history] of CVA [stroke], Hemiplegia and hemiparesis of Left side .Resident c/o [complained of] headache, neck pain, nauseated, very clammy and sweaty. BP [blood pressure] 198/116 P [pulse] 89. Top of head without redness but yells out in pain when touched. PERRLA [pupils equal, round, reactive to light and accommodation] .Became more confused as time went on. Refused to do hand grasps due to pain .Spoke with .NP [nurse practitioner] and made decision to send to ED [emergency department]. 911 called .left facility at approx [approximately] 1935 [7:35 p.m.] . (Sic) A nurse documented on [DATE] at 3:09 a.m. that the hospital called and reported that the resident had expired and that .DON [director of nursing] will be informed in the am [morning] . The local emergency room physician's report dated [DATE] documented, .presents to the ER with complaints of fall .Per patient he states while he was walking to the bathroom, with assistance he fell hitting the top of his head .He complains of HA [headache], nausea, neck pain and upper back pain .Pt is on Eliquis . The physician ordered a CT scan. Prior to the scan the resident became unresponsive and was intubated. The CT scan was then performed, and the resident diagnosed with an intracranial hemorrhage. Resident #1 was transferred to a larger medical center for hospitalization/treatment. The hospital record dated [DATE] documented, .presents to ED .for evaluation of intracranial hemorrhage .Per EMS patient fell in the bathroom at .nursing home and hit his head .Patient is anticoagulated by Eliquis .Despite best efforts at outside hospital, large ICH [intracranial hemorrhage] and low probability of neurological outcomes . The hospital record documented the family was consulted and chose comfort care for the resident due to his condition. The hospital record dated [DATE] documented the resident was pronounced dead at 2:48 a.m. and that the medical examiner's office was contacted. The facility's investigation of Resident #1's injury of [DATE] documented a written statement from CNA #11, who was with the resident at the time of the incident. CNA #11's statement dated [DATE] documented, On [DATE]th [Resident #1] rang his call bell to go [to] the bathroom. I went in to assist him he was sitting in the wheelchair .I pushed him in the wheelchair into the bathroom. I pushed chair close to toilet, resident was able to grab the hand bar and pull himself up. While resident was standing I removed the brief and assisted him to the toilet. I remained in the room outside the bathroom door to provide privacy. Resident rang the emergency bathroom light and I was still in the room. Resident grabbed hold of handrail and I assisted him into the standing position. I assisted with pulling brief up, while pulling the brief up resident stated 'I can not stand much longer'. Residents legs buckled and resident was still holding handrail and tapped his forehead against the wall. I was able to reach behind me to get wheelchair to position under resident. I then proceeded to pull him out of the bathroom and place him back in front of television. I asked resident if he needed anything else. resident said 'no, but my neck and head are hurting' Upon exiting the room I went to the kiosk across from the desk to document on resident because I did not see nurse at that time .Nurse exited resident's room and asked me 'did [Resident #1] fall'? I proceeded to notify the nurse of what occurred. (Sic) The investigation documented an undated written statement by the licensed practical nurse (LPN #1) caring for Resident #1 on the evening of [DATE]. LPN #1's written statement documented, On 5/10 @ approx [approximately] 1900 [7:00 p.m.] was told by CNA that [Resident #1] needed a 'pain pill' .no order for pain med [medicine] so I wrote a standing order for Tylenol. Approx 2 minutes [after] being told went into res [resident's] room [with] pain med and saw res. hunched over moaning in w/c [wheelchair]. Asked what was wrong, res stated could not move neck and head was severly [severely] hurting. Asked what happened res told me that aid went to pull up pants in bathroom and res legs became weak and when aid pulled up pants, res went forward hitting top of head in wall. Res. skin clammy and sweaty took BP [with] extremely high reading. Pupils responded to light. Would not squeeze hands due to hurting. Called physician on call .order given to send to ED .911 called . observed res becoming more confused, drowsey [drowsy] .asked aid .what happened was told res in bathroom @ bar, legs gave out and she assisted res towards toilet, resident bumped head against wall. (Sic) The facility's investigation documented CNA #11, who was with Resident #1 at the time of the injury, was suspended on [DATE] due to the incident. The administrator documented a verbal education with CNA #11 on [DATE] at 2:31 p.m. about checking the [NAME] for transfer status on each resident and that if listed as requiring two-persons, to make sure two certified staff members were providing transfer assistance. The administrator and CNA #11 signed the education sheet on [DATE]. Resident #1's death certificate issued on [DATE] documented the resident's primary cause of death as subdural and subarachnoid hemorrhage from a ground level fall that occurred on [DATE] at the nursing home. A facility report sent to the state agency dated [DATE] documented, On [DATE] the C.N.A [CNA #11] was assisting .[Resident #1] toileting. Resident bumped his head on wall while transferring off the toiilet [toilet]. Resident sent to ER .Resident declared dead at 2:48 am. Cause of death established on [DATE]. Cause of death Subdermal [subdural] hemorrage [hemorrhage] and subarachnoid hemorrage [hemorrhage] .Employee terminated. Staff re-educated on transfers and [NAME] usuage [usage] . The report documented notification to adult protection services, department of health professions, ombudsman, and the local police. The facility's investigation documented CNA #11 was terminated on [DATE] due to not following proper care protocol during Resident #1's transfer from the toilet. The facility documented that after completing the investigation and receiving the medical examiner's report with cause of death, it was determined that CNA #11 did not follow the [NAME] documentation or verbal reports provided that indicated a requirement for two-person assistance during transfers with Resident #1. The investigation documented re-education with all direct-care staff starting on [DATE] regarding use/reference of the [NAME] to determine proper transfer assistance requirements for each resident. Resident #1's [NAME], used by CNAs as a guide for individualized safety/care requirements, was reviewed. Resident #1's [NAME] in use on [DATE] documented the resident required the extensive assistance of two + persons for transfers and personal hygiene and required limited assistance of two + persons for toileting. This [NAME] documented the resident was not steady when moving from seated to standing, when walking, turning around, moving on/off toilet, and had limited function of upper and lower extremities. Resident #1's plan of care on [DATE] documented the resident was at risk of falls due to left sided hemiparesis, had a physical functioning/self-care deficit due to impaired mobility, limited range of motion and was at risk of bleeding due to use of anticoagulant medication. Interventions to prevent significant fall related injuries and complications from anticoagulant use included provision of needed assistance for toileting, transfers, personal hygiene, locomotion, task segmentation, and monitoring Resident #1 for signs of bleeding or changes in condition. On [DATE] at 1:15 p.m., the nurse practitioner (NP - other staff #1) that cared for Resident #1 was interviewed. The NP stated that she had assessed Resident #1 earlier in the day on [DATE] in follow up to recent treatment for nausea. The NP stated that Resident #1 was neurologically intact during that assessment and stated he felt great with no further nausea or gastrointestinal symptoms. The NP stated that Resident #1 had a history of strokes and was weak in the legs. The NP stated that she was notified on [DATE] around 7:00 p.m. by nursing that the resident bumped his head, when his pants were being pulled up after toileting, and that he had complaints of headache. The NP stated that she ordered Resident #1 immediately to the emergency room, due to the symptoms and Resident #1's use of an anticoagulant (Eliquis), which increases risk of bleeding. On [DATE] at 12:05 p.m., LPN #1 caring for Resident #1 at the time of the incident, was interviewed by telephone. LPN #1 stated she had cared for Resident #1 since 7:00 a.m. on [DATE] and Resident #1 'was fine that day. LPN #1 stated on [DATE] around 7:00 p.m., a CNA (not CNA #11) reported to her that Resident #1 said he was hurting and wanted something for pain. LPN #1 stated that she checked the orders and retrieved Tylenol. LPN #1 stated, As soon as I hit the door, I knew something was wrong. LPN #1 stated that Resident #1 reported he was not able to move his neck and that his head was pounding. LPN #1 stated that the resident said when the aide was pulling up his pants in the bathroom, he hit the top of his head against the wall as his legs gave way. LPN #1 stated that she checked Resident #1's vital signs and noted a high blood pressure. LPN #1 stated that the resident refused to squeeze her hands, as he said he was in too much pain. LPN #1 stated that she called the NP who ordered the resident immediately be sent to the emergency room. LPN #1 stated CNA #11 had not previously reported to her that Resident #1 hit his head during the toilet transfer. LPN #1 stated that she was not aware of the incident until she went to Resident #1's room to assess his report of pain. LPN #1 stated that Resident #1 required two-person assistance for transfers/toileting. LPN #1 stated that Resident #1 usually requested assistance to/from the bathroom and required more assistance later in the day. LPN #1 stated that Resident #1's [NAME], used by CNAs for care instructions, listed a requirement for two-person assistance. On [DATE] at 1:45 p.m., CNA #2 that routinely cared for Resident #1 was interviewed about level of assistance with transfers/toileting. CNA #2 stated that Resident #1 was a two-person assist. CNA #2 stated that Resident #1 was weak in the legs. When questioned further, CNA #2 stated that he referenced the [NAME] book to know what type of assistance/care residents required. On [DATE] at 2:00 p.m., the administrator and DON were interviewed about Resident #1's injury during transfer on [DATE]. The DON stated that she was notified that Resident #1 was sent to the hospital on the evening of [DATE] and was notified early the next morning ([DATE]) of the resident's death. The DON stated CNA #11 was suspended on [DATE] but came in and provided a written statement and demonstration of how the incident happened. The DON stated CNA #11 reported that Resident #1's legs got weak, and he hit his head against the wall as she was pulling up his pants/brief after toileting. The DON stated she was not sure of the exact time of the incident but stated CNA #11 reported to work on [DATE] at 6:00 p.m. and the nurse assessed the resident for headache/neck pain around 7:00 p.m. The DON stated that Resident #1 was listed as requiring two-person assistance during transfers/toileting, due to his weakness. The DON stated that when Resident #1 said his legs were weak, CNA #11 should have returned the resident to the toilet and called for help. The DON stated that Resident #1 was known to require two-person assistance especially late in the day. The DON stated that CNAs were expected to reference and follow the [NAME] instructions for resident care, including the requirement for two-person assistance with transfers for Resident #1. The DON stated that CNA #11 was re-educated on [DATE] regarding use of the [NAME] for resident care instructions and ensuring two certified staff members provided assisted for anyone listed as two-person assist for transfers. The DON stated CNA #11 did not work on [DATE], [DATE] or [DATE]. The DON stated CNA #11 worked on [DATE], but was terminated on [DATE] after the cause of death was provided. The administrator stated that when the cause of death was verified as intracranial hemorrhage from the head injury of [DATE], CNA #11 was terminated for not following Resident #1's [NAME] for provision of two-person assistance. The administrator stated that all [NAME] sheets were reviewed for accuracy on [DATE] and all direct-care staff were educated on [DATE] regarding provision of transfer assistance per the [NAME] instructions. On [DATE] at 7:36 p.m., CNA #6 that previously provided care for Resident #1 was interviewed. CNA #6 stated Resident #1 was a two-person assist for going to the bathroom and transferring to bed. CNA #6 stated that she cared for Resident #1 during her orientation and always provided transfer assistance to him along with another aide. CNA #6 stated that the [NAME] provided her with instructions for each resident's care. On [DATE] at 8:00 p.m., CNA #8 that previously provided care for Resident #1 was interviewed. CNA #8 stated Resident #1 was able to call for assistance to go/come from the bathroom and used the safety bar when transferring from the toilet. CNA #8 stated that Resident #1 required two-person assistance, especially when he was tired, and sometimes he was tired in the evening. CNA #8 was familiar with the [NAME] and stated that this was the reference aides used for resident care instructions. On [DATE] at 8:15 p.m., CNA #9 was interviewed about Resident #1. CNA #9 stated that she only cared for Resident #1 during her orientation and that transfers were provided then with two-person assistance. CNA #9 stated that if she encountered problems during a transfer, she would use the call bell to get assistance, assist the resident back down if possible, and would get additional help. CNA #9 stated that she was aware the [NAME] listed the care required for each resident. On [DATE] at 9:55 a.m., the registered nurse unit manager (RN #3) that cared for Resident #1 was interviewed. RN #3 stated the [NAME] was updated based upon data entered routinely by CNAs about assistance provided with activities of daily living. RN #3 stated that Resident #1 was in the MDS/[NAME] system as requiring two-person assistance for transfers/toileting and that CNAs were expected to follow the [NAME] for resident care. These findings were reviewed with the administrator and director of nursing on [DATE] at 8:40 a.m. During this meeting, the administrator presented a correction plan initiated on [DATE] regarding Resident #1's improper transfer on [DATE] that resulting in serious injury/death. The correction plan included the following. [DATE] - CNA #11 suspended; written statements obtained from CNA #11 and LPN #1; CNA #11 provided demonstration to administrator and DON of the incident events; drug test administered to CNA #11; CNA #11 re-educated on providing required transfer assistance and following [NAME] instructions for resident care. [DATE] - Cause of death verified through official medical examiner's report; CNA #11 terminated due to failure to provide required assistance that led to injury; Educated all administrative and direct-care staff on providing adequate transfer assistance and following [NAME] instructions for care; 100% audit of all resident [NAME] instructions for accuracy with updates made as needed; Initiated requirement for unit managers to bring [NAME] binders to each morning meeting for review and updates for any changes in condition, new falls/incidents or new admissions; Reported incident to state agency, ombudsman, adult protective services, department of health professions and local police. [DATE] - Meeting held with remaining staff with re-education about proper transfer assistance and use of [NAME] for care instructions. Audits were ongoing to ensure compliance. The administrator advised a date of compliance as [DATE]. The facility's incident and accident log for the past 30 days was reviewed with no other incidents/injuries involving staff assisted transfers listed. Five additional residents with injuries/incidents occurring after [DATE] were included in the survey sample with no deficient practice identified regarding transfer safety, falls and/or injuries. Care plan interventions for fall/injury prevention were observed in use. Education was documented for staff as listed in the correction plan. Interviews were conducted during the survey with direct-care staff from each unit and shift that included RN #1, CNA #1, CNA #2, LPN #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, RN #2, CNA #8, CNA #9, and CNA #10. All staff interviewed were aware of the care instructions provided on the [NAME], the expectation to follow the care instructions and knew where to access the [NAME] book or [NAME] information from a kiosk. The unit managers (LPN #3 and RN #3) were interviewed on [DATE] at 9:50 a.m. and stated they were now bringing the [NAME] binder to each morning meeting for review/updates. The plan of correction was accepted. This deficiency cited as past non-compliance. There was no further information presented to the survey team regarding Resident #1's injury/death prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to promptly assess, implement interventions, and provide immediate care for the prevention and/or treatment of pressure ulcers for one of 22 residents in the survey sample (Resident #50), resulting in harm. Resident #50 developed two pressure ulcers on the inside of both knees initially identified at an unstageable status with thick, necrotic tissue over the wounds. There was no prior assessment of impaired skin in those areas, and after treatment, were assessed as stage 4 pressure ulcers. Staff failed to follow physician orders and infection control practices during dressing changes to Resident #50's pressure ulcers. Facility staff failed to promptly assess and initiate treatment for Resident #50 regarding a newly identified pressure ulcer found during the dressing change observation and not previously reported to nursing. The findings include: Resident #50 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #50 included multiple sclerosis, chronic pressure ulcers, diabetes, encephalopathy, reflex neuropathic bladder, insomnia, dementia and abnormal posture. The minimum data set (MDS) dated [DATE] assessed Resident #50 with moderately impaired cognitive skills and as requiring extensive assistance of two people for bed mobility, total assistance of two people for transfers and limited functional range of motion in both upper and lower extremities. a) Resident #50 developed two pressure ulcers on the inside of both knees initially identified at an unstageable status with thick, necrotic tissue covering the wound beds. Weekly skin checks never listed the knee wounds and the clinical record made no mention of the acquisition sequence of the new pressure ulcers. After treatment by the wound consultant, Resident #50's unstageable wounds were assessed as stage 4 pressure ulcers. Resident #50's clinical record documented the resident was currently treated for pressure ulcers that included two stage 4 pressure ulcers on the inside of both knees. The clinical record documented Resident #50 was evaluated by occupational therapy (OT) on 3/26/21 for positioning due to abnormal posture and contractures. The OT plan of care dated 3/26/21 documented as underlying impairments, .Wounds - pt [patient] has wound .medial aspect of B [both] knees . Resident #50's clinical record documented the initial assessment of the medial knee ulcers on 4/1/21 by the facility's licensed practical nurse responsible for wounds (LPN #6). These assessments documented the knee ulcers were unstageable upon the initial assessment on 4/1/21 and listed the following: 4/1/21 - Left medial knee - unstageable pressure ulcer measuring 4.0 cm x 1.8 cm (length by width), Pressure injury currently presenting with dry scab covering wound. No drainage .Periwound red without breakdown . 4/1/21 - Right medial knee - unstageable pressure ulcer measuring 2.0 cm x 2.5 cm, Pressure injury to right medial knee presenting with dry scab covering wound. Periwound red without breakdown . The clinical record documented weekly skin integrity checks performed by nursing. In the weeks prior to, and week of the assessed unstageable ulcers, the skin checks documented no new areas of skin impairment. Skin integrity check sheets dated 3/5/21, 3/12/21, 3/19/21, 3/26/21 and 4/2/21 documented, Wound/Skin condition Present/No new change of condition. Documentation already established on all existing Wound/Skin Conditions. The weekly skin integrity sheets including the 4/2/21 sheet did not mention or identify the newly acquired unstageable pressure ulcers on the resident's knees. Nursing notes included no documentation of who initially found the knee ulcers, when the ulcers were found or who reported the ulcers to the wound nurse and physician. The facility's wound nurse (LPN #6) documented the first notes about the knee pressure ulcers on 4/1/21. A nursing note by the wound nurse (LPN #6) dated 4/1/21 at 1:44 p.m. documented, .Left Medial Knee - Pressure: Length = 4.0, Width = 1.8, Depth = NM [not measurable], - Stage Unstageable Drainage? No .No tunnelling or undermining present. The wound nurse documented a note on 4/1/21 at 1:50 p.m. stating, -Other (specify): : -Pressure: Length = 2.0, Width = 1.5, Depth = NM, - Stage Unstageable Drainage? No .No tunnelling or undermining present. (Sic) Other than the OT note referencing bilateral knee wounds on 3/26/21, the clinical record made no mention of the pressure ulcers to the medial aspect of both knees until 4/1/21 when they were assessed by the wound nurse as unstageable. The facility's consultant wound physician (other staff #8) assessed the resident's knee ulcers on 4/1/21 and listed both wounds as unstageable with thick necrotic tissue covering 100% of the wound beds. The physician's wound evaluation dated 4/1/21 documented the following initial assessment of the medial knee pressure ulcers: Left medial knee - pressure ulcer; unstageable due to necrosis, wound size 1.5 cm x 2.5 cm x non-measurable depth; moderate serosanguineous drainage; Thick adherent devitalized necrotic tissue: 100%. Right medial knee - pressure ulcer unstageable due to necrosis; wound size 2 cm x 1.5 cm x non-measurable depth; moderate serosanguineous; Think adherent devitalized necrotic tissue: 100%. The wound physician surgically debrided the left knee ulcer on 4/1/21. The resident refused surgical debridement of the right knee ulcer. The wound physician's note on the 4/1/21 assessment documented, Debridement refused. Patient/surrogate made aware of risks of not removing necrosis including infection; sepsis; limb loss or death . The wound physician ordered treatment for both knee wounds that included Dakin's solution, Alginate calcium and Santyl debriding agent with dressing changes once daily. Follow up evaluations/treatments by the wound physician were documented on 4/8/21, 4/15/21, 4/22/21, 4/29/21, 5/6/21 and 5/13/21. The most recent wound physician assessment dated [DATE] documented the following status of the medial knee pressure ulcers. Left medial knee - stage 4 pressure, 3.9 cm x 3.9 cm x 0.2 cm, 10% granulation tissue Right medial knee - stage 4 pressure, 1.6 cm x 1 cm x 0.2 cm, 10% thick adherent devitalized tissue, granulation 90%. The most recent nursing assessment dated [DATE] documented the following assessments of the knee ulcers. Left medial knee - stage 4 measuring 3.4 cm x 4.0 cm x 0.4 cm (length x width x depth in centimeters) Right medial knee - stage 4 measuring 1.7 cm x 1.4 cm x 0.6 cm On 5/26/21 at 1:30 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #5 and LPN #1, dressing changes to Resident #50's pressure ulcers were observed. The resident had a circular pressure ulcer on the inside of the left knee approximately the size of a 50-cent piece. The wound had serosanguineous drainage on the existing dressing with the edges of the wound slightly raised with the skin around the wound red. The resident had a circular wound on the inside of the right knee slightly smaller than a dime with small amount of black tissue noted in the wound bed. The skin around the right knee wound was red/pink. On 5/26/21 at 2:05 p.m., LPN #5 was interviewed about interventions in place prior to the resident's acquisition of unstageable pressure ulcers on both knees. LPN #5 stated they were using a pillow at one time between his knees but switched to a wedge after development of the knee wounds. On 5/26/21 at 3:06 p.m., Resident #50 was interviewed about the pressure ulcers on his knees. The resident stated a bed pillow was used prior to the knee wounds and now he had a firm wedge between his legs to keep his knees from resting against each other. Resident #50 stated he did not remember the exact dates of when the pillow and wedge were started. Resident #50 stated he had feeling in his extremities but was unable to move his legs and lower body due to severe contractures related to multiple sclerosis. When asked about the pillow used prior to the unstageable knee wounds, Resident #50 stated the pillow must not have been working because now he had wounds inside both knees. On 5/26/21 at 3:30 p.m., LPN #1 that worked on Resident #50's living unit was interviewed about the resident's wounds and any preventive interventions. LPN #1 stated that they tried to keep bed pillows between his knees. LPN #1 stated, I'm not 100% sure about whether they [pillows] have been there as she stated she worked mostly on the opposite end of Resident #50's unit. On 5/26/21 at 3:33 p.m., LPN #5 was interviewed again about Resident #50's knee wounds and why they were found covered with necrotic tissue. LPN #5 stated she did not know why the wounds were found at unstageable. LPN #5 stated nurses were assigned to perform weekly skin assessments and any new wounds or areas of concern were supposed to be reported immediately to the wound nurse. On 5/26/21 at 3:45 p.m., the certified nurses' aide (CNA #1) caring for Resident #50 was interviewed about any preventive measures regarding the knee wounds. CNA #1 stated, I'm agency. This is my second day. CNA #1 stated she was not familiar with Resident #50's wounds and did not know what preventive treatments were used in the past. CNA #1 stated she thought they were using pillows to keep his legs from rubbing. On 5/26/21 at 4:51 p.m., the registered nurse unit manager (RN #1) was interviewed about development of Resident #50's knee ulcers. RN #1 stated she remembered talking about the knee ulcers in the weekly wound meeting but did not remember the exact date. On 5/27/21 at 7:30 a.m., the director of nursing (DON) was interviewed about Resident #50's knee ulcers. The DON stated the resident's knee wounds started on 4/1/21 and care was initiated and had been provided since then. The DON stated, I read nursing notes. They were doing pillows. The DON stated the resident refused care at times. The DON stated she looked through the care plan and all the interventions used were listed. The DON stated she did not know who originally found the wounds or who reported the ulcers to the wound nurse. The DON stated the wound nurse did not document who reported or found the wounds. The DON stated the facility met weekly to review wounds. The DON stated prior to 4/1/21 she did not recall the knee ulcers being discussed in the weekly meeting. When asked why the weekly skin assessment sheets never documented the acquisition of the new knee pressure ulcers, the DON had no response. The wound nurse (LPN #6) was out on leave and not available for interview. On 5/27/21 at 7:50 a.m., LPN #4 that routinely cared for Resident #50 was interviewed about the acquisition of the knee ulcers at an unstageable status. LPN #4 stated they were using a blue cushion between the resident's knees prior to 4/1/21. LPN #4 stated when the blue cushion was in laundry, bed pillows were used. LPN #4 stated they attempted to keep the resident more on his left side to keep pressure off the right buttock wound. LPN #4 stated she did not know if this put more pressure on his knees. LPN #4 stated she did not know why the unstageable wounds were not identified earlier. LPN #4 stated nurses were assigned weekly skin assessments and were to report any new wounds to the wound nurse. On 5/27/21 at 8:10 a.m., the certified nurses' aide (CNA #2) that routinely cared for Resident #50 was interviewed. CNA #2 stated she used the blue cushion between the resident's legs when in bed and used the wedge when the resident was up in the wheelchair. CNA #2 did not know when the knee ulcers started and stated if she found new open skin areas she was supposed to be reported them immediately to a nurse. On 5/27/21 at 8:20 a.m., the physical therapist (PT - other staff #3) was interviewed about Resident #50. The PT stated he was not aware the resident had pressure ulcers on both knees. The PT stated the resident was very challenging due to his contractures and the best prevention was frequent repositioning. The PT stated occupational therapy (OT) evaluated the resident in March 2021 for positioning. On 5/27/21 at 9:25 a.m., the OT (other staff #4) that treated Resident #50 was interviewed. The OT stated she evaluated and treated the resident regarding bed and wheelchair positioning. The OT stated Resident #50 required constant monitoring due to contractures that caused his knees to rest against each other. The OT stated prior to 4/1/21 an abduction (blue) pillow was used with the resident when up in the wheelchair and bed pillows and/or a wedge were used when the resident was in bed. The OT stated all those interventions (pillow, blue cushion and wedge) were initiated months prior to 4/1/21. The OT stated the resident was very tight at the knees and she was concerned because his positioning was very complex and his contractures were aggressive. The OT stated that even with devices in place, there could be pressure created because the muscle tone/contractures were so aggressive. On 5/27/21 at 9:40 a.m., the DON was interviewed again about any explanation of why wounds were not identified prior to being found with adhered 100% necrotic tissue. The DON stated, No. I don't have that information. The DON stated nothing was documented about the knees until 4/1/21. The DON stated she did not have proof of how the wounds occurred or who found them because nothing was documented. The DON stated the wound nurse assessed the ulcers on 4/1/21 and we moved forward from there. On 5/27/21 at 10:07 a.m., the unit manager (RN #1) was interviewed again about Resident #50's knee wounds. RN #1 stated she knew a small wedge was implemented at some point but she did not go back and observe to see if the wedge contributed to any issues. RN #1 stated she did not know who originally found and/or reported the knee ulcers to the wound nurse as nothing was documented in the clinical record. RN #1 stated pressure ulcers typically did not begin as unstageable wounds and she had no explanation of why the knee ulcers were found at an unstageable status. On 5/27/21 at 11:15 a.m., the OT was interviewed again about her documented evaluation on 3/26/21 listing the resident had bilateral knee wounds. The OT reviewed the documented note and stated the information was not her observation but most likely came from communication from nursing or information shared during the weekly wound meeting. On 5/27/21 at 1:50 p.m., the wound physician (other staff #8) was interviewed by telephone about Resident #50. The physician stated he first assessed the knee ulcers on 4/1/21 and described the wounds upon his initial assessment as clearly unstageable. The physician stated after surgical debridement both wounds were assessed as stage 4. The physician stated Resident #50 was severely deconditioned and at high risk of skin breakdown due to contractures. The physician stated he performed a head-to-toe assessment only on new patients. The physician stated he was already treating Resident #50 for wounds on his foot and buttocks. The physician stated that for established patients like Resident #50, he depended on the wound nurses to perform assessments and notify him of changes or new wounds requiring treatment. The physician stated he knew they were using pillows for positioning at one time but did not know all the preventive interventions implemented. Resident #50's plan of care (revised 5/6/21) documented the resident had impaired mobility, self-care impairment, limited range of motion, right side weakness and contractures due to multiple sclerosis. Interventions to maintain physical functioning included, .Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse . This care plan documented the resident was at risk of pressure and non-pressure related skin impairment due to assistance required for bed mobility, deconditioning, diabetes, immobility, history of diabetic/pressure ulcers and history of moisture related skin impairment. Interventions to prevent/heal pressure ulcers were initiated on 12/28/20 and included Braden risk assessment, weekly skin inspection, float heels, heel boots, monitor labs, nutrition support, pressure reduction mattress, treatments as ordered, turning and repositioning in bed and weekly wound assessments. The care plan was updated on 5/6/21 listing the resident had stage 4 pressure ulcers on the right medial knee, right buttock/thigh, right proximal foot, left medial knee and right lateral foot. Interventions listed to prevent complications from pressure ulcers were dated 5/6/21 and included Braden risk assessment, weekly skin inspections, diabetic foot monitoring, do not massage bony prominences, lotion to skin, monitor labs, monitor under braces, splints, casts, nutrition support, pressure reducing wheelchair cushion, pressure reduction mattress, skin care after incontinence, therapy referral, treatments as ordered and weekly wound assessments. The care plan documented the resident had contractures due to multiple sclerosis and limited range of motion of all extremities. The care plan made no mention of the blue cushion, pillows or wedge referenced during staff interviews. The clinical record documented a physician's order dated 3/20/18 for an air/fluidized mattress and an order 10/28/20 to ensure resident was positioned on left side as much as possible for off-loading to right leg wound. A physician's order was entered on 4/26/21 to, Ensure Prevalon Boots are in place at all times. The clinical record documented Braden pressure ulcer risk assessments as part of a quarterly data collection tool. Resident #50's pressure ulcer risk assessment dated [DATE] and 4/20/21 listed the resident as a moderate risk for pressure ulcers with a total score of 13. Nursing notes from 3/1/21 through 5/25/21 made one reference to use of a pillow and wedge for positioning. A nursing note dated 4/25/21 documented, Resident is currently on ATB [antibiotic] therapy for cellulitis. Redness to back and legs almost resolved .Continue to provide pressure wound dsgs [dressings] per MD [physician] orders. Refused to get out of bed this weekend. Has been experiencing multiple loose stools both days. Positioning resident of left side with pillow in between knees, and under bil [bilateral] feet-wedges used to keep positioned properly . (Sic) A note dated 5/24/21 documented the resident refused the Prevalon boots. Nursing notes from 3/1/21 through 5/25/21 made no other mention of positioning devices or the resident's refusal of skin care interventions. The facility's policy titled Skin Assessment - Weekly (effective 1/2107) documented, A Licensed Nurse will complete a total body assessment on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, lesions, abrasions, reddened areas and skin turgor problems. The purpose of the Skin Assessment is to evaluate the condition of the resident's skin on a regular basis. As the nursing assistants are the residents' primary care giver, Licensed Nurses do not routinely observe the resident's skin. This process not only provides a system for Licensed Nurses to regularly assess each resident's skin condition, but also provides a means of evaluating the nursing assistant's reporting of and response to residents with skin problems . b) Staff failed to follow infection control practices during dressing changes to Resident #50's pressure ulcers, failed to have a physician ordered dressing in place on the right buttock/thigh pressure ulcer and failed to have Prevalon boots in use for pressure ulcer prevention as ordered by the physician. On 5/26/21 at 1:30 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #5 and LPN #1, dressing changes to Resident #50's pressure ulcers were observed. The resident was observed in bed without Prevalon boots in place. Without prior hand hygiene, LPN #5 sanitized the bed table with a wipe, placed a clean barrier and positioned gauze and other supplies onto the clean field. LPN #5 washed her hands, applied clean gloves, removed and then discarded the dirty dressing from two wounds on the resident's right foot. LPN #5 removed her gloves and donned a new pair of gloves but performed no hand hygiene between the glove changes. LPN #5 then cleansed the larger right foot ulcer with a Dakin's solution and then cleansed the smaller right foot ulcer with a Dakin's soaked gauze. LPN #5 then patted the wounds dry, applied a Dakin's soaked gauze to the larger foot ulcer and covered it with a non-stick gauze and Hypafix adhesive dressing. LPN #5 removed her gloves and without performing hand hygiene put on clean gloves then applied the Dakin's soaked gauze dressing to the smaller foot ulcer. LPN #5 removed her gloves after the dressing application and without prior hand hygiene, donned a new pair of gloves. The resident was then positioned for a dressing change to the right buttock/thigh pressure ulcer. The right buttock/upper thigh pressure ulcer had no existing dressing in place at the time of the dressing change. A new open area was observed on the right buttock adjacent to the existing wound. This new area was approximately postage stamp size with a red wound bed. LPN #5 stated she did not know why the right buttock ulcer had no dressing and she had not been made aware of the new open area. LPN #5 proceeded to cleanse the right buttock ulcer then the smaller new open area with Dakin's solution, packed the existing ulcer wound with Dakin's soaked gauze, applied a non-stick gauze then covered the wound with Hypafix. LPN #5 removed her gloves, donned new gloves without prior hand hygiene and placed a non-stick gauze with Hypafix over the new open area. LPN #5 changed gloves again without hand hygiene between the glove changes. LPN #5 removed the dirty dressing for the right knee ulcer and then cleansed this ulcer with Dakin's solution. LPN #5 removed her gloves, without hand hygiene put on clean gloves and then applied Dakin's soaked gauze, non-stick gauze and Hypafix dressing to the right knee ulcer. LPN #5 took off gloves then left the room to get more gauze. Upon return to the room, LPN #5 washed her hands. LPN #5 put on clean gloves and then removed the drainage soaked dressing for the ulcer on the inside of the left knee. LPN #5 changed gloves again without hand hygiene between the glove changes. LPN #5 failed to cleanse the left knee ulcer prior to application of the Dakin's soaked gauze, non-stick gauze and Hypafix dressing. LPN #5 removed gloves, put on new gloves without prior hand hygiene and then moved the trash can to the other side of the bed. LPN #5 then changed gloves without hand hygiene between glove changes, removed the soiled dressing on the left hip ulcer and discarded it. LPN #5 took off gloves and without prior hand hygiene, donned clean gloves then applied the Dakin's soaked gauze, non-stick gauze and Hypafix dressing to the left hip wound. LPN #5 then changed gloves, assisted LPN #1 with a brief change for the resident, discarded gloves and supplies then went to the treatment cart and applied hand sanitizer. The resident's clinical record documented current physician orders as of 5/26/21 for wet to dry dressing changes twice per day as follows for all the resident's pressure ulcers: Cleanse with Dakin's solution, apply Dakin's soaked gauze and cover with dry dressing. The record documented a physician's order dated 4/26/21 for Prevalon boots in place at all times. On 5/26/21 at 2:05 p.m., LPN #5 was interviewed about the lack of hand hygiene between glove changes, no dressing in place on the right buttock wound and not cleansing the left knee ulcer prior to application of the dressings. LPN #5 stated, I was very nervous. LPN #5 stated she should have taken hand sanitizer in with the dressing change supplies. LPN #5 stated she was not familiar with the resident's wound as the wound nurse usually performed treatments. LPN #5 stated the wound nurse was out on leave so floor nurses were now doing wound care. LPN #5 stated she did not know why there was no dressing in place on the existing right buttock ulcer. LPN #5 stated if a dressing came off during care the aides were supposed to inform the nurse so the dressing could be replaced. LPN #5 stated she did not know why the boots were not in use and again stated she had not been made aware of the new open area on the right buttock. On 5/26/21 at 3:00 p.m., the director of nursing (DON) was interviewed about assessments and treatments for wounds. The DON stated the wound nurse had been out since 5/19/21. The DON stated it was hodge podge on who was performing care with the wound nurse out. The DON stated a nurse was assigned daily from the schedule to perform dressing changes in the facility. On 5/26/21 at 3:45 p.m., the DON was interviewed again about a dressing change policy. The DON stated she did not have a policy about dressing changes. The DON stated they reviewed competencies for all the nurses that included wound care, prevention, treatments, weekly skin assessments and infection control. When asked about LPN #5 not performing hand hygiene between the glove changes during the dressing changes to multiple wounds, the DON stated it was nursing 101 to perform hand hygiene between glove changes and between wounds. The DON stated that new open areas were supposed to be reported immediately to nursing for assessment and treatment. 5/26/21 at 4:51 p.m., the registered nurse (RN #1) responsible for the infection control program was interviewed about the dressing change observation. RN #1 stated the nurse should have washed hands prior to the start of the dressing change and then performed hand hygiene after each glove change. RN #1 stated the sequence for dressing changes should be hand hygiene, gloves on, remove dirty dressing, remove gloves, perform hand hygiene, put on clean gloves, cleanse wound, remove gloves, perform hand hygiene, apply new gloves, apply treatments/clean dressings, discard supplies, remove gloves and perform hand hygiene. RN #1 stated she did not have a specific policy about dressing changes but presented dressing change information included with the policy about documenting wounds. RN #1 stated any new open areas or displaced dressings were supposed to be reported immediately to the nurse caring for the resident. On 5/27/21 at 7:45 a.m., LPN #2 that was assigned to Resident #50 on 5/26/21 was interviewed about the dressing not in place on the right buttock ulcer and the new open area observed on the right buttock. LPN #2 stated, I had him [Resident #50] yesterday [5/26/21] and nobody reported a new wound, open area or that the dressing had come off. The dressing change policy provided was titled Non-Sterile Dressing Change and was undated. This policy documented the following steps for a dressing change, Non-sterile dressings protect open wounds from contamination and absorb drainage .Wash hands, apply gloves .Remove soiled dressing, place it in trash bag .Remove gloves, wash hands, apply new gloves .Cleanse wound with normal saline or prescribed cleanser .Pat the tissue surrounding the wound dry with a 4 x 4 .Assess wound characteristics .Remove gloves, wash hands, apply new gloves .Apply prescribed topical agent to wound .Apply wound dressing .Discard gloves and all used supplies in trash bag .Wash hands .Document the dressing change in medical record . Resident #50's care plan (revised 5/6/21) listed the resident had stage 4 pressure ulcers on the right medial knee, right buttock/thigh, right proximal foot, left medial knee and right lateral foot. Interventions listed to prevent complications from pressure ulcers were dated 5/6/21 and included Braden risk assessment, weekly skin inspections, diabetic foot monitoring, do not massage bony prominences, lotion to skin, monitor labs, monitor under braces, splints, casts, nutrition support, pressure reducing wheelchair cushion, pressure reduction mattress, skin care after incontinence, therapy referral, treatments as ordered and weekly wound assessments. The Lippincott Manual of Nursing Practice 11th edition documents on page 843 concerning hand hygiene, Hand hygiene is the single most recommended measure to reduce the risks of transmitting microorganisms .Hand hygiene should be performed between patient contacts; after contact with blood, body fluids, secretions, excretions, and contaminated equipment or articles; before donning and after removing gloves is vital for infection control. It may be necessary to clean hands between tasks on the same patient to prevent cross-contamination of different body sites . Page 847 of this reference documents, .Gloves are worn to provide a protective barrier and prevent gross contamination of the hands of health care workers; if used properly, they reduce the transmission of microorganisms and help prevent cross-contamination within a patient. Wearing gloves does not replace the need for hand hygiene because gloves may have small defects or may be torn during use, and during the removal of gloves, hands may become contaminated .Perform hand hygiene before putting on gloves .Change gloves after contact with infective material, such as feces and wound drainage .Remove gloves before leaving the patient's environment and perform appropriate hand hygiene immediately . (2) c) Facility staff failed to promptly assess, notify the provider and seek treatment orders for the newly found pressure ulcer on Resident #50's right buttock. On 5/26/21 at 1:30 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #5 and LPN #1, dressing changes to Resident #50's pressure ulcers were observed. Observed during the dressing change was a new open wound to the resident's right buttock adjacent to an existing right buttock/thigh ulcer. The open wound was approximately postage stamp size with a red wound bed. LPN #5 cleansed the wound, applied a non-stick gauze and covered the wound with a Hypafix dressing. LPN #5 stated at the time of the dressing changes that she had not previously been made aware of this new wound. On 5/26/21 at 2:05 p.m., LPN #5 was interviewed about the new open area on the resident's right buttock. LPN #5 stated she had not been made aware of the any new wounds and the aides and other nurses had reported no newly impaired skin integrity. LPN #5 stated she covered the wound and would contact the nurse practitioner for treatment orders. On 5/26/21 at 3:33 p.m., LPN #5 stated nurses were required to perform weekly skin assessments and if a new area was found, report it immediately to the wound nurse who would assess and obtain treatment orders. LPN #5 states aides were also to report any new skin impairments seen during care with the residents. On 5/26/21 at 5:00 p.m., the new open area found on the resident's right buttock during the dressing changes was reviewed with the administrator, director of nursing (DON) and registered nurse unit manager (RN #1) during a meeting with the survey team. On 5/27/21 at 7:45 a.m., LPN #2 that cared for Resident #50 was interviewed about the new open wound found on the right buttock. LPN #2 stated she was assigned to Resident #50 yesterday (5/26/21) and nobody reported a new wound or open area to her during the shift. LPN #2 stated she was performing wound care today (5/27/21) but had not been made aware of any new open area on Resident #50's buttock. On 5/27/21 at 9:15 a.m., Resident #50's clinical record was reviewed. The clinical record including nursing notes made no mention of the open area on the resident's right buttock found on 5/26/21. There was no nursing note, no assessment of the wound, no notification to a provider